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A Novel Approach

Whole-class novels, student-centered teaching, and choice.

By Kate Roberts

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As an English teacher, Kate Roberts has seen the power of whole-class novels to build community in her classroom.  But she’s also seen too many kids struggle too much to read them--and consequently, check out of reading altogether.  Kate’s had better success getting kids to actually read – and enjoy it—when they choose their own books within a workshop model.   “And yet,” she says, “I missed my whole-class novels.”

In A Novel Approach , Kate takes a deep dive into the troubles and triumphs of both whole-class novels and independent reading and arrives at a persuasive conclusion: we can find a student-centered, balanced approach to teaching reading.  Kate offers a practical framework for creating units that join both teaching methods together and helps you:

• Identify the skills your students need to learn • Choose whole-class texts that will be most relevant to your kids • Map out the timing of a unit and the strategies you’ll teach • Meet individual needs while teaching whole novels • Guide students to choice books and book clubs that build on the skills being taught.

Above all, Kate’s plan emphasizes teaching reading skills and strategies over the books themselves. “By making sure that our classes are structured in a way that really sees students and strives to meet their needs,” she argues, “we can keep reaching for the dream of a class where no student is unmoved, no reader unchanged by the end of the year.” Video clips of Kate working with students in diverse classrooms bring the content to life throughout the book.

(click any section below to continue reading)

1. You Can Have It Both Ways: Reading Literature Deeply and Fostering Joyful, Independent Reading

2. Start with the Students: Identify the Skills Your Students Need

3. Look Beyond the Usual Suspects: Choose the Book Your Students Need

4. Map Out the Unit: Plan the Timing and the Strategies You'll Teach

5. Delight in the Details: Play Your Daily Instruction: Read-Alouds and Minilessons

6. Reach Everyone: Differentiate with Small Groups and Conferences

7. Keep Students Engaged: Address the Challenges of Teaching a Whole-Class Text

8. Track Growth: Assess Along the Way Through Writing About Reading

9. Launch Readers: Honor Choice to Develop Stronger, Independent Students

10. Celebrate Achievements: Assessing, Writing, and Making as an End to the Unit

Can’t we provide both individualized instruction and challenging reading for our students? This book shows how we can do just that. In a nutshell: 

1. We plan a unit in our classroom, naming the skill or skills that will be our primary focus. 

2. We choose a whole-class novel that will both interest the kids and do the heavy lifting for the skills we plan to teach. 

3. We plan our lessons accordingly.

That’s it. Pretty simple. Of course, like many simple ideas in and out of education, the execution takes some doing. That’s what the rest of the book is for. We’ll begin with a deep dive into the troubles and triumphs of both whole-class novels and readers workshop and think about what we can aim for in our teaching (Chapter 1). Then, we’ll follow the trajectory of a unit: choosing the skills and book you’ll be using (Chapters 2 and 3), teaching with the whole-class novel (Chapters 4 and 5) and meeting individual needs while doing so (Chapters 6 and 7), assessing formatively (Chapter 8), helping students transfer the skills they’ve learned to book-club books (Chapter 9), and assessing summatively (Chapter 10). 

— Introduction

• Sample Chapter

Companion Resources

“A Novel Approach dismantles timeworn methods for teaching whole class novels that consume class time, provide little relevance or rigor, and disengage students from reading. Kate Roberts offers an empowering road map for navigating whole class novels with your students while supporting their independent reading lives. A forward-thinking model for progressive literacy education.”—Donalyn Miller, author of The Book Whisperer and Reading in the Wild

“I wish this book was around back when I completely stopped reading in High School. I lost years of my reading life, just as so many students turn away from reading in secondary grades because the assigned books are uninteresting, too confusing, or seem to drag on. Kate's approach shows us that when novel teaching is skills driven, brief, and complimented with book clubs, it can be more engaging to students and more rewarding for teachers.”—Christopher Lehman, coauthor of Falling in Love with Close Reading and author of Energize Research Writing

“Increasing the volume of student reading starts with finding the right balance between independent reading, book club reading, and core work reading. And this is where A Novel Approach proves invaluable. Kate Roberts not only shows secondary teachers why achieving this balance is important, she demonstrates how to do it.”—Kelly Gallagher, coauthor of 180 Days and author of Readicide

“There isn’t a teacher among us who hasn’t wondered, “How do I do all of this?” Reading this book is like having the world’s best instructional coach by your side to help you craft a clear, manageable, and responsive approach to helping your students become better readers, thinkers, and people. Kate reminds us of the tremendous power of our instructional decisions on our students’ reading lives, all the while, handing us resources, instilling in us a necessary confidence, and high-fiving us through pages of this book.” –Allison Marchetti and Rebekah O’Dell, coauthors of Beyond Literary Analysis and Writing With Mentors

“Like any author worth her salt, Kate trusts her readers to bring their own expertise to the text.  If you are expecting the definitive answer to the age-old question, “What’s better: giving students opportunities for independent choice, or teaching with a whole class novel?” you won’t get the answer.  What you will get is Kate’s straightforward, common sense approach on how to use both.  Kate helps teachers weigh their options and make choices about what’s best for their students.   She shares her systems and structures and reassures readers that students of all levels can make growth.”—Cris Tovani, coauthor of No More Telling as Teaching and I Read It, But I Don’t Get It

“In A Novel Approach, Kate Roberts offers those of us in the classroom a witty, engaging, and thoughtful examination of a problem we are all grappling with one way or another: How to teach whole-classs novels in ways that challenge and engage not only our students but us!  This thoughtful book provides a range of approaches that would work in different classes with different kids. Just as important, though, it shows us that it is still possible to be the sort of English teacher we wanted to be when we entered the profession.”—Jim Burke, author of The English Teacher’s Companion

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• Open access
• Published: 04 September 2021

Journey mapping as a novel approach to healthcare: a qualitative mixed methods study in palliative care

• Stephanie Ly 1 ,
• Fiona Runacres 1 , 2 , 3 &
• Peter Poon 1 , 2  

BMC Health Services Research volume  21 , Article number:  915 ( 2021 ) Cite this article

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Journey mapping involves the creation of visual narrative timelines depicting the multidimensional relationship between a consumer and a service. The use of journey maps in medical research is a novel and innovative approach to understanding patient healthcare encounters.

To determine possible applications of journey mapping in medical research and the clinical setting. Specialist palliative care services were selected as the model to evaluate this paradigm, as there are numerous evidence gaps and inconsistencies in the delivery of care that may be addressed using this tool.

A purposive convenience sample of specialist palliative care providers from the Supportive and Palliative Care unit of a major Australian tertiary health service were invited to evaluate journey maps illustrating the final year of life of inpatient palliative care patients. Sixteen maps were purposively selected from a sample of 104 consecutive patients. This study utilised a qualitative mixed-methods approach, incorporating a modified Delphi technique and thematic analysis in an online questionnaire.

Our thematic and Delphi analyses were congruent, with consensus findings consistent with emerging themes. Journey maps provided a holistic patient-centred perspective of care that characterised healthcare interactions within a longitudinal trajectory. Through these journey maps, participants were able to identify barriers to effective palliative care and opportunities to improve care delivery by observing patterns of patient function and healthcare encounters over multiple settings.

Conclusions

This unique qualitative study noted many promising applications of the journey mapping suitable for extrapolation outside of the palliative care setting as a review and audit tool, or a mechanism for providing proactive patient-centred care. This is particularly significant as machine learning and big data is increasingly applied to healthcare.

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Introduction

Patterns of healthcare utilisation are evolving in response to the ageing population and increasing burden of chronic disease. There is an urgent need to ensure timely proactive medical care, effective and efficient resource deployment, while averting unnecessary, often distressing, emergency department (ED) presentations, admissions and conveyor belt medicine. A key area of medicine able to address these issues is palliative care.

Central to optimal delivery of palliative care is timely initiation [ 1 , 2 , 3 ]. However, differing patient, illness trajectory and clinical factors have resulted in inconsistencies in the degree of care provided [ 4 , 5 ]. This has subsequently translated into significant variability in palliative care research and limitations in applying international evidence to clinical practice [ 6 ]. The utilisation of journey mapping has the potential to address these inconsistencies and to our knowledge, this research is the first of its kind.

Journey mapping is a relatively new approach in medical research that has been adapted from customer service and marketing research [ 7 ]. It is gaining increasing recognition for its ability to organise complex multifaceted data from numerous sources and explore interactions across care settings and over time. Medical journey mapping involves creating narrative timelines, by incorporating markers of the patient experience with healthcare service encounters. Integrating diverse components of the patient healthcare journey provides a holistic perspective of the relationships between the different elements that may guide directions for change and service improvement. As medical journey mapping is still in its infancy, there is an absence of literature exploring implementation. Of the existing literature, journey mapping techniques are described mainly in process papers, outlining their potential utility in observing healthcare delivery and patient outcomes [ 8 , 9 , 10 , 11 , 12 ]. However journey mapping paradigms have broader significance across healthcare, especially in an environment for which machine learning, big data and artificial intelligence is maturing.

We aimed to determine whether journey mapping could contribute to the improvement of patient-centred medical research in a palliative care setting and provide new insight into possible “pivot-points” or moments of care that could be altered to improve care delivery. Specifically, we sought to determine whether journey maps were able to assist in capturing a holistic, longitudinal and more integrative patient history whilst outlining healthcare provision and identifying gaps in care.

Study design

We performed a qualitative mixed-methods analysis of a journey mapping tool. The tool was purpose-developed and sample journey maps were derived from the scanned medical records of palliative care patients. A panel of specialist palliative care providers were then involved in an online questionnaire combining a modified Delphi approach with inductive thematic analysis. Figure  1 depicts a flow diagram of the methodology.

Flow chart detailing data collection, journey map development and analysis. This figure illustrates the phases and processes of this study. Data was collected from a retrospective cohort of 104 palliative care patients and journey maps were subsequently developed. Preliminary screening of the journey maps was performed to obtain a purposive sample that best highlighted the breadth of information and healthcare encounters captured within the journey maps. A total of 16 maps were selected for further analysis. Following questionnaire development and pre-test, questionnaires were distributed, and responses collected and analysed over two rounds to obtain consensus. Free-text comments from both rounds were collected for thematic analysis

All methods were carried out and reported in accordance with Standards for Reporting Qualitative Research (SRQR) guidelines and Consolidated criteria for Reporting Qualitative research (COREQ) criteria for reporting qualitative studies.

Ethics approval for this study was obtained from Monash Health Human Research Ethics Committee Monash Health Ref: RES-29-0000-071Q) and Monash University Human Research Ethics Committee (Project ID: 18,853).

Data was collected from a retrospective cohort of 104 consecutive palliative care patients from a major tertiary hospital network in Melbourne, Australia. Inclusion criteria were patients greater than 18 years of age who had died in hospital between the 1st of August 2018 and 31st of October 2018, had at least one inpatient palliative care admission in their last year of life and scanned medical records data spanning at least three months’ duration. This sample size was considered sufficient to incorporate a varied and representative sample of palliative care patients encountered in the tertiary hospital.

Following data collection, a Python Software-based code was designed to extract de-identified data and create journey map visuals. All 104 journey maps were independently screened by two investigators (PP and FR) and a purposive sample of 16 maps was selected for analysis based on seven criteria for informative value. The criteria that the 104 maps were assessed on included their ability to provide insight into the initiation, triggers, delivery and barriers of palliative care, SPICT scores, pivot points and disease trajectories.

Modified Delphi approach and thematic analysis

A qualitative mixed-methods approach involving thematic analysis and a modified Delphi technique was utilised as an explorative analysis of expert opinion. The consensus agreement was used to reinforce and confirm the patterns of significance identified through thematic analysis. In combining these two approaches, there was greater flexibility in responses and additional structure to support analysis.

The modified Delphi approach used in this study was adapted from the enhanced Delphi method described by Yang et al. [ 13 ] and consisted of a questionnaire pre-test and two rounds of questionnaire distribution. A total of 14 email invitations were sent to a purposive sample of seven senior palliative care physicians and seven palliative care nurse consultants across two palliative care inpatient units within a major tertiary hospital network in Melbourne, Australia. The emails contained an explanatory statement, a questionnaire link and the file containing the 16 de-identified journey maps.

The questionnaires consisted of 16 statements per journey map, covering eight palliative care domains: palliative care triggers, initiation, delivery, outcomes, barriers, pivot-points, needs assessment (using the Supportive and Palliative Care Indicators Tool, SPICT) and the utility of advanced care plans. An additional nine statements assessed the utility of the journey map approach (see Table 2 ). All statements were ranked using Likert scales. A four-point Likert scale including the options: insufficient information, disagree, neither agree nor disagree and agree was used to assess individual journey maps. A five-point Likert scale including options: strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree and strongly agree was used to assess the journey mapping approach. For analysis of consensus, the results were categorised to reflect overall agreement by using a three-point scale consisting of disagree, neutral and agree . Consensus was defined as agreement of greater than 70 % of respondents in any one of these three categories. Following the first round, all consensus statements were determined and participants were sent a second questionnaire containing anonymous feedback from the first round and statements which did not reach consensus for re-evaluation using the condensed three-point Likert scale.

Following each palliative care domain, free-text fields were included to collect comments and provide data for inductive thematic analysis. Analysis of the free-text comments from both rounds was guided by Braun and Clarke’s phases of thematic analysis [ 14 ]. The codes and themes were derived from the data using NVivo 12 Plus software to generate nodes, initial codes and preliminary subthemes. Candidate themes were reviewed by two additional investigators (PP and FR) to ensure consistency and the final themes were defined. Providing participants with the opportunity to review de-identified feedback through the Delphi questionnaire enabled discussion, reflection and clarification of comments, thus achieving thematic saturation with a smaller group of participants.

Additional steps were taken to increase trustworthiness of the qualitative data per Lincoln and Guba’s criteria for credibility, transferability, dependability and confirmability across all phases of analysis [ 15 , 16 , 17 ]. Triangulation of the methods, researchers and analysts aimed to increase consistency and accuracy, whilst reducing interpretation errors and the effects of bias. Thorough audit trails and reflexive journaling were maintained. The use of the online questionnaire with free-text fields for thematic data collection limited the role of the researcher and the potential for associated bias.

While this study also produced findings relevant to current issues of palliative care delivery, we will for the purpose of this paper, present results specific to the clinical utility of journey maps.

The journey maps

Figure  2 depicts one of the 16-sample journey maps analysed by participants and illustrates the key elements of a map. While journey maps are interactive visualisations with options for providing additional information summarising patient healthcare encounters, we are unable to fully convey the dynamic functions of the mapping tool in this paper. The journey map in Fig.  2 illustrates the final year of life of a 73 year old male patient with diffuse large B-cell lymphoma.

Screen capture of Journey Map 6. A screen capture of one of the 16 interactive journey maps that was analysed by the Delphi panel. The lower segment of the map depicts healthcare interactions that occurred in hospital and in the community. Delphi participants are able to hover over specific health service touch points to obtain more information about the specific interaction that occurred. The upper segment represents functional performance scores using two different tools- the Australian Karnofsky Performance Scale (AKPS) and the Resource Utilisation Groups-Activities of Daily Living (RUG-ADL). The orange vertical line indicates when palliative care needs first presented using the SPICT screening tool. The vertical purple line indicates when specialist palliative care was initiated. Delphi participants were able to analyse the maps and respond to statements on the palliative care provided

The map reveals that at day 112 prior to death, palliative care needs were noted using the SPICT screening tool. It is also at this point that the patient’s functional performance scores began to decline, with patient notes from day admissions and clinic visits also documenting poor tolerance of chemotherapy side effects, fatigue, anorexia and weight loss. In response to this pattern of decline, participants noted that there was an opportunistic role for community palliative care support that was missed and could have potentially negated the need for the final ED admission.

“Onc (sic)(oncology) outpatient notes describing symptoms, deterioration, carer distress… Community pall care (sic)(palliative care) could have been helpful” – Participant 2, Journey Map (JM) 6.

Another major pivot-point occurred during the patient’s admission to ED on day 50 when notes indicated that the patient’s wife was struggling to cope with care at home. Given the nature of the prolonged admission with multiple complications that followed, Delphi participants questioned the suitability of the transfer to the rehabilitation ward.

“Symptoms and functional decline appear to be related to lymphoma and not an acute illness. More appropriate for pall care (sic) than rehab (sic)(rehabilitation).” – Participant 6, JM6.

Additionally, the decision to initiate palliative care only four days prior to death was delayed and there was a role for earlier palliative care involvement.

“Clearly PC (sic)(palliative care) involvement inadequate and was a later referral for terminal care only” – Participant 1, JM6.

“Pt (sic)(patient) would have benefitted from earlier palliative care referral” – Participant 7, JM6.

Through the maps, participants were able to observe patterns of deterioration with a broader view of continuity of care and determine pivot-points, where the involvement of specialist palliative care had the potential to improve the patient experience.

Modified Delphi

The two Delphi rounds were conducted over 31 days with the first round taking 13 days and the second round spanning 18 days. A total of seven responses were collected from the first round of the online Delphi questionnaire. Six members of the medical staff and one member of the nursing team responded, representing a 50 % response rate. All seven participants completed the questionnaire in full. For the second round, all first round participants were re-contacted and invited to participate. All seven participants from the first round agreed to participate, attributing to a 100 % second round response rate and 100 % questionnaire completion rate. Participant characteristics have been described in Table 1 . All participants are senior palliative care team members.

The statements assessing journey map utility are shown in Table  2 . As there was a strong overall consensus following the first round of the Delphi questionnaire, these statements were not rechallenged in a second round. However free-text fields were included to allow participants to provide any further comments.

Thematic analysis

Following analysis of all free-text comments, the following themes were derived regarding the applications of the journey mapping tool: (1) design and information, (2) longitudinal care and the patient trajectory and (3) opportunities for care improvement. These are discussed with supporting quotations listed in Table  3 .

Theme 1: tool design and information

A large determinant of the practicality of the tool relates to its design. Participants provided feedback regarding the design and informational elements of the journey mapping tool used in this study.

Aspects of the interface

Participants found that there were certain elements of the journey maps that limited functionality of the tool, however these were associated with the specific design of the tool interface, rather than the actual components underlying the journey mapping approach. Participants responded well to the concept of a visual representation of patient information and the timeline view of care that was constructed.

Catering information needs

Given the palliative care specific focus on patient care presented in these maps, participants found that at times there was an excess of unnecessary information and insufficient palliative care appropriate information. The absence of objective measures of quality of life also restricted the ability of participants to determine whether outcomes were improved as a result of interventions.

Theme 2: Longitudinal care and the patient trajectory

The benefits of conveying patient information and healthcare encounters in the form of journey maps were also recognised. Journey maps provided a patient-centred focus of care that characterises patient healthcare interactions within a longitudinal trajectory rather than individual care episodes as is standard in conventional medical records. In doing so, patterns of the disease trajectory and also patient decline can be mapped to provide more proactive patient care.

Theme 3: Opportunities for care improvement

The benefits of having the journey mapping tool and its utility if incorporated into patient care were also explored, with participants noting numerous possible applications and opportunities to improve patient care.

Identifying barriers and missed opportunities for care

By framing the patient healthcare experience as a longitudinal and continuous journey, participants were able to recognise missed opportunities to address barriers and initiate more timely palliative care.

Clinical applications

Participants also noted that journey maps were a useful tool for identifying gaps in care provision and underlying barriers to initiation and delivery. This could assist clinicians with recognition of pivot-points and opportunities to enhance care by pre-emptively managing issues. Additionally, journey maps presented possible applications as a review or screening tool to evaluate patient care needs and enable better patient-centred care practices both in the clinical and research setting.

Findings from both the modified Delphi and thematic analysis appeared congruent, with the consensus consistent with emerging themes.

Journey mapping is a novel approach to reviewing patient healthcare interactions over time and across care settings to identify potential pivot points, which in turn can facilitate timely healthcare and promote proactive delivery of patient-centred care. Our research has focused on palliative care as the model to explore this approach, especially given its importance in an ageing population and considering many aspects of care are ubiquitous to this cohort.

Variation and inconsistencies in palliative care initiation and delivery have limited the applicability and role of research in informing evidence-based practice [ 6 ]. A journey map approach may provide one solution to address these challenges. The journey mapping tool used in this study was found to enable a patient-centred focus to the clinician’s perspective, increasing opportunities to pro-actively identify pivot-points and deliver more effective patient care.

In comparison to conventional medical records, journey maps link patient healthcare encounters longitudinally, promoting continuity and a holistic understanding of care across settings and over time. As described in conceptual studies, journey maps offer a perspective that takes into account the more dynamic and multidimensional aspects of healthcare interactions to facilitate enhanced insight into the patient experience within medical research [ 10 , 18 ]. This enables a more integrated interpretation and awareness of individual episodes of care and how these contribute to a patient’s overall health and their interaction with health services. Our participants also noted that journey mapping enabled greater emphasis on particular patient outcomes that may be difficult to observe or measure using conventional research methods. The journey mapping tool was also able to highlight gaps in care and facilitate recognition of patterns of disease progression and deterioration with a greater emphasis on patient needs and experiences.

The use of the journey mapping approach has further enabled identification of barriers and potential biases to providing effective care. This study confirms that journey mapping as a tool is effective at identifying specific barriers and trends in care provision and increase opportunities for care providers to pro-actively and appropriately address these.

Journey maps have traditionally been used in research to review and analyse the consumer experience and provide feedback on avenues for development [ 7 ]. Our panel consensus affirmed that journey mapping had applications as a clinical audit tool to identify gaps in care and opportunities for improvement when used to assess retrospective patient experiences. This is consistent with known utilities of previous journey mapping tools. Other identified benefits included potential to achieve better collaboration between healthcare providers, enabling smoother transitions of care and improving communication between healthcare providers and patients.

Limitations of this study include the design and interface of the journey mapping tool. Following a thorough search, pre-existing journey mapping software and tools were considered inappropriate for this study as they were oversimplified, unable to convey complex information appropriately and not designed for use in a medical setting. Consequently, self-designing a tool was considered the most suitable approach. The technical limitations identified did not reflect the utility of the journey mapping paradigm.

The retrospective nature of this study prohibits direct patient feedback. Consequently, the patient and caregiver perspective, including quality of life and symptom burden experienced were not well represented. Future research utilising a prospective approach with patient and caregiver involvement is needed to address these research gaps.

The response rate to the initial Delphi questionnaire was only 50 % due to time constraints and limited ability to accommodate delayed responses, however the response rate to the second Delphi questionnaire was 100 %. While this does limit the diversity of responses, it suggests good retention and engagement of involved participants with meaningful contributions.

The size of the Delphi panel in this study was seven. Studies have noted that smaller panels are still able to provide effective and reliable results and a minimum panel size of seven is considered suitable in most cases [ 19 , 20 ]. Our modified approach complied with this. Despite being a single institution study, the participants come from a diverse clinical background covering multiple domains of specialty palliative care, henceforth reducing potential bias. This study demonstrates that there is a role for journey mapping in clinical practice, however, considerations must be made for future design. Given the volume of patient data available, the amount of information presented needs to be appropriately moderated to provide clarity and best utilisation of the resources available. With the gradual transition of most health services from paper medical records to electronic medical records, the inclusion of a journey mapping tool into clinical practice is becoming more feasible. As medical technology continues to grow, the potential for incorporation of artificial intelligence, machine learning and big data into journey maps could be the key to providing pro-active, holistic patient-centred care that pre-emptively anticipates patient needs.

This study is one of the first to use a journey mapping tool in clinical practice to explore the healthcare journey and patient experience on a larger scale. The maps were used to depict a more fluid and continuous interpretation of the patient healthcare experience which enabled a more holistic and patient-centred analysis of palliative care provision. Furthermore, this is one of the first medical journey mapping studies to consider and propose potential pivot-points and opportunities for changes in the delivery of care. The use of journey maps can enhance the holistic patient healthcare experience and enable better patient-centred care not only in the palliative care setting, but also more broadly across healthcare from both a research and clinical practice perspective. Further application studies in other contexts are required.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to the confidential nature of the patient data, but are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to acknowledge and extend our thanks to Kevin Shi who contributed to the Python code used for the journey map visuals.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

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Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, VIC, Australia

Stephanie Ly, Fiona Runacres & Peter Poon

Supportive & Palliative Care Department, McCulloch House, Monash Medical Centre, 246 Clayton Road, VIC, 3168, Clayton, Australia

Fiona Runacres & Peter Poon

Calvary Health Care Bethlehem, Parkdale, VIC, Australia

Fiona Runacres

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Contributions

Conceptualisation PP. Methodology: PP, FR, SL. Formal analysis PP, FR, SL. Investigation: PP, FR, SL. Writing –original draft: SL. Writing- Review and Editing: PP, FR. Supervision : PP, FR. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Peter Poon .

Ethics declarations

Ethics approval and consent to participate.

Ethics approval for this study was obtained from Monash Health Human Research Ethics Committee Monash Health Ref: RES-29-0000-071Q) and Monash University Human Research Ethics Committee (Project ID: 18853). Informed consent from patients was not required as this was a retrospective audit of pre-existing available data which was de-identified prior to analysis. All participants of the Delphi questionnaire were provided with an explanatory statement and by completing and returning the questionnaires, consent was implied.

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Not applicable.

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The authors declare that they have no competing interests.

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Ly, S., Runacres, F. & Poon, P. Journey mapping as a novel approach to healthcare: a qualitative mixed methods study in palliative care. BMC Health Serv Res 21 , 915 (2021). https://doi.org/10.1186/s12913-021-06934-y

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A Systematic Approach to Teaching Case Studies and Solving Novel Problems †

Carolyn a. meyer.

1 Department of Biomedical Sciences, Colorado State University, Fort Collins, CO 80523

Heather Hall

Natascha heise, karen kaminski.

2 School of Education, Colorado State University, Fort Collins, CO 80523

Kenneth R. Ivie

Tod r. clapp, associated data.

Both research and practical experience in education support the use of case studies in the classroom to engage students and develop critical thinking skills. In particular, working through case studies in scientific disciplines encourages students to incorporate knowledge from a variety of backgrounds and apply a breadth of information. While it is recognized that critical thinking is important for student success in professional school and future careers, a specific strategy to tackle a novel problem is lacking in student training. We have developed a four-step systematic approach to solving case studies that improves student confidence and provides them with a definitive road map that is useful when solving any novel problem, both in and out of the classroom. This approach encourages students to define unfamiliar terms, create a timeline, describe the systems involved, and identify any unique features. This method allows students to solve complex problems by organizing and applying information in a logical progression. We have incorporated case studies in anatomy and neuroanatomy courses and are confident that this systematic approach will translate well to courses in various scientific disciplines.

INTRODUCTION

There is increasing emphasis in pedagogical research on encouraging critical thinking in the classroom. The specific mental processes and behaviors involved require the individual to engage in reflective and purposeful thinking. Critical thinking encompasses the ability to examine ideas, make decisions, and solve problems ( 1 , 2 ). The skills necessary to think critically are essential for learners to evaluate multiple perspectives and solve novel problems in the classroom and throughout life. Career success in the 21st century requires a complex set of workforce skills. Current labor market assessments indicate that by the year 2020, the majority of occupations will require workers to display cognitive skills such as active listening, critical thinking, and decision making ( 3 , 4 ). In particular, current studies show that the US economy is impacted by a deficit of skilled workers able to solve problems and transfer learning to any unique situation ( 3 ).

The critical thinking skills necessary to tackle novel problems can best be addressed in higher education institutions ( 5 , 6 ). Throughout education, and specifically in college courses, students tend to be required to regurgitate knowledge through a myriad of multiple-choice exams. Breaking this habit and incorporating critical thinking can be difficult for students. While the ability to recite information is helpful for establishing base knowledge, it does not prepare students to tackle novel problems. Ideally, the objective of any course is to encourage students to move beyond recognition of knowledge into its application ( 7 ). Considering this, the importance of critical thinking is widely accepted; however, there has been some debate in educational research regarding how to teach these skills ( 8 ). Research has demonstrated that students show significant improvements in critical thinking as a result of explicit methods of instruction in related skills ( 9 , 10 ). Explicit instruction provides a protocol on how to approach a problem. By establishing the necessary framework to work through unfamiliar details, we enable students to independently solve complex problems.

These skills, which are important in every facet of the workforce, are vital for students in the sciences ( 10 , 11 ). Here, we discuss a specific process that teaches students a systematic approach to solving case studies in the anatomical sciences. Case studies are a popular method to encourage critical thinking and engage students in the learning process ( 12 ). While the examples described here are specifically designed to be implemented in anatomy and neuroanatomy courses, this platform lends itself to teaching critical thinking skills across scientific disciplines. This four-step approach encourages students to work through four separate facets of a problem:

• Define unfamiliar terms
• Create a timeline associated with the problem
• Describe the (anatomical) systems involved
• Identify any unique features associated with the case

Often, students start by trying to plug in memorized facts to answer a complicated question quickly. With the four-step approach, students learn that before “solving” the case study, they must analyze the information presented in the case. The case studies implemented are anatomically-based case studies that emphasize important structural relationships. The case may include terminology with which the students are not familiar. They therefore begin by identifying and defining unfamiliar terms. They then specify the timeline in which the problem occurred. Establishing a timeline and narrowing the focus can be critical when considering the relevant pathology. Students must then describe the anatomical systems involved (e.g., musculoskeletal or circulatory), and finally list any additional unique features of the case (e.g., lateral leg was struck or patient could not abduct the right eye). By dissecting the details along the lines of these four categories, students create a clear roadmap to approach the problem. Case studies with a clinical focus are complex and can be overwhelming for unpracticed students. However, teaching students to follow this systematic approach gives them the tools to begin to carefully dismantle even the most convoluted problem.

Intended audience

This approach to solving case studies has been applied in undergraduate courses, specifically in the sciences. This curriculum is currently utilized in both human gross anatomy and functional neuroanatomy capstone courses. While it is ideal to implement this process in a course that runs in parallel with a lecture-heavy course, it can also be utilized with case studies in a typical lecture class.

Anatomy-based case studies lend themselves well to this problem-solving approach due to the complexities of clinical problems. However, we believe with an appropriately designed case study, this model of teaching critical thinking can easily be expanded to any discipline. This activity encourages critical thinking and engages students in the learning process, which we believe will better prepare them for professional school and careers in the sciences.

Prerequisite student knowledge

Required previous student knowledge only extends to that which students learn through the related course taken previously or concurrently. Application of this approach in different classroom settings only requires that students have a basic understanding of the material needed to solve the case study. As such, the case study problem and questions should be built around current topics being studied in the classroom.

Using unfamiliar words teaches students to identify important information. This encourages integration of information and terminology, which can be critical for understanding anatomy. Simple terms, like superficial or deep, guide discussions about anatomical relationships. While students may be able to recite the definitions of these concepts, applying that information to a case study requires integrating the basic definition with an understanding of the relevant anatomy. Specific prerequisite knowledge for the sample case study is detailed in Appendix 1 .

Learning time

This process needs to be learned and practiced over the course of a semester to ensure long-term retention. With structured and guided attempts, students will be able to implement this approach to solving case studies in one 50-minute class period ( Table 1 ). The course described in this study is a capstone course that meets once weekly. Each 50-minute class period centers around working through a case study. As some class sessions are reserved for other activities, students complete approximately 10 case studies during the semester. Students begin to show increased confidence with this method within a few weeks and ultimately are able to integrate this approach into their critical thinking skillset by the end of the semester. Presentation of the case study, individual or small group work, and class discussion are all achieved in one standard class session ( Table 1 ). The current model does not require student work prior to the class meeting. However, because this course is taken concurrently with a related, content-heavy lecture component, students are expected to be up to date on relevant material. Presenting the case study in class to their peers encourages students to work through the systematic approach we describe here. Each case study is designed to correlate with current topics from the lecture-based course. Following the class period, students are expected to complete a written summary of the discussed case study. The written summary should include a detailed explanation of the approach they utilized to solve the problem, as well as a definitive solution. Written summaries are to be completed two days after the original class period.

Anticipated in-class time to implement this model.

Learning objectives

This model for teaching a systematic approach to solving case studies provides a framework to teach students how to think critically and how to become engaged learners when given a novel problem. By mastering this technique, students will be able to:

• Recognize words and concepts that need to be defined before solving a novel problem
• Recall, interpret, and apply previous knowledge as it relates to larger anatomical concepts
• Construct questions that guide them through which systems are affected, the timeline of the pathologies, and what is unique about the case
• Formulate and justify a hypothesis both verbally and in writing

As a faculty member, it can be challenging to create appropriate case studies when developing this model for use in a specific classroom. There are resources that provide case studies and examples that can be tailored to specific classroom needs. The National Center for Case Study Teaching in Science (University at Buffalo) can be a useful tool. The ultimate goal of this model is to teach an approach to problem solving, and a properly designed case study is crucial to success. To build an effective case study, faculty must include sufficient information to provide students with enough base knowledge to begin to tackle the problem. This model is ideal in a course that pairs with a lecture-heavy component, utilized in either a supplementary course or during a recitation. The case study should be complex and not quickly solved. An example of a simplified case study utilized in Human Gross Anatomy is detailed in Appendix 1 .

This particular case study encourages students to think through the anatomy of the lateral knee, relevant structures in this area, and which muscle compartments may be affected based on movement disabilities within the case. While more complex case studies can certainly be developed for the Neuroanatomy course through Clinical Case Studies, this case study provides a good example of a problem to which students cannot immediately provide the answer. They must think critically through the four-step process to identify the “diagnosis” for this patient.

This approach to solving case studies can be integrated into the classroom with no special materials. However, we use a Power-Point presentation and personal whiteboards (2.5’ × 2’) to both improve delivery of the case study and facilitate small group discussion, respectively. The Power-Point presentation is utilized by faculty to assist in leading the classroom discussion, prompting student responses and projecting relevant images. As the faculty member is presenting the case study during the first five minutes of class ( Table 1 ), the wording of the case study can be displayed on the PowerPoint slide as a reference while students take notes.

Faculty instructions

It is helpful to first present an overview of the approach and to solve a case study together as a class. We recommend giving students a lecture describing the benefits of a systematic approach to case studies and emphasizing the four-step approach outlined in this paper. Following this lecture, it is imperative that faculty walk the students through the first case study. This helps to familiarize students with the approach and lays out expectations on how to break down the individual components of the case. During the initial case study, faculty must heavily moderate the discussion, leading students through each step of the approach using the provided Case Study Handout ( Appendix 2 ). In subsequent weeks, students can be expected to show increasing independence.

Following initial presentation of the case study in class, students begin work that is largely independent or done in small groups. This discussion has no grades assigned. However, following the in-class discussion and small group work, students are asked to detail their approach to solving the case study and their efforts are graded according to a set rubric ( Appendix 3 ). This written report should document each step of their thought process and detail the questions they asked to reach the final answer, providing students with a chance for continual self-evaluation on their mastery of the method.

Implementing this model in the classroom should focus not only on the individual student approach, but also on creating an encouraging classroom environment and promoting student participation. Student questions may prompt other student questions, leading to an engaging discussion-based presentation of the case study, which is crucial to increasing confidence among students, as has been seen with the data represented in this paper. When moderating the discussion, it is important that faculty emphasize to students that the most critical goal of the exercise is to learn how to ask the next most appropriate question. The questions should begin with broad concepts and evolve to discussing specific details. Efforts to quickly arrive at the answer should be discouraged.

Students should be randomly assigned to groups of two to three individuals as faculty members moderate small group discussion during class. Randomly assigning students to different groups each week encourages interaction between all students in the class and promotes a collaborative environment. Within their small groups, students should work through the systematic four-step process for solving a novel problem. Students are not assigned specific roles within the group. However, all group members are expected to contribute equally. During this process, it can be beneficial to provide students with a template to follow ( Appendix 2 ). This template guides their discussion and encourages them to use the four-step process. Additionally, each small group is given a white board that they can use to facilitate their small group discussions. Specifically, asking students to write down details of each of the four facets of the problem (definitions, timeline, systems involved, unique features) and how they arrived at these encourages them to commit to their answers. This also ensures they have concrete evidence to support their “diagnosis” and that they have confidence in presenting it to the class. Two or three small groups are chosen randomly each week to present their hypothesis to the class using their whiteboard.

Suggestions for determining student learning

The cadence of the in-class discussion can provide an informal gauge of how students are progressing with their ability to apply the systematic approach. The discussion for the initial case studies should be largely faculty led. Then, as the semester progresses, faculty should step back into a facilitator role, allowing the dialogue to be carried by the students.

Additionally, requiring students to write a detailed summary of their approach to the problem provides a strong measure of student learning. While it is important for students to document their final “diagnosis” or solution to the problem, the focus of this assignment is primarily on the process and the series of relevant questions the student used to arrive at the answer. These assignments are graded according to a set rubric ( Appendix 3 ).

Sample data

The following excerpt is from a student who showed marked improvement over the course of the semester in implementing this approach to solving case studies. The initial submission for the case study write-up was rudimentary, did not document the thought process through appropriate questions, and lacked an in-depth explanation to demonstrate any critical thinking. By the end of the semester, this student documented a logical thought progression through this four-step approach to solving the case study. This student, additionally, detailed the questions that led each stage of critical thinking until a “diagnosis” was reached (complete sample data are available in Appendix 4 ).

Initial sample

“Given loss of sensory and motor input to left lower limb, right anterior cerebral artery ischemia caused the sensory and motor cortices of the contralateral (left) lower limb to be without blood flow for a short amount of time (last night). The lack of flow led to a fast onset of motor and sensory paresis to limb.”

Final sample

“…the left vestibular nuclei which explains the nystagmus, and the left cerebellar peduncles which carry information that aids in coordinating intention movements. My next question was where in the brainstem are all of these components located together? I narrowed this to the left caudal pons. Finally, I asked which artery supplies the area that was damaged by the lesion? This would be the left anterior inferior cerebellar artery.”

Safety issues

There are no known safety issues associated with implementing this approach to solving case studies.

The primary goal of the model discussed here is to give students a method that uses critical reasoning and helps them incorporate facts into a complete story to solve case studies. We believe that this model addresses the need for teaching the specific skill set necessary to develop critical thinking and engage students in the learning process. By encouraging critical thinking, we begin to redirect the tendency to simply recite a memorized answer. This four-step approach to solving case studies is ideal for the college classroom, as it is easily implemented, requires minimal resources, and is simple enough that students demonstrate mastery within one semester. While it was designed to be used in anatomy and neuroanatomy courses, this platform can be used across scientific disciplines. Outside of the classroom, in professional school and future careers, this approach can help students to break down the details, ask appropriate questions, and ultimately solve any complex, novel problem.

Field testing

This model has been implemented in several courses in both undergraduate and graduate settings. The data and approach detailed here are specific to an undergraduate senior capstone course with approximately 25 students. The lecture-based course, which is required to be taken concurrently or as a prerequisite, provides a strong base of information from which faculty can develop complex case studies.

Evidence of student learning

Student performance on written case study summaries improved over approximately ten weeks of practicing the systematic four-step approach ( Fig. 1 ). As indicated by the data, scores improve and begin to plateau around five weeks, indicating a mastery of the approach. In the spring 2016 semester, a marked drop in scores was observed at week 8. We believe that this reflects a particularly difficult case study that was assigned that week. After observing the overall trend in scores, instructional format was adjusted to provide students with more guidance as they worked through this particular case study.

Grade performance in case study written summaries as measured with the grading rubric throughout the semester. A) Mean (with SD) grade performance in case study write-ups in the spring semester of 2016. B) Mean (with SD) grade performance in case study write-ups in the spring semester of 2017. Overall grade performance in case study written summaries improved throughout the 10 weeks in which this method was implemented in the classroom. Written summaries are graded based on a set rubric ( Appendix 3 ) that assigned a score between 0 and 1 for five different categories. Data represent the mean of students’ scores and the associated standard deviation. Improved student performance throughout the semester indicates progress in successful incorporation of this method to solve a complex novel problem.

After the class session, students were asked to provide a written summary of their findings. A set rubric ( Appendix 3 ) was used to assess students on their ability to apply basic anatomical knowledge as it relates to the timeline, systems involved, and what is unique in each case study. Students were also asked to describe the questions that they had asked in order to reach a diagnosis for the case study. The questions formulated by students indicate their ability to bring together previous knowledge to larger anatomical concepts. In this written summary, students were also required to justify the answer they arrived at in each step of the process. In addition to these four steps, students were assessed on the organization of their paper and whether their diagnosis is well supported.

Although class participation was not formally assessed, the improvements demonstrated in the written assignments were mirrored in student discussions in the classroom. While it is difficult to accurately assess how well students think critically, students demonstrated success in learning this module, which provides the necessary framework for approaching and solving a novel problem.

Student perceptions

Students were asked to answer the open response question, “Describe the process you use to figure out a novel problem or case study.” Responses were anonymized, then coded based on frequency of responses. Responses were collected at the start of the semester, prior to any instruction in the described systematic approach, and again at the end of the semester ( Figs. 2 and ​ and3). 3 ). Overall, student comments indicated that mastering this four-step approach greatly increased their confidence in tackling a novel problem. Below are some sample student responses.

Student responses to a survey regarding their approach to solving a novel problem. Data were collected prior to and following the completion of the spring semester of 2016. A) Student approach to solving a novel problem at the beginning of the semester. B) Student approach to solving a novel problem at the end of the semester. Student responses indicate that following a semester of training in using this method, students prefer to use this four-step systematic approach to solve a novel problem.

Student responses to a survey regarding their approach to solving a novel problem. Data were collected prior to and following the completion of spring semester of 2017. A) Student approach to solving a novel problem at the beginning of the semester. B) Student approach to solving a novel problem at the end of the semester. Student responses indicate that students overwhelmingly utilize this systematic approach when solving a novel problem.

“Rather than being intimidated with a set of symptoms I can’t explain, I’m now able to break them down into simpler questions that will lead me down a path of understanding and accurate explanation.” “I now know how to address an exam question or life problem by considering what is needed to solve it. This knowledge will help me to address each problem efficiently and calmly. As a future nurse, I will benefit from developing a logical and stereotypical approach to solving problems. I have learned to assess my thinking and questioning and modify my approach to problem-solving. While the problems may be different in the future, I am confident that I will be able to efficiently learn from my successes and setbacks and continually improve.” “I’m sure I’ll use this approach when I’m faced with any other novel problem, whether it’s scientific or not. Stepping back and establishing what I know and what I need to find out makes difficult problems a lot more approachable.” “Before, I would look at all the information presented and try to find things that I recognized. Then I would simply ask myself if I knew the answer. Even if I did actually know the answer, I had no formula to make the information understandable, cohesive, or approachable. I now feel far more confident when dealing with novel problems and do not become immediately overwhelmed.”

This approach encourages students to quickly sort through a large amount of information and think critically. Although students can find the novel nature of this method cumbersome in the initial implementation in the classroom, once they become familiar with the approach, it provides a valuable platform for attacking any novel problem in the future. The ability to apply this approach to critical thinking in any discipline was also demonstrated, as is evidenced by the two following student responses.

“When I first thought about this question and when solving case studies I tried to find the answer immediately. I’m good at memorizing information and spitting it back out but not working through an issue and having a method. I definitely have a more successful way to think through complex problems and being patient and coming up with an answer.” “I already use it in many of my other classes and life cases. When I take an exam that is asking a complicated question or is in a long format, I work to break it down like I did in this class and try to find the base question and what the answer may be. It has actually helped significantly.”

Possible modifications

Currently, students are randomly assigned to groups each week. In future semesters, we could improve small group work by utilizing software that helps to identify individual student strengths and assign groups accordingly. Additionally, while students are given flexibility within their small groups, if groups struggle with equality of workload we could assign specific roles and tasks.

We are also using this model in a large class (100 students) and assessing understanding of the case study through instant student response questions (ICLICKER). While this model does not allow for the valuable in-depth classroom discussions, it still presents the approach to students and allows them to begin to implement it in solving complex problems. Preliminary data from these large classes indicate that students initially find the method difficult and cumbersome. Further development and testing of this model in a large classroom will improve its use for future semesters.

SUPPLEMENTAL MATERIALS

Appendix 1: sample case study, appendix 2: case study handout, appendix 3: case study grading rubric, appendix 4: student writing sample, acknowledgments.

Use of anonymized student data and student responses to surveys was approved by the Institutional Review Board at Colorado State University. The authors declare that there are no conflicts of interest.

† Supplemental materials available at http://asmscience.org/jmbe

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A novel approach with an extensive case study and experiment for automatic code generation from the XMI schema Of UML models

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Software models at different levels of abstraction and from different perspectives contribute to the creation of compilable code in the implementation phase of the SDLC. Traditionally, the development of the code is a human-intensive act and prone to misinterpretation and defects. The defect elimination process is again an arduous time-consuming task with increased time-to-deliver and cost. Hence, a novel approach is proposed to generate the code with the activity diagram and sequence diagram as the focus. The activity diagram and sequence diagrams and are defined as part of the UML definition to define the object flow of the system and interaction between the objects, respectively. An XMI schema is a text representation of any software model that is exported from a modeling tool. The modeling tool BoUML exports the required schema from the given input models such as sequence diagrams and activity diagrams. The proposed JC_Gen extracts artifacts from the XMI schema of these two models to generate the code automatically. The focus is mainly on class definition, member declaration, methods’ definition, and function call in generated code.

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A novel approach to frontline health worker support: a case study in increasing social power among private, fee-for-service birthing attendants in rural Bangladesh

• Dora Curry   ORCID: orcid.org/0000-0002-9418-1548 1 , 2 ,
• Md. Ahsanul Islam 1 ,
• Bidhan Krishna Sarker 3 ,
• Anne Laterra 1 &
• Ikhtiar Khandaker 1  

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Expanding the health workforce to increase the availability of skilled birth attendants (SBAs) presents an opportunity to expand the power and well-being of frontline health workers. The role of the SBA holds enormous potential to transform the relationship between women, birthing caregivers, and the broader health care delivery system. This paper will present a novel approach to the community-based skilled birth attendant (SBA) role, the Skilled Health Entrepreneur (SHE) program implemented in rural Sylhet District, Bangladesh.

Case presentation

The SHE model developed a public–private approach to developing and supporting a cadre of SBAs. The program focused on economic empowerment, skills building, and formal linkage to the health system for self-employed SBAs among women residents. The SHEs comprise a cadre of frontline health workers in remote, underserved areas with a stable strategy to earn adequate income and are likely to remain in practice in the area. The program design included capacity-building for the SHEs covering traditional techno-managerial training and supervision in programmatic skills and for developing their entrepreneurial skills, professional confidence, and individual decision-making. The program supported women from the community who were social peers of their clients and long-term residents of the community in becoming recognized, respected health workers linked to the public system and securing their livelihood while improving quality and access to maternal health services. This paper will describe the SHE program's design elements to enhance SHE empowerment in the context of discourse on social power and FLHWs.

The SHE model successfully established a private SBA cadre that improved birth outcomes and enhanced their social power and technical skills in challenging settings through the mainstream health system. Strengthening the agency, voice, and well-being of the SHEs has transformative potential. Designing SBA interventions that increase their power in their social context could expand their economic independence and reinforce positive gender and power norms in the community, addressing long-standing issues of poor remuneration, overburdened workloads, and poor retention. Witnessing the introduction of peer or near-peer women with well-respected, well-compensated roles among their neighbors can significantly expand the effectiveness of frontline health workers and offer a model for other women in their own lives.

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The Sustainable Development Goals (SDG) for 2030 target reducing the Maternal Mortality Ratio to 70 maternal deaths per 100,000 live births. Increased availability of skilled birth attendants (SBAs) is well established as one essential ingredient of reducing maternal mortality and is a primary indicator for documenting progress in this area [ 1 , 2 , 3 ]. Within a system-wide approach to improving maternal health outcomes, universal availability of skilled birthing care is one critical element of achieving progress on this crucial SDG [ 5 , 6 , 7 ]. The WHO Global Strategy for Human Resources for Health: Workforce 2030 calls on countries to increase investment in frontline health workers and explore new ways to optimize health service expertise [ 8 ].

Expanding the health workforce to increase the availability of SBAs presents an opportunity. The role of the SBA holds enormous potential to transform the relationship between women, birthing caregivers, and the broader health care delivery system. This paper will focus on the community-based skilled birth attendant (SBA) role and its transformative potential, using a novel approach to SBAs, implemented in rural Sylhet District, Bangladesh, as an illustrative example. The introduction of diverse processes, like this one, to increase the uptake of basic skilled birthing care can play an essential role in improving coverage with skilled birthing attendants. In addition, insights from such new approaches to financing and supporting frontline health workers can contribute to health workforce expansion and quality improvement in health areas beyond safe delivery.

The Skilled Health Entrepreneur (SHE) model developed a public–private approach to developing and training a cadre of SBAs. The program focused on economic empowerment, skills building, and formal linkage to the health system for self-employed SBAs among women residents. This model shifts the view of community-based birth attendants from one of a substandard, stopgap force extender to one of a unique class of skilled providers. The program invests the SHEs with income, autonomy, and external professional recognition. Creating a cadre of providers of similar socioeconomic status and culture to clients enhances the value of the SBA and her services in her clients' eyes.

The Sumanganj District of Bangladesh provides a valuable context to explore these issues in several ways. Not only does the area experience a critical gap in the availability of health care service providers, but a market also exists for fee-for-service health care, as community members are already accustomed to seeking care or unreliable quality from often unskilled private providers due to the gap in the availability of providers in public facilities. In addition, an established cadre of community-based skilled birth attendants already existed, but was underutilized due mainly to inadequate supervision and low community awareness of their capabilities. Finally, women faced barriers to seeking delivery services at facilities due to social norms and religious practices [ 9 ].

Other models exist with some similarities. For example, this model is similar to the Shasthya Shebika (SS) approach. The SHE and the SSs are selected from the community, provided training and supervision, provided community-based services, and rely on their activities to earn compensation. The distinctive element of the SHE approach is that the SHEs charge for their services directly on a fee-for-service basis. SSs receive a financial incentive from relatively small mark-ups of resale health-related products provided or subsidized by a sponsoring organization such as an INGO or the MOH. This feature also sets the SHE model apart from similar models in other countries, like kaders’ posyandu in Indonesia or the LiveWell model in Zambia [ 4 ].

This paper will first present an overview of factors influencing the uptake of skilled birthing care and then describe the SHE model and its transformational potential. The SHE model comprises a cadre of frontline health workers in remote, underserved areas with a stable strategy to earn adequate income and are likely to remain in practice in the area. They can provide high-quality basic clinical skills and access to higher care. The community and the health system recognize them as legitimate. In addition, they are female, come from the same geographical, and cultural background as their clients, and are closer to their clients' socioeconomic peers than most other health workers.

These features of the SHE model can potentially increase clients' uptake of skilled birthing services and contribute positively to social and gender dynamics. Selecting SBAs from among women within traditionally underrepresented and marginalized communities ensures that they have networks, social connections, capital, and a desire to continue building a life there. Designing SBA interventions that increase their power in their social context could expand their economic independence and reinforce positive gender and power norms in the community, addressing long-standing issues of poor remuneration, overburdened workloads, and poor retention.

These shifts could also enhance the perception of quality and accessibility among clients and contribute more to women’s agency. This model amplifies and gives greater weight to client perception and builds on frontline providers’ and clients’ agency, making it more robust in challenging settings, more acceptable to clients, and more sustainable than other options.

This paper is a descriptive exercise depicting a novel intervention in detail. A selective review of relevant literature provides an overview of maternal health strategies to improve skilled birth attendant availability and skill. The literature review included both peer-reviewed publications and "grey" literature. The project description draws on an in-depth desk review of project documentation. The desk review covered the project proposal, routine project reporting covering supportive supervision findings, training materials, activity logs, and internal assessments; midline and end-line reports; and journal articles published on program data. Program monitoring and evaluation data included in the review covered project outputs such as health services delivered, commodities sold, community events conducted, and project outcomes such as the percentage of the coverage area accessing critical maternal and child health services.

International calls for more significant investment in skilled birthing care underestimate the complexity of women's needs and preferences and providers' needs and preferences [ 7 ]. To maximize the impact of such investments, health worker support interventions must offer a specific pathway to address the unique challenges of a range of women's preferences [ 11 ]. Women's preference for birthing care that is convenient, respectful, or culturally congruent may overshadow clinical quality, as defined by technical experts, in their care-seeking.

Afulani and Moyer proposed a framework that includes perceived need, accessibility, and quality as three factors affecting the uptake of skilled birthing care [ 12 ]. The critical insight their analysis contributes model is the influence of client perception on their decisions about seeking services. Distinguishing between perceived quality and accessibility, on the one hand, and clinical quality and distance to care, on the other, highlights the connection between client experience and whether a woman chooses skilled birthing care or not. Many factors affect perceived and actual quality and accessibility, such as service cost, quality monitoring, and the governance environment for financing and regulation. This discussion will use the concepts of perceived accessibility and quality, as distinct from objectively measured accessibility and quality, as a framework to consider the influence of the social context for the SHE role and its influence on women's uptake of services and gender and power dynamics.

Perceived accessibility

In Bangladesh and globally, rural areas face a more limited supply of providers and more significant challenges to ensuring high-quality, respectful care among providers [ 5 ]. The difficulty in improving provider coverage in underserved areas and the prevalence of disrespectful care is well-documented and persistent [ 11 , 13 , 14 ].

The considerable body of evidence on frontline health workers (FLHWs) demonstrates that fundamental issues like adequate, regular pay and safe working conditions are essential prerequisites to maintaining a successful frontline cadre of health workers [ 15 ]. (The term frontline health worker encompasses community skilled birth attendants, midwives, nurses, and physicians) [ 15 ]. Recruitment and retention of midwives, nurses, and physicians through financial incentives and other added compensation are common strategies for a geographic redistribution of skilled providers [ 1 , 16 ]. Unfortunately, these efforts have failed to identify a stable solution to the adequate supply of providers in underserved areas [ 17 ].

While additional factors undoubtedly influence the difficulty of attracting providers in remote areas, the inability to earn an adequate, stable income is critical [ 18 , 19 , 20 ]. Solutions that rely on unpaid or underpaid lay health workers in the community are not viable [ 7 ] and are not sure to improve perceived accessibility.

Perceived quality

The second mediating pathway considered here—perceived quality—is even more complex in its relationship to the uptake of services; the WHO acknowledged in 2014 guidelines on preventing pregnancy-related morbidity and mortality that respectful care still defies definition [ 21 ]. Researchers have identified involving women in their care and preparing a supportive environment that supports the woman's choice of companionship as a crucial element of respect [ 22 ]. In addition to being a fundamental right, respectful care significantly affects whether and where women seek care [ 23 ].

Factors like distance, lack of ancillary services, and desire for a cesarian section affect women's choice to give birth outside a facility. Avoidance of care that does not meet the standards for respectful care is also a significant driver for opting for non-facility deliveries [ 21 , 24 ]. In response to disrespectful care, women frequently seek care from traditional birth attendants and deliver at home [ 25 ].

Simply ensuring an adequate number of providers practicing in underserved areas will not adequately address the challenge of ensuring equitable access to maternity care that is both skilled and respectful [ 13 ]. Underlying factors increasing the likelihood of receiving disrespectful maternity care include caste, class, race discrimination, harmful gender norms, and social status. Strategies that incentivize providers from elsewhere to practice in underserved areas may increase the availability of providers. However, they may not increase perceived accessibility or respectfulness of care if newly recruited providers are more urban, of higher social status, or of different ethnic or language groups than their clients, which is likely.

Approaches to improving perceived quality and accessibility

Approaches to improving quality in ways valued by women are a critical need. For example, an intervention in Afghanistan that prioritized cultural compatibility in underserved areas by working with regional midwifery training centers found high satisfaction among midwives and their clients [ 27 ]. They may enhance the attractiveness of the service to individual clients by marrying clinically high-quality care with respectful, culturally congruent care.

An alternative approach must also establish a mechanism to ensure sustainable financing to ensure adequate provider income in underserved areas and facilitate a respectful relationship between providers and clients. One widely employed strategy to address the need to pay FLHW is to rely on a cadre of "volunteer" community-based providers. A risk in designing programming to extend access to health services is that the FLHW/CHW role may shift responsibility, work burden, and even financial contributions onto FLHWs/CHWs as individuals. For example, Schaaf et al. [ 28 ] observe that targeted vertical programs relied heavily on volunteer or minimally compensated community health workers to extend the program's reach. Closser and Maes discuss the "appropriation" of the role of the CHW. In these situations, the scope of duties and time commitment demanded of "volunteer" CHWs far exceed the typical expectations of a volunteer role [ 29 ]. Over-reliance on these predominantly female, lower-status cadres can decrease their effectiveness and undermine their impact among their social peers in the community as models of women respected and compensated for critical health services.

Skilled Health Entrepreneurs: a new approach

The Skilled Health Entrepreneurs Footnote 1 (SHE) model emerged from a collaboration between CARE International in Bangladesh, Bangladesh's Ministry of Health, and other partners. This coalition proposed creating a sustainable system to ensure SBA services are available in the remote, underserved rural Sunamganj District in the Sylhet Division, the northeast region of Bangladesh. Skilled providers were scarce in government facilities for at least two significant reasons. The cost of staffing many small clinics in remote locations can pose a substantial obstacle to the health system because of the high per-beneficiary cost for staffing in sparsely populated areas [ 30 ]. The government facilities struggled to retain those health workers they successfully recruited in the few rural facilities they could support [ 30 ]. Residents were accustomed to seeking delivery care from untrained private birth attendants [ 31 ]. The robust market for private traditional birthing care signals a gap in publicly provided services, in quality, quantity, or both. While the care provided by traditional birth attendants might not have met clinical quality standards, it was providing value to clients, potentially through convenience and culturally appropriate, respectful care.

The SHE model proposed increasing the availability of high-quality care and stabilizing access to care from SHEs by selecting residents of the area. As community members, they were less likely to leave the site and more motivated to improve health outcomes for those giving birth in their areas. With support from program staff, they also negotiated a standardized, sliding-scale fee schedule that allows them to continue generating revenue independently while ensuring low-income women can access their services [ 5 ].

The program design included measures to increase the capacities of the SHEs in ways beyond the traditional techno-managerial training and supervision in technical skills, such as growing and controlling their earnings and expanding their professional skills. The program intended to support women from the community, as social peers of clients and long-term residents, in becoming recognized, respected health workers linked to the public system while protecting their livelihood and improving quality and access to maternal health services [ 32 ] This paper will describe the SHE program's design elements to enhance SHE empowerment in the academic literature on social power and FLHWs.

Hossain, et al. [ 5 ] described the Skilled Health Entrepreneur program. The project's purpose was to provide clients with the option of a maternal health service provider that meets clients' needs and preferences. Women in the community preferred traditional birth attendants because they were available outside of business hours, accepted non-monetary payments, and shared social norms and beliefs [ 5 ]. The SHE program provided training to fellow community members so that women could receive services from their trusted, culturally congruent providers while ensuring that services offered were safe, high-quality, and linked to referrals for complications.

The project included five central interventions: selection and training of private birth attendants, social entrepreneurship capacity building, community engagement to establish the new cadre in the community, linkages to quality monitoring and referral facilities, and mechanisms to bolster the community's financial support of the program's activities. The program selected participants by inviting applications and conducting interviews and written exams. Women aged 25 to 40 years with at least ten years of schooling were eligible to apply. Over the 5-year life of the project, 319 completed the training.

The project delivered 3 months of training in health service and promotion. The clinical and health promotion training prepared SHEs to support a comprehensive maternal and child package, including antenatal care, assistance in uncomplicated deliveries, postnatal and newborn care, referral for complications, family planning counseling, short-term family planning method provision, and referral. The program used MOH training materials and trainers based on WHO standards. The program also linked SHEs with community support groups, community health workers, government health facilities, and supervisors. See Hossain et al. [ 5 ] for more details on the program in general. Once SHEs were prepared to offer services, the program provided ongoing supervision and professional development, including mobile skill labs and advancement opportunities to serve as trainers for incoming new SHEs.

The program also coordinated an alignment between municipal authorities, the health department, and the SHEs. As a result of CARE's coordination, the Health Department provided SHEs with an ongoing supply of health commodities, such as iron folate tablets, soap, and misoprostol, and refresher training. The SHEs charged clients on a sliding scale negotiated by the local government and community representatives. Prices paid were independently monitored periodically. Program staff collaborated with local leaders to explore mechanisms to extend care to the lowest wealth quintile care free of charge.

Over the project's life, SHEs accomplished 47,123 skilled deliveries and dispensed 2.7 million folic acid tablets. As of the end of the program, the median monthly earnings of the SHEs was 5000 BDT (67 USD), compared to 1500 BDT (20 USD) at the beginning of the program. SHEs are formally linked with 136 community clinics and 29 union councils on health and family welfare [ 33 ]. A mid-term analysis found that women in the coverage area were more than twice as likely to have delivered with a skilled birth attendant present at their most recent childbirth than at the beginning of the program [ 5 ]. The end-line assessment conducted in 2018 demonstrated significant achievements. The percentage of women using a skilled attendant during birth increased from 13.4 to 37.4% in the intervention area compared to 21.4% to 35.8% in a comparison district. Neonatal, infant, and under-five mortality rates all showed similar improvement [ 33 ] (see Table 1 ).

Compensation: financial and marketing skills building

One of the intervention arms most directly related to an increase in SHEs' social power focused on building their capacity to earn an adequate income. SHEs developed two potential sources of revenue: direct fee-for-service charges for maternal health services and the sale of health-related products. SHE revenue was not the sole source of household income, however. According to the program’s intake questionnaire administered to SHEs, most SHEs have some additional household income from another adult earner, and some may have had other sources of revenue as individuals unrelated to SHE duties. In addition, SHEs may compete with other providers of similar goods and services. Including income as an element of SHE empowerment should not be considered a comprehensive economic analysis but rather one of the multiple components influencing SHEs' social power (Fig. 1 ).

Mediating pathways in uptake of skilled birthing care

The program facilitated a market analysis process with the SHEs. The intervention included a 2-day social entrepreneurship capacity-building workshop drawing on a market analysis of the local market and developing business plans. The workshop covered targeting their service offerings and minimizing conflict with untrained traditional birth attendants. The SHEs received coaching from facilitators skilled in entrepreneurship to determine their potential clients' market size and characteristics. They developed individual business plans targeted to their communities, including outreach to potential clients. The project also conducted promotional and marketing activities ranging from health awareness days to stakeholder meetings to print, video, and media outreach. Another program element connected the SHEs to a supply chain of saleable commodities, such as non-prescription medicine, nutritional supplements, and baby care articles, at wholesale prices. The SHEs then resold these items at a small profit [ 30 ].

Professional engagement and community recognition

Other project elements contributed to SHEs' agency and external recognition by enhancing their recognition as valuable contributors to the community by authorities outside their homes. CARE's training to the SHEs earned them accreditation by the Bangladesh Nursing Council as a community skilled birth attendant, a professionally recognized designation in Bangladesh [ 32 ]. The professional development and skills-building component included coaching by nurses and physicians and organized rotations for the SHEs in healthcare facilities. These inputs conferred legitimacy and status on previously marginalized traditional providers.

Also, the project facilitated negotiation among the SHEs, the local municipal authorities, and the closest primary healthcare facility to establish a formally recognized role for the SHEs. This process set the sliding-scale fee structure discussed above. These negotiations afforded the SHEs recognition as accredited community midwives and secured support from local and neighborhood leaders to provide safe, clean space to perform services and accompaniment on travel to remote locations for home deliveries. The program developed a Memorandum of Understanding between the SHEs and the union parishads and negotiated specific budget line items in UP budgets to supervise the SHEs (These line items did not cover SHE remuneration.)

The formal recognition of their authority and value afforded them greater personal power in negotiating with family and community members about their mobility and control over resources. The provisions for their security removed the threat of violence, stigma, and harassment that could otherwise have accompanied their professional activities.

Agency: personal power to act

A third pillar of the program's approach to empowering SHEs was to build their sense of agency on an individual level. Program activities included group planning sessions among SHEs for the SHEs to engage with each other (As each SHE worked in a different neighborhood geographically, the risk of competition among SHEs was minimal). Also, program facilitators worked one-on-one with SHEs, identifying what changes could further develop their businesses [ 34 ]. For example, when a regular review revealed that one SHE was not earning as much revenue as targeted, program facilitators examined the factors affecting her ability to make money through her work. They found those factors to include a lack of family support and insecurity when visiting clients in remote locations. The action plan included family support for childcare, introductions to community members, and expanding the products she could sell to generate revenue. In the end, her revenue well exceeded her target [ 34 ].

Limitations

The primary limitation of this discussion is that it is a purely descriptive exercise. A deeper examination of the SHE program provides insight into where and how the SHE approach may be broadly relevant. However, the merit of the approach cannot be demonstrated without empirical data analysis. Further research should cover both the causal pathway and the ultimate outcomes of the model.

Also, context presents a dilemma in this approach. One of the keys to the success of the SHE model was its careful observation of the factors driving women's choices in obtaining birthing care in this setting. The participatory design process allowed for significant tailoring to the market forces and client preferences unique to Sylhet District in rural Bangladesh. Notably, birthing care from traditional birth attendants was in demand before the SHE program and was an essential prerequisite. This demand for birthing care may be necessary for this model to be helpful.

According to Renfrew, et al., any comprehensive solution to introducing and supporting an influential health worker cadre must include minimum educational requirements and processes to ensure training, licensure, and regulation and be systematically integrated into the health system [ 7 ]. The SHE program met those criteria and improved birth outcomes. The SHE successfully established a private SBA cadre that enhanced their social power and technical skills in settings challenging to access through the mainstream health system. The SHE model stands out from many adopted globally for this purpose, such as Ethiopia's Women's Development Army and Nepal's Female Community Health Volunteers [ 29 , 35 ]. The SHE model dedicates concerted efforts to enhance women's decision-making authority, status in their work lives, and economic independence.

Witter (2017) cite concrete measures to address gender barriers as an essential element of building a stable health workforce suited to meet the needs of vulnerable populations [ 36 ]. In the SHE program, recognizing the SHEs as sanctioned health service providers legitimizes their status in the community. As community members before receiving SHE training, the SHEs are more likely to be rural, less educated, of marginalized ethnic ups, and lower status than most mainstream service providers. The introduction of peer or near-peer women with well-respected, well-compensated roles among their neighbors may have a powerful effect on other women and offer a model for their lives in different fields.

Focusing on enhancing the SHEs’ agency, voice, and well-being is necessary for this transformative potential. Asking a traditional birth attendant to assume more work for little or no money may increase the burden of unpaid labor on her and also reinforce existing harmful power relations ( 28 ). Calling on CHWs to provide services with no guarantee of compensation and refer to facility-based care providers reinforces the notion that it is her feminine duty to care for her neighbors and is more naturally caring and motivated. The SHE model structurally counters those harmful notions. Instead, the SHE model reinforces the perception that the caretaking work, often performed unpaid, usually by women, is worthy of the respect and economic investment of the community.

The importance of class, caste, and race in these power relations also influences the SHE's role. SHEs are more likely to be of lower status on several criteria, such as wealth and education level, than female FLHWs with more training and authority, such as nurses and female physicians [ 37 ]. Part of the transformative power of a model like the SHEs is that they are women from the same community and background and have less elite status otherwise. Services offered at the site preferred by the client by a social near-peer coach in prioritizing client-centered care communicates a high value placed on the client's preferences [ 36 ].

The sustainability of such approaches is a crucial element of any potential for long-term success or expansion of the SHE model and similar interventions. The fundamental sustainability strategy rests on market forces. The SHEs’ ongoing presence depends on their continued ability to provide services and charge for them. The SHEs could continue earning a substantially increased income from their service provision by the end of the program. The program phased out any direct financial support to the SHEs well before the program concluded. Fundamentally the sustainability strategy is for the SHEs to continue to cost-recover for their services, whether from private clients or through reimbursement from public payers for those unable to pay.

The sustainability of additional support activities remains challenging in at least two ways. First, supervision and entrepreneurship support was provided by grant funding. Supportive supervision and in-service training would require additional approval and investment from health authorities or elsewhere. A combination of health and other agencies at multiple levels (municipal, district, and national) could provide the moderate additional oversight needed to assure quality at a much lower cost than alternatives like providing salary support to community-based SBAs or extending the availability of facility-based SBAs. Secondly, ensuring sustainable financial resources to ensure access to care for lower-income families is a critical challenge for the sustainability of this model. Municipal budgets and community savings groups contributed funding to allow the SHEs to cost-recover services provided to mothers unable to pay during the program. Still, those arrangements were difficult to formalize and vulnerable to changes in budget allocations. Allowing the SHEs to receive reimbursement for skilled delivery services provided outside the facility would be one option for ensuring sustainable financing for SBA services for lower-income clients.

Taken within the growing body of scholarly work demonstrating the potential benefit of supporting positive gender norms and power dynamics among frontline health workers, these findings suggest some recommendations for health service delivery policy and practice:

Support robust investment in financing mechanisms to ensure adequate financial compensation for community health workers, especially predominantly or exclusively female cadres.

Build meaningful commitment to including community-based FLHW cadre in decision-making and planning within the health system through binding agreements among government and private sector stakeholders at local, as well as district and national, levels.

Include support in addressing gender-related barriers to paid work among female frontline health workers in supervision protocols and intervention design (Such support may include items in the SHE approach like coaching in negotiating social norm barriers among families and training on professional business skills such as public speaking and financial management.)

In addition, an assessment of the SHEs' experience and assessing health outcomes and social relations in the broader community can provide insights into the social role she fills. Understanding the effect of the SHEs’ agency on the women in the communities they serve is vital for the effective implementation of recommendations in other contexts.

Building on these learnings and implementing these recommendations could contribute to expanding women’s access to safe, acceptable care and strengthening social norms supportive of women in influential, professional roles.

Availability of data and materials

N/A (No datasets were presented in this article.)

In the first phase of the project the SHEs were known as Private Community Skilled Birth Attendants (PCSBAs) and are mentioned in the cited project documentation interchangeably as SHEs and PCSBAs.

Abbreviations

• Frontline health workers

Skilled birth attendant

Skilled Health Entrepreneurs

Union Parishad

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Curry, D., Islam, M.A., Sarker, B.K. et al. A novel approach to frontline health worker support: a case study in increasing social power among private, fee-for-service birthing attendants in rural Bangladesh. Hum Resour Health 21 , 7 (2023). https://doi.org/10.1186/s12960-022-00773-6

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Team up with GMF to deliver climate adaptation training. Learn more

Case study: A novel approach to geothermal energy systems in Canada

How the Toronto and Region Conservation Authority updated building plans to include open-loop geothermal energy

When designing its new head office building, the Toronto and Region Conservation Authority (TRCA) intended to use a closed-loop geothermal system for heating and cooling. But subsequent testing led them to pivot to an open-loop system due to its increased environmental benefits and the opportunity to demonstrate the value of this innovative technology.

The Toronto and Region Conservation Authority (TRCA) has a mandate to care for the natural environment and protect communities and ecosystems from the impact of flooding and other extreme weather events. Its jurisdiction covers 3,467 km2.

TRCA is building a new head office and has been incorporating sustainability into all aspects of the process, with the aim of achieving a zero-carbon design. The intention is for the building to be both a functional space and a demonstration of green and net-zero construction techniques that can inform and inspire others.

Original plans included a closed-loop geothermal system as an energy-efficient way to provide heating and cooling. However, during test drilling, engineers found they could potentially switch to an open-loop geothermal system or an aquifer thermal energy storage system, both of which can be more energy efficient and cost effective than closed-loop systems but are uncommon in Canada. All of these systems use underground pipes to draw heat from the earth in the winter and expel heat from the building in the summer, but in different ways and with different infrastructure needs.

The challenge

While TRCA was prepared to move forward with a closed-loop system, they knew that the discovery of the aquifer presented an opportunity to test the feasibility of the alternatives. The questions were: would an open-loop or aquifer thermal system work for their building? And if so, would it be worth it for them to implement it?

With financial support from FCM, TRCA decided to do a feasibility study to discover which of the three systems would be the best choice for their site. This included exploratory drilling to answer the following questions:

• Is there sufficient groundwater under the site?
• Does the groundwater move slowly enough for interseasonal storage of heating and cooling potential?
• Is the groundwater chemistry likely to cause scaling or corrosion, which could hinder system performance?

The study also included analysis of the costs, construction-related environmental impact and future energy use of each option.

The study showed that any of the options would work on the TRCA building site. TRCA decided to abandon its plans for closed-loop geothermal in favour of an open-loop system for reasons including:

• Lowest cost, with a savings of approximately 25 percent.
• Lower emissions from installation and 25-year operation, at 77.8 tCO2e.
• Less disruption of the surrounding natural environment, in part due to requiring only four open loop boreholes rather than 44 closed loop boreholes.

Given TRCA’s mandate to showcase green building technologies, installing a highly functional yet less common open-loop system is an opportunity to share knowledge and advance uptake of this kind of technology.

Lessons learned

TRCA realized they should have done a hydrogeology study initially upon selection of geothermal heating and cooling, rather than embarking on test drilling with only a closed-loop system in mind. Many costs could have been avoided by considering all potential options when test-drilling.

On a regional level, there could be advantages to understanding the underlying geology of specific regions ahead of time to identify high-potential sites for open-loop or aquifer thermal systems.

TRCA has moved forward on design and installation of an open-loop system for its head office site. In order to maximize the longevity of this system, they are planning a monitoring and maintenance program that will help them minimize the impact of common issues such as scaling and clogging.

Want to explore all GMF-funded projects? Check out the Projects Database for a complete overview of funded projects and get inspired by municipalities of all sizes, across Canada. 

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• Open access
• Published: 10 August 2024

How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK

• Charlotte Parbery-Clark 1 ,
• Lorraine McSweeney 2 ,
• Joanne Lally 3 &
• Sarah Sowden 4  

BMC Public Health volume  24 , Article number:  2168 ( 2024 ) Cite this article

427 Accesses

Metrics details

Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system’s level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions.

In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach.

Interviews ( n  = 14) with wide representation from local authority ( n  = 8), NHS ( n  = 5) and voluntary, community and social enterprise (VCSE) sector ( n  = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system’s approach to reducing health inequalities was evident as was collective action and involving people, with links to a “strong third sector”. Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system.

We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system’s working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Highlights:

• Reducing health inequalities in avoidable hospital admissions is yet to be explicitly linked in practice and is an important area to address.

• Understanding the local context helps to identify existing assets and threats including the leverage points for action.

• Requiring action includes building the resilience of our complex systems by addressing structural barriers and threats as well as supporting the workforce (training and wellbeing with improved retention and recruitment) in addition to the analysis and accessibility of data across the system.

Peer Review reports

Introduction

The health of our population is determined by the complex interaction of several factors which are either non-modifiable (such as age, genetics) or modifiable (such as the environment, social, economic conditions in which we live, our behaviours as well as our access to healthcare and its quality) [ 1 ]. Health inequalities are the avoidable and unfair systematic differences in health and healthcare across different population groups explained by the differences in distribution of power, wealth and resources which drive the conditions of daily life [ 2 , 3 ]. Essentially, health inequalities arise due to the systematic differences of the factors that influence our health. To effectively deal with most public health challenges, including reducing health inequalities and improving population health, broader integrated approaches [ 4 ] and an emphasis on systems is required [ 5 , 6 ] . A system is defined as ‘the set of actors, activities, and settings that are directly or indirectly perceived to have influence in or be affected by a given problem situation’ (p.198) [ 7 ]. In this case, the ‘given problem situation' is reducing health inequalities with a focus on avoidable admissions. Therefore, we must consider health systems, which are the organisations, resources and people aiming to improve or maintain health [ 8 , 9 ] of which health services provision is an aspect. In this study, the system considers NHS bodies, Integrated Care Systems, Local Authority departments, and the voluntary and community sector in a UK region.

A plethora of theories [ 10 ], recommended policies [ 3 , 11 , 12 , 13 ], frameworks [ 1 , 14 , 15 ], and tools [ 16 ] exist to help understand the existence of health inequalities as well as provide suggestions for improvement. However, it is reported that healthcare leaders feel under-skilled to reduce health inequalities [ 17 ]. A lack of clarity exists on how to achieve a system’s multi-agency coherence to reduce health inequalities systematically [ 17 , 18 ]. This is despite some countries having legal obligations to have a regard to the need to attend to health and healthcare inequalities. For example, the Health and Social Care Act 2012 [ 19 ], in England, mandated Clinical Commissioning Groups (CCGs), now transferred to Integrated Care Boards (ICBs) [ 20 ], to ‘have a regard to the need to reduce inequalities between patients with respect to their ability to access health services, and reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services’. The wider determinants of health must also be considered. For example, local areas have a mandatory requirement to have a joint strategic needs assessment (JSNA) and joint health and wellbeing strategy (JHWS) whose purpose is to ‘improve the health and wellbeing of the local community and reduce inequalities for all ages' [ 21 ] This includes addressing the wider determinants of health [ 21 ]. Furthermore, the hospital care costs to the NHS associated with socioeconomic inequalities has been previously reported at £4.8 billion a year due to excess hospitalisations [ 22 ]. Avoidable emergency admissions are admissions into hospital that are considered to be preventable with high-quality ambulatory care [ 23 ]. Both ambulatory care sensitive conditions (where effective personalised care based in the community can aid the prevention of needing an admission) and urgent care sensitive conditions (where a system on the whole should be able to treat and manage without an admission) are considered within this definition [ 24 ] (encompassing more than 100 International Classification of Diseases (ICD) codes). The disease burden sits disproportionately with our most disadvantaged communities, therefore highlighting the importance of addressing inequalities in hospital pressures in a concerted manner [ 25 , 26 ].

Research examining one component of an intervention, or even one part of the system, [ 27 ] or which uses specific research techniques to control for the system’s context [ 28 ] are considered as having limited use for identifying the key ingredients to achieve better population health and wellbeing [ 5 , 28 ]. Instead, systems thinking considers how the system’s components and sub-components interconnect and interrelate within and between each other (and indeed other systems) to gain an understanding of the mechanisms by which things work [ 29 , 30 ]. Complex interventions or work programmes may perform differently in varying contexts and through different mechanisms, and therefore cannot simply be replicated from one context to another to automatically achieve the same outcomes. Ensuring that research into systems and systems thinking considers real-world context, such as where individuals live, where policies are created and interventions are delivered, is vital [ 5 ]. How the context and implementation of complex or even simple interventions interact is viewed as becoming increasingly important [ 31 , 32 ]. Case study research methodology is founded on the ‘in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings’ (p.2) [ 33 ]. Case study approaches can deepen the understanding of complexity addressing the ‘how’, ‘what’ and ‘why’ questions in a real-life context [ 34 ]. Researchers have highlighted the importance of engaging more deeply with case-based study methodology [ 31 , 33 ]. Previous case study research has shown promise [ 35 ] which we build on by exploring a systems lens to consider the local area’s context [ 16 ] within which the work is implemented. By using case-study methodology, our study aimed to explore and develop an in-depth understanding of how a local area addresses health inequalities, with a focus on avoidable hospital admissions. As part of this, systems processes were included.

Study design

This in-depth case study is part of an ongoing larger multiple (collective [ 36 ]) case study approach. An instrumental approach [ 34 ] was taken allowing an in-depth investigation of an issue, event or phenomenon, in its natural real-life context; referred to as a ‘naturalistic’ design [ 34 ]. Ethics approval was obtained by Newcastle University’s Ethics Committee (ref 13633/2020).

Study selection

This case study, alongside the other three cases, was purposively [ 36 ] chosen considering overall deprivation level of the area (Indices of Multiple Deprivation (IMD) [ 37 ]), their urban/rural location, differing geographical spread across the UK (highlighted in patient and public feedback and important for considering the North/South health divide [ 38 ]), and a pragmatic judgement of likely ability to achieve the depth of insight required [ 39 ]. In this paper, we report the findings from one of the case studies, an urban local authority in the Northern region of the UK with high levels of socioeconomic disadvantage. This area was chosen for this in-depth case analysis due to high-level of need, and prior to the COVID-19 pandemic (2009-2018) had experienced a trend towards reducing socioeconomic inequalities in avoidable hospital admission rates between neighbourhoods within the local area [ 40 ]. Thereby this case study represents an ‘unusual’ case [ 41 ] to facilitate learning regarding what is reported and considered to be the key elements required to reduce health inequalities, including inequalities in avoidable admissions, in a local area.

Semi-structured interviews

The key informants were identified iteratively through the documentary analysis and in consultation with the research advisory group. Initially board level committee members (including lay, managerial, and clinical members) within relevant local organisations were purposively identified. These individuals were systems leaders charged with the remit of tackling health inequalities and therefore well placed to identify both key personnel and documents. Snowball sampling [ 42 ] was undertaken thereafter whereby interviewees helped to identify additional key informants within the local system who were working on health inequalities, including avoidable emergency admissions, at a systems level. Interview questions were based on an iteratively developed topic guide (supplementary data 1), informed from previous work’s findings [ 43 ] and the research advisory network’s input. A study information sheet was emailed to perspective interviewees, and participants were asked to complete an e-consent form using Microsoft Forms [ 42 ]. Each interviewee was interviewed by either L.M. or C.P.-C. using the online platforms Zoom or Teams, and lasted up to one hour. Participants were informed of interviewers’ role, workplace as well as purpose of the study. Interviewees were asked a range of questions including any work relating to reducing health inequalities, particularly avoidable emergency admissions, within the last 5 years. Brief notes were taken, and the interviews were recorded, transcribed verbatim and anonymised.

Documentary analysis

The documentary analysis followed the READ approach [ 44 ]. Any documents from the relevant local/regional area with sections addressing health inequalities and/or avoidable emergency admissions, either explicitly stated or implicitly inferred, were included. A list of core documents was chosen, including the local Health and Wellbeing Strategy (Table 1 ). Subsequently, other documents were identified by snowballing from these core documents and identification by the interviewees. All document types were within scope if produced/covered a period within 5 years (2017-2022), including documents in the public domain or not as well as documents pertaining to either a regional, local and neighbourhood level. This 5-year period was a pragmatic decision in line with the interviews and considered to be a balance of legacy and relevance. Attempts were made to include the final version of each document, where possible/applicable, otherwise the most up-to-date version or version available was used.

An Excel spreadsheet data extraction tool was adapted with a priori criteria [ 44 ] to extract the data. This tool included contextual information (such as authors, target area and document’s purpose). Also, information based on previous research on addressing socioeconomic inequalities in avoidable emergency admissions, such as who stands to benefit, was extracted [ 43 ]. Additionally, all documents were summarised according to a template designed according to the research’s aims. Data extraction and summaries were undertaken by L.M. and C.P.-C. A selection was doubled coded to enhance validity and any discrepancies were resolved by discussion.

Interviews and documents were coded and analysed independently based on a thematic analysis approach [ 45 ], managed by NVivo software. A combination of ‘interpretive’ and ‘positivist’ stance [ 34 , 46 ] was taken which involved understanding meanings/contexts and processes as perceived from different perspectives (interviewees and documents). This allowed for an understanding of individual and shared social meanings/reasonings [ 34 , 36 ]. For the documentary analysis, a combination of both content and thematic analysis as described by Bowen [ 47 ] informed by Braun and Clarke’s approach to thematic analysis [ 45 ] was used. This type of content analysis does not include the typical quantification but rather a review of the document for pertinent and meaningful passages of text/other data [ 47 ]. Both an inductive and deductive approach for the documentary analysis’ coding [ 46 , 47 ] was chosen. The inductive approach was developed a posteriori; the deductive codes being informed by the interviews and previous findings from research addressing socioeconomic inequalities in avoidable emergency admissions [ 43 ]. In line with qualitative epistemological approach to enquiry, the interview and documentary findings were viewed as ‘truths’ in themselves with the acceptance that multiple realities can co-exist [ 48 ]. The analysis of each set of themes (with subthemes) from the documentary analysis and interviews were cross-referenced and integrated with each other to provide a cohesive in-depth analysis [ 49 ] by generating thematic maps to explore the relationships between the themes. The codes, themes and thematic maps were peer-reviewed continually with regular meetings between L.M., C.P.-C., J.L. and S.S. Direct quotes are provided from the interviews and documentary analysis. Some quotes from the documents are paraphrased to protect anonymity of the case study after following a set process considering a range of options. This involved searching each quote from the documentary analysis in Google and if the quote was found in the first page of the result, we shortened extracts and repeated the process. Where the shortened extracts were still identifiable, we were required to paraphrase that quote. Each paraphrased quote and original was shared and agreed with all the authors reducing the likelihood of inadvertently misinterpreting or misquoting. Where multiple components over large bodies of text were present in the documents, models were used to evidence the broadness, for example, using Dahlgren’s and Whitehead’s model of health determinants [ 1 ]. Due to the nature of the study, transcripts and findings were not shared with participants for checking but will be shared in a dissemination workshop in 2024.

Patient and public involvement and engagement

Four public contributors from the National Institute for Health and Care Research (NIHR) Research Design Service (RDS) North East and North Cumbria (NENC) Public and Patient Involvement (PPI) panel have been actively engaged in this research from its inception. They have been part of the research advisory group along with professional stakeholders and were involved in the identification of the sampling frame’s key criteria. Furthermore, a diverse group of public contributors has been actively involved in other parts of the project including developing the moral argument around action by producing a public facing resource exploring what health inequalities mean to people and public views of possible solutions [ 50 ].

Semi-structured interviews: description

Sixteen participants working in health or social care, identified through the documentary analysis or snowballing, were contacted for interview; fourteen consented to participate. No further interviews were sought as data sufficiency was reached whereby no new information or themes were being identified. Participant roles were broken down by NHS ( n  = 5), local authority/council ( n  = 8), and voluntary, community and social enterprise (VSCE) ( n  = 1). To protect the participants’ anonymity, their employment titles/status are not disclosed. However, a broad spectrum of interviewees with varying roles from senior health system leadership (including strategic and commissioner roles) to roles within provider organisations and the VSCE sector were included.

Documentary analysis: description

75 documents were reviewed with documents considering regional ( n  = 20), local ( n  = 64) or neighbourhood ( n  = 2) area with some documents covering two or more areas. Table 2 summarises the respective number of each document type which included statutory documents to websites from across the system (NHS, local government and VSCE). 45 documents were named by interviewees and 42 documents were identified as either a core document or through snowballing from other documents. Of these, 12 documents were identified from both. The timescales of the documents varied and where possible to identify, was from 2014 to 2031.

Integrative analysis of the documentary analysis and interviews

The overarching themes encompass:

Understanding the local context

Facilitators to tacking health inequalities: the assets

Emerging risks and concerns

Figure 1 demonstrates the relationships between the main themes identified from the analysis for tackling health inequalities and improving health in this case study.

Diagram of the relationship between the key themes identified regarding tackling health inequalities and improving health in a local area informed by 2 previous work [ 14 , 51 ]. NCDs = non-communicable diseases; HI = health inequalities

Understanding the local context was discussed extensively in both the documents and the interviews. This was informed by local intelligence and data that was routinely collected, monitored, and analysed to help understand the local context and where inequalities lie. More bespoke, in-depth collection and analysis were also described to get a better understanding of the situation. This not only took the form of quantitative but also considered qualitative data with lived experience:

‛So, our data comes from going out to talk to people. I mean, yes, especially the voice of inequalities, those traditional mechanisms, like surveys, don't really work. And it's about going out to communities, linking in with third sector organisations, going out to communities, and just going out to listen…I think the more we can bring out those real stories. I mean, we find quotes really, really powerful in terms of helping people understand what it is that matters.’ (LP16).

However, there were limitations to the available data including the quality as well as having enough time to do the analysis justice. This resulted in difficulties in being able to fully understand the context to help identify and act on the required improvements.

‘A lack of available data means we cannot quantify the total number of vulnerable migrants in [region]’ (Document V).

‛So there’s lots of data. The issue is joining that data up and analysing it, and making sense of it. That’s where we don’t have the capacity.’ (LP15).

Despite the caveats, understanding the context and its data limitations were important to inform local priorities and approaches on tackling health inequalities. This understanding was underpinned by three subthemes which were understanding:

the population’s needs including identification of people at higher risk of worse health and health inequalities

the driving forces of those needs with acknowledgement of the impact of the wider determinants of health

the threats and barriers to physical and mental health, as well as wellbeing

Firstly, the population’s needs, including identification of people at higher risk of worse health and health inequalities, was important. This included considering risk factors, such as smoking, specific groups of people and who was presenting with which conditions. Between the interviews and documents, variation was seen between groups deemed at-risk or high-risk with the documents identifying a wider range. The groups identified across both included marginalised communities, such as ethnic minority groups, gypsy and travellers, refugees and asylum seekers as well as people/children living in disadvantaged area.

‘There are significant health inequalities in children with asthma between deprived and more affluent areas, and this is reflected in A&E admissions.' (Document J).

Secondly, the driving forces of those needs with acknowledgement of the impact of the wider determinants of health were described. These forces mapped onto Dahlgren’s and Whitehead’s model of health determinants [ 1 ] consisting of individual lifestyle factors, social and community networks, living and working conditions (which include access to health care services) as well as general socio-economic, cultural and environmental conditions across the life course.

…. at the centre of our approach considering the requirements to improve the health and wellbeing of our area are the wider determinants of health and wellbeing, acknowledging how factors, such as housing, education, the environment and economy, impact on health outcomes and wellbeing over people’s lifetime and are therefore pivotal to our ambition to ameliorate the health of the poorest the quickest. (Paraphrased Document P).

Thirdly, the threats and barriers to health included environmental risks, communicable diseases and associated challenges, non-communicable conditions and diseases, mental health as well as structural barriers. In terms of communicable diseases, COVID-19 predominated. The environmental risks included climate change and air pollution. Non-communicable diseases were considered as a substantial and increasing threat and encompassed a wide range of chronic conditions such as diabetes, and obesity.

‛Long term conditions are the leading causes of death and disability in [case study] and account for most of our health and care spending. Cases of cancer, diabetes, respiratory disease, dementia and cardiovascular disease will increase as the population of [case study] grows and ages.’ (Document A).

Structural barriers to accessing and using support and/or services for health and wellbeing were identified. These barriers included how the services are set up, such as some GP practices asking for proof of a fixed address or form of identification to register. For example:

Complicated systems (such as having to make multiple calls, the need to speak to many people/gatekeepers or to call at specific time) can be a massive barrier to accessing healthcare and appointments. This is the case particularly for people who have complex mental health needs or chaotic/destabilized circumstances. People who do not have stable housing face difficulties in registering for GP and other services that require an address or rely on post to communicate appointments. (Paraphrased Document R).

A structural threat regarding support and/or services for health and wellbeing was the sustainability of current funding with future uncertainty posing potential threats to the delivery of current services. This also affected the ability to adapt and develop the services, or indeed build new ones.

‛I would say the other thing is I have a beef [sic] [disagreement] with pilot studies or new innovations. Often soft funded, temporary funded, charity funded, partnership work run by enthusiasts. Me, I've done them, or supported people doing many of these. And they're great. They can make a huge impact on the individuals involved on that local area. You can see fantastic work. You get inspired and you want to stand up in a crowd and go, “Wahey, isn't this fantastic?” But actually the sad part of it is on these things, I've seen so many where we then see some good, positive work being done, but we can't make it permanent or we can't spread it because there's no funding behind it.’ (LP8).

Facilitators to tackling health inequalities: the assets

The facilitators for improving health and wellbeing and tackling health inequalities are considered as assets which were underpinned by values and principles.

Values driven supported by four key principles

Being values driven was an important concept and considered as the underpinning attitudes or beliefs that guide decision making [ 52 ]. Particularly, the system’s approach was underpinned by a culture and a system's commitment to tackle health inequalities across the documents and interviews. This was also demonstrated by how passionately and emotively some interviewees spoke about their work.

‛There's a really strong desire and ethos around understanding that we will only ever solve these problems as a system, not by individual organisations or even just part of the system working together. And that feels great.’ (LP3).

Other values driving the approach included accountability, justice, and equity. Reducing health inequalities and improving health were considered to be the right things to do. For example:

We feel strongly about social justice and being inclusive, wishing to reflect the diversity of [case study]. We campaign on subjects that are important to people who are older with respect and kindness. (Paraphrased Document O).

Four key principles were identified that crosscut the assets which were:

Shared vision

Strong partnership

Asset-based approaches

Willingness and ability to act on learning

The mandated strategy, identifying priorities for health and wellbeing for the local population with the required actions, provided the shared vision across each part of the system, and provided the foundations for the work. This shared vision was repeated consistently in the documents and interviews from across the system.

[Case study] will be a place where individuals who have the lowest socioeconomic status will ameliorate their health the quickest. [Case study] will be a place for good health and compassion for all people, regardless of their age. (Paraphrased Document A).

‛One thing that is obviously becoming stronger and stronger is the focus on health inequalities within all of that, and making sure that we are helping people and provide support to people with the poorest health as fast as possible, so that agenda hasn’t shifted.’ (LP7).

This drive to embed the reduction of health inequalities was supported by clear new national guidance encapsulated by the NHS Core20PLUS5 priorities. Core20PLUS5 is the UK's approach to support a system to improve their healthcare inequalities [ 53 ]. Additionally, the system's restructuring from Clinical Commissioning Groups (CCGs) to Integrated Care Boards (ICBs) and formalisation of the now statutory Integrated Care Systems (ICS) in England was also reported to facilitate the driving of further improvement in health inequalities. These changes at a regional and local level helped bring key partners across the system (NHS and local government among others) to build upon their collective responsibility for improving health and reducing health inequalities for their area [ 54 ].

‛I don’t remember the last time we’ve had that so clear, or the last time that health inequalities has had such a prominent place, both in the NHS planning guidance or in the NHS contract. ’ (LP15). ‛The Health and Care Act has now got a, kind of, pillar around health inequalities, the new establishment of ICPs and ICBs, and also the planning guidance this year had a very clear element on health inequalities.’ (LP12)

A strong partnership and collaborative team approach across the system underpinned the work from the documents and included the reoccurrence of the concept that this case study acted as one team: ‘Team [case study]'.

Supporting one another to ensure [case study] is the best it can be: Team [case study]. It involves learning, sharing ideas as well as organisations sharing assets and resources, authentic partnerships, and striving for collective impact (environmental and social) to work towards shared goals . (Paraphrased Document B).

This was corroborated in the interviews as working in partnership to tackle health inequalities was considered by the interviewees as moving in the right direction. There were reports that the relationship between local government, health care and the third sector had improved in recent years which was still an ongoing priority:

‘I think the only improvement I would cite, which is not an improvement in terms of health outcomes, but in terms of how we work across [case study] together has moved on quite a lot, in terms of teams leads and talking across us, and how we join up on things, rather than see ourselves all as separate bodies' (LP15).

‘I think the relationship between local authorities and health and the third sector, actually, has much more parity and esteem than it had before.' (LP11)

The approaches described above were supported by all health and care partners signing up to principles around partnership; it is likely this has helped foster the case study's approach. This also builds on the asset-based approaches that were another key principle building on co-production and co-creation which is described below.

We begin with people : instead of doing things to people or for them, we work with them, augmenting the skills, assets and strength of [case study]’s people, workforce and carers. We achieve : actions are focused on over words and by using intelligence, every action hones in on the actual difference that we will make to ameliorate outcomes, quality and spend [case study]’s money wisely; We are Team [case study ]: having kindness, working as one organisation, taking responsibility collectively and delivering on what we agreed. Problems are discussed with a high challenge and high support attitude. (Paraphrased Document D).

At times, the degree to which the asset-based approaches were embedded differed from the documents compared to the interviews, even when from the same part of the system. For example, the documents often referred to the asset-based approach as having occurred whilst interviewees viewed it more as a work in progress.

‘We have re-designed many of our services to focus on needs-led, asset-based early intervention and prevention, and have given citizens more control over decisions that directly affect them .’ (Document M).

‘But we’re trying to take an asset-based approach, which is looking at the good stuff in communities as well. So the buildings, the green space, the services, but then also the social capital stuff that happens under the radar.’ (LP11).

A willingness to learn and put in action plans to address the learning were present. This enables future proofing by building on what is already in place to build the capacity, capability and flexibility of the system. This was particularly important for developing the workforce as described below.

‘So we’ve got a task and finish group set up, […] So this group shows good practice and is a space for people to discuss some of the challenges or to share what interventions they are doing around the table, and also look at what other opportunities that they have within a region or that we could build upon and share and scale.’ (LP12).

These assets that are considered as facilitators are divided into four key levels which are the system, services and support, communities and individuals, and workforce which are discussed in turn below.

Firstly, the system within this case study was made up of many organisations and partnerships within the NHS, local government, VSCE sector and communities. The interviewees reported the presence of a strong VCSE sector which had been facilitated by the local council's commitment to funding this sector:

‘Within [case study], we have a brilliant third sector, the council has been longstanding funders of infrastructure in [case study], third sector infrastructure, to enable those links [of community engagement] to be made' (LP16).

In both the documents and interviews, a strong coherent strategic integrated population health management plan with a system’s approach to embed the reduction of health inequalities was evident. For example, on a system level regionally:

‘To contribute towards a reduction in health inequalities we will: take a system wide approach for improving outcomes for specific groups known to be affected by health inequalities, starting with those living in our most deprived communities….’ (Document H).

This case study’s approach within the system included using creative solutions and harnessing technology. This included making bold and inventive changes to improve how the city and the system linked up and worked together to improve health. For example, regeneration work within the city to ameliorate and transform healthcare facilities as well as certain neighbourhoods by having new green spaces, better transport links in order to improve city-wide innovation and collaboration (paraphrased Document F) were described. The changes were not only related to physical aspects of the city but also aimed at how the city digitally linked up. Being a leader in digital innovation to optimise the health benefits from technology and information was identified in several documents.

‘ Having the best connected city using digital technology to improve health and wellbeing in innovative ways.’ (Document G).

The digital approaches included ongoing development of a digitalised personalised care record facilitating access to the most up-to-date information to developing as well as having the ‘ latest, cutting edge technologies’ ( Document F) in hospital care. However, the importance of not leaving people behind by embedding digital alternatives was recognised in both the documents and interviews.

‘ We are trying to just embed the culture of doing an equity health impact assessment whenever you are bringing in a digital solution or a digital pathway, and that there is always an alternative there for people who don’t have the capability or capacity to use it. ’ (LP1).

The successful one hundred percent [redacted] programme is targeting some of our most digitally excluded citizens in [case study]. For our city to continue to thrive, we all need the appropriate skills, technology and support to get the most out of being online. (Paraphrased Document Q)

This all links in with the system that functions in a ‘place' which includes the importance of where people are born, grow, work and live. Working towards this place being welcoming and appealing was described both regionally and locally. This included aiming to make the case study the place of choice for people.

‘Making [case study] a centre for good growth becoming the place of choice in the UK to live, to study, for businesses to invest in, for people to come and work.’ (Document G).

Services and support

Secondly, a variety of available services and support were described from the local authority, NHS, and voluntary community sectors. Specific areas of work, such as local initiatives (including targeted work or campaigns for specific groups or specific health conditions) as well as parts of the system working together with communities collaboratively, were identified. This included a wide range of work being done such as avoiding delayed discharges or re-admissions, providing high quality affordable housing as well as services offering peer support.

‘We have a community health development programme called [redacted], that works with particular groups in deprived communities and ethnically diverse communities to work in a very trusted and culturally appropriate way on the things that they want to get involved with to support their health.’ (LP3 ).

It is worth noting that reducing health inequalities in avoidable admissions was not often explicitly specified in the documents or interviews. However, either specified or otherwise inferred, preventing ill health and improving access, experience, and outcomes were vital components to addressing inequalities. This was approached by working with communities to deliver services in communities that worked for all people. Having co-designed, accessible, equitable integrated services and support appeared to be key.

‘Reducing inequalities in unplanned admissions for conditions that could be cared for in the community and access to planned hospital care is key.’ (Document H)

Creating plans with people: understanding the needs of local population and designing joined-up services around these needs. (Paraphrased Document A).

‘ So I think a core element is engagement with your population, so that ownership and that co-production, if you're going to make an intervention, don't do it without because you might miss the mark. ’ (LP8).

Clear, consistent and appropriate communication that was trusted was considered important to improve health and wellbeing as well as to tackle health inequalities. For example, trusted community members being engaged to speak on the behalf of the service providers:

‘The messenger is more important than the message, sometimes.’ (LP11).

This included making sure the processes are in place so that the information is accessible for all, including people who have additional communication needs. This was considered as a work in progress in this case study.

‘I think for me, things do come down to those core things, of health, literacy, that digital exclusion and understanding the wider complexities of people.’ (LP12)

‘ But even more confusing if you've got an additional communication need. And we've done quite a lot of work around the accessible information standard which sounds quite dry, and doesn't sound very- but actually, it's fundamental in accessing health and care. And that is, that all health and care organisations should record your communication preferences. So, if I've got a learning disability, people should know. If I've got a hearing impairment, people should know. But the systems don’t record it, so blind people are getting sent letters for appointments, or if I've got hearing loss, the right provisions are not made for appointments. So, actually, we're putting up barriers before people even come in, or can even get access to services.’ (LP16).

Flexible, empowering, holistic care and support that was person-centric was more apparent in the documents than the interviews.

At the centre of our vision is having more people benefiting from the life chances currently enjoyed by the few to make [case study] a more equal place. Therefore, we accentuate the importance of good health, the requirement to boost resilience, and focus on prevention as a way of enabling higher quality service provision that is person-centred. [Paraphrased Document N).

Through this [work], we will give all children and young people in [case study], particularly if they are vulnerable and/or disadvantaged, a start in life that is empowering and enable them to flourish in a compassionate and lively city. [Paraphrased Document M].

Communities and individuals

Thirdly, having communities and individuals at the heart of the work appeared essential and viewed as crucial to nurture in this case study. The interconnectedness of the place, communities and individuals were considered a key part of the foundations for good health and wellbeing.

In [case study], our belief is that our people are our greatest strength and our most important asset. Wellbeing starts with people: our connections with our friends, family, and colleagues, our behaviour, understanding, and support for one another, as well as the environment we build to live in together . (Paraphrased Document A).

A recognition of the power of communities and individuals with the requirement to support that key principle of a strength-based approach was found. This involved close working with communities to help identify what was important, what was needed and what interventions would work. This could then lead to improved resilience and cohesion.

‛You can't make effective health and care decisions without having the voice of people at the centre of that. It just won't work. You won't make the right decisions.’ (LP16).

‘Build on the strengths in ourselves, our families, carers and our community; working with people, actively listening to what matters most to people, with a focus on what’s strong rather than what’s wrong’ (Document G).

Meaningful engagement with communities as well as strengths and asset-based approaches to ensure self-sufficiency and sustainability of communities can help communities flourish. This includes promoting friendships, building community resilience and capacity, and inspiring residents to find solutions to change the things they feel needs altering in their community . (Paraphrased Document B).

This close community engagement had been reported to foster trust and to lead to improvements in health.

‘But where a system or an area has done a lot of community engagement, worked really closely with the community, gained their trust and built a programme around them rather than just said, “Here it is. You need to come and use it now,” you can tell that has had the impact. ' (LP1).

Finally, workforce was another key asset; the documents raised the concept of one workforce across health and care. The key principles of having a shared vision, asset-based approaches and strong partnership were also present in this example:

By working together, the Health and Care sector makes [case study] the best area to not only work but also train for people of all ages. Opportunities for skills and jobs are provided with recruitment and engagement from our most disadvantaged communities, galvanizing the future’s health and care workforce. By doing this, we have a very skilled and diverse workforce we need to work with our people now as well as in the future. (Paraphrased Document E).

An action identified for the health and care system to address health inequalities in case study 1 was ‘ the importance of having an inclusive workforce trained in person-centred working practices ’ (Document R). Several ways were found to improve and support workforce skills development and embed awareness of health inequalities in practice and training. Various initiatives were available such as an interactive health inequalities toolkit, theme-related fellowships, platforms and networks to share learning and develop skills.

‛We've recently launched a [redacted] Fellowship across [case study’s region], and we've got a number of clinicians and managers on that………. We've got training modules that we've put on across [case study’s region], as well for health inequalities…we've got learning and web resources where we share good practice from across the system, so that is our [redacted] Academy.’ (LP2).

This case study also recognised the importance of considering the welfare of the workforce; being skilled was not enough. This had been recognised pre-pandemic but was seen as even more important post COVID-19 due to the impact that COVID-19 had on staff, particularly in health and social care.

‛The impacts of the pandemic cannot be underestimated; our colleagues and services are fatigued and still dealing with the pressures. This context makes it even more essential that we share the responsibility, learn from each other at least and collaborate with each other at best, and hold each other up to be the best we can.’ (Document U).

Concerns were raised such as the widening of health inequalities since the pandemic and cost of living crisis. Post-pandemic and Brexit, recruiting health, social care and third sector staff was compounding the capacity throughout this already heavily pressurised system.

In [case study], we have seen the stalling of life expectancy and worsening of the health inequality gap, which is expected to be compounded by the effects of the pandemic. (Paraphrased Document T)

‘I think key barriers, just the immense pressure on the system still really […] under a significant workload, catching up on activity, catching up on NHS Health Checks, catching up on long-term condition reviews. There is a significant strain on the system still in terms of catching up. It has been really difficult because of the impact of COVID.’ (LP7).

‘Workforce is a challenge, because the pipelines that we’ve got, we’ve got fewer people coming through many of them. And that’s not just particular to, I don't know, nursing, which is often talking talked [sic] about as a challenged area, isn't it? And of course, it is. But we’ve got similar challenges in social care, in third sector.’ (LP5).

The pandemic was reported to have increased pressures on the NHS and services not only in relation to staff capacity but also regarding increases in referrals to services, such as mental health. Access to healthcare changed during the pandemic increasing barriers for some:

‘I think people are just confused about where they're supposed to go, in terms of accessing health and care at the moment. It's really complex to understand where you're supposed to go, especially, at the moment, coming out of COVID, and the fact that GPs are not the accessible front door. You can't just walk into your GP anymore.’ (LP16).

‘Meeting this increased demand [for work related to reducing ethnic inequalities in mental health] is starting to prove a challenge and necessitates some discussion about future resourcing.’ (Document S)

Several ways were identified to aid effective adaptation and/or mitigation. This included building resilience such as developing the existing capacity, capability and flexibility of the system by learning from previous work, adapting structures and strengthening workforce development. Considerations, such as a commitment to Marmot Principles and how funding could/would contribute, were also discussed.

The funding’s [linked to Core20PLUS5] purpose is to help systems to ensure that health inequalities are not made worse when cost-savings or efficiencies are sought…The available data and insight are clear and [health inequalities are] likely to worsen in the short term, the delays generated by pandemic, the disproportionate effect of that on the most deprived and the worsening food and fuel poverty in all our places. (Paraphrased Document L).

Learning from the pandemic was thought to be useful as some working practices had altered during COVID-19 for the better, such as needing to continue to embed how the system had collaborated and resist old patterns of working:

‘So I think that emphasis between collaboration – extreme collaboration – which is what we did during COVID is great. I suppose the problem is, as we go back into trying to save money, we go back into our old ways of working, about working in silos. And I think we’ve got to be very mindful of that, and continue to work in a different way.’ (LP11).

Another area identified as requiring action, was the collection, analysis, sharing and use of data accessible by the whole system.

‘So I think there is a lot of data out there. It’s just how do we present that in such a way that it’s accessible to everyone as well, because I think sometimes, what happens is that we have one group looking at data in one format, but then how do we cascade that out?’ (LP12)

We aimed to explore a system’s level understanding of how a local area addresses health inequalities with a focus on avoidable emergency admissions using a case study approach. Therefore, the focus of our research was strategic and systematic approaches to inequalities reduction. Gaining an overview of what was occurring within a system is pertinent because local areas are required to have a regard to address health inequalities in their local areas [ 20 , 21 ]. Through this exploration, we also developed an understanding of the system's processes reported to be required. For example, an area requiring action was viewed as the accessibility and analysis of data. The case study described having health inequalities ‘at the heart of its health and wellbeing strategy ’ which was echoed across the documents from multiple sectors across the system. Evidence of a values driven partnership with whole systems working was centred on the importance of place and involving people, with links to a ‘strong third sector ’ . Working together to support and strengthen local assets (the system, services/support, communities/individuals, and the workforce) were vital components. This suggested a system’s committed and integrated approach to improve population health and reduce health inequalities as well as concerted effort to increase system resilience. However, there was juxtaposition at times with what the documents contained versus what interviewees spoke about, for example, the degree to which asset-based approaches were embedded.

Furthermore, despite having a priori codes for the documentary analysis and including specific questions around work being undertaken to reduce health inequalities in avoidable admissions in the interviews with key systems leaders, this explicit link was still very much under-developed for this case study. For example, how to reduce health inequalities in avoidable emergency admissions was not often specified in the documents but could be inferred from existing work. This included work around improving COVID-19 vaccine uptake in groups who were identified as being at high-risk (such as older people and socially excluded populations) by using local intelligence to inform where to offer local outreach targeted pop-up clinics. This limited explicit action linking reduction of health inequalities in avoidable emergency admissions was echoed in the interviews and it became clear as we progressed through the research that a focus on reduction of health inequalities in avoidable hospital admissions at a systems level was not a dominant aspect of people’s work. Health inequalities were viewed as a key part of the work but not necessarily examined together with avoidable admissions. A strengthened will to take action is reported, particularly around reducing health inequalities, but there were limited examples of action to explicitly reduce health inequalities in avoidable admissions. This gap in the systems thinking is important to highlight. When it was explicitly linked, upstream strategies and thinking were acknowledged as requirements to reduce health inequalities in avoidable emergency admissions.

Similar to our findings, other research have also found networks to be considered as the system’s backbone [ 30 ] as well as the recognition that communities need to be central to public health approaches [ 51 , 55 , 56 ]. Furthermore, this study highlighted the importance of understanding the local context by using local routine and bespoke intelligence. It demonstrated that population-based approaches to reduce health inequalities are complex, multi-dimensional and interconnected. It is not about one part of the system but how the whole system interlinks. The interconnectedness and interdependence of the system (and the relevant players/stakeholders) have been reported by other research [ 30 , 57 ], for example without effective exchange of knowledge and information, social networks and systems do not function optimally [ 30 ]. Previous research found that for systems to work effectively, management and transfer of knowledge needs to be collaborative [ 30 ], which was recognised in this case study as requiring action. By understanding the context, including the strengths and challenges, the support or action needed to overcome the barriers can be identified.

There are very limited number of case studies that explore health inequalities with a focus on hospital admissions. Of the existing research, only one part of the health system was considered with interviews looking at data trends [ 35 ]. To our knowledge, this research is the first to build on this evidence by encompassing the wider health system using wider-ranging interviews and documentary analysis. Ford et al. [ 35 ] found that geographical areas typically had plans to reduce total avoidable emergency admissions but not comprehensive plans to reduce health inequalities in avoidable emergency admissions. This approach may indeed widen health inequalities. Health inequalities have considerable health and costs impacts. Pertinently, the hospital care costs associated with socioeconomic inequalities being reported as £4.8 billion a year, mainly due to excess hospitalisations such as avoidable admissions [ 58 ] and the burden of disease lies disproportionately with our most disadvantaged communities, addressing inequalities in hospital pressures is required [ 25 , 26 ].

Implications for research and policy

Improvements to life expectancy have stalled in the UK with a widening of health inequalities [ 12 ]. Health inequalities are not inevitable; it is imperative that the health gap between the deprived and affluent areas is narrowed [ 12 ]. This research demonstrates the complexity and intertwining factors that are perceived to address health inequalities in an area. Despite the evidence of the cost (societal and individual) of avoidable admissions, explicit tackling of inequality in avoidable emergency admissions is not yet embedded into the system, therefore highlights an area for policy and action. This in-depth account and exploration of the characteristics of ‘whole systems’ working to address health inequalities, including where challenges remain, generated in this research will be instrumental for decision makers tasked with addressing health and care inequalities.

This research informs the next step of exploring each identified theme in more detail and moving beyond description to develop tools, using a suite of multidimensional and multidisciplinary methods, to investigate the effects of interventions on systems as previously highlighted by Rutter et al. [ 5 ].

Strengths and limitations

Documentary analysis is often used in health policy research but poorly described [ 44 ]. Furthermore, Yin reports that case study research is often criticised for not adhering to ‘systematic procedures’ p. 18 [ 41 ]. A clear strength of this study was the clearly defined boundary (in time and space) case as well as following a defined systematic approach, with critical thought and rationale provided at each stage [ 34 , 41 ]. A wide range and large number of documents were included as well as interviewees from across the system thereby resulting in a comprehensive case study. Integrating the analysis from two separate methodologies (interviews and documentary analysis), analysed separately before being combined, is also a strength to provide a coherent rich account [ 49 ]. We did not limit the reasons for hospital admission to enable a broad as possible perspective; this is likely to be a strength in this case study as this connection between health inequalities and avoidable hospital admissions was still infrequently made. However, for example, if a specific care pathway for a health condition had been highlighted by key informants this would have been explored.

Due to concerns about identifiability, we took several steps. These included providing a summary of the sectors that the interviewees and document were from but we were not able to specify which sectors each quote pertained. Additionally, some of the document quotes required paraphrasing. However, we followed a set process to ensure this was as rigorous as possible as described in the methods section. For example, where we were required to paraphrase, each paraphrased quote and original was shared and agreed with all the authors to reduce the likelihood to inadvertently misinterpreting or misquoting.

The themes are unlikely to represent an exhaustive list of the key elements requiring attention, but they represent the key themes that were identified using a robust methodological process. The results are from a single urban local authority with high levels of socioeconomic disadvantage in the North of England which may limit generalisability to different contexts. However, the findings are still generalisable to theoretical considerations [ 41 ]. Attempts to integrate a case study with a known framework can result in ‘force-fit’ [ 34 ] which we avoided by developing our own framework (Fig. 1 ) considering other existing models [ 14 , 59 ]. The results are unable to establish causation, strength of association, or direction of influence [ 60 ] and disentangling conclusively what works versus what is thought to work is difficult. The documents’ contents may not represent exactly what occurs in reality, the degree to which plans are implemented or why variation may occur or how variation may affect what is found [ 43 , 61 ]. Further research, such as participatory or non-participatory observation, could address this gap.

Conclusions

This case study provides an in-depth exploration of how local areas are working to address health and care inequalities, with a focus on avoidable hospital admissions. Key elements of this system’s reported approach included fostering strategic coherence, cross-agency working, and community-asset based working. An area requiring action was viewed as the accessibility and analysis of data. Therefore, local areas could consider the challenges of data sharing across organisations as well as the organisational capacity and capability required to generate useful analysis in order to create meaningful insights to assist work to reduce health and care inequalities. This would lead to improved understanding of the context including where the key barriers lie for a local area. Addressing structural barriers and threats as well as supporting the training and wellbeing of the workforce are viewed as key to building resilience within a system to reduce health inequalities. Furthermore, more action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Availability of data and materials

Individual participants’ data that underlie the results reported in this article and a data dictionary defining each field in the set are available to investigators whose proposed use of the data has been approved by an independent review committee for work. Proposals should be directed to [email protected] to gain access, data requestors will need to sign a data access agreement. Such requests are decided on a case by case basis.

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Acknowledgements

Thanks to our Understanding Factors that explain Avoidable hospital admission Inequalities - Research study (UNFAIR) PPI contributors, for their involvement in the project particularly in the identification of the key criteria for the sampling frame. Thanks to the research advisory team as well.

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Informed consent was obtained from all subjects involved in the study.

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The manuscript is not currently under consideration or published in another journal. All authors have read and approved the final manuscript.

This research was funded by the National Institute for Health and Care Research (NIHR), grant number (ref CA-CL-2018-04-ST2-010). The funding body was not involved in the study design, collection of data, inter-pretation, write-up, or submission for publication. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or Newcastle University.

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Charlotte Parbery-Clark

Post-Doctoral Research Associate, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

Lorraine McSweeney

Senior Research Methodologist & Public Involvement Lead, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

Joanne Lally

Senior Clinical Lecturer &, Faculty of Medical Sciences, Honorary Consultant in Public Health, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

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Conceptualization - J.L. and S.S.; methodology - C.P.-C., J.L. & S.S.; formal analysis - C. P.-C. & L.M.; investigation- C. P.-C. & L.M., resources, writing of draft manuscript - C.P.-C.; review and editing manuscript L.M., J.L., & S.S.; visualization including figures and tables - C.P.-C.; supervision - J.L. & S.S.; project administration - L.M. & S.S.; funding acquisition - S.S. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Charlotte Parbery-Clark or Sarah Sowden .

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Parbery-Clark, C., McSweeney, L., Lally, J. et al. How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK. BMC Public Health 24 , 2168 (2024). https://doi.org/10.1186/s12889-024-19531-5

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A novel approach for material handling-driven facility layout.

1. Introduction

• Layouts with facilities that have different areas;
• Facilities whose shape can change with an aspect ratio;
• Layouts with FBSs;
• Assignment of different types of MHD;
• Considering the purchase, use, and non-use of MHD;
• Decisions on facility layouts are made simultaneously with decisions on material-handling vehicles.

2. Background

3. materials and methods, 3.1. the mathematical model used for the problem, 3.2. outline of the proposed hybrid heuristics, 3.3. genetic algorithm, 3.3.1. individual representation, 3.3.2. evaluation of an individual.

3.3.3. Selection Method

3.3.4. crossover process, 3.3.5. mutation process, 3.4. the simulated annealing algorithm, 3.4.1. solution encoding in the hsa, 3.4.2. evaluation of a solution, 3.4.3. neighborhood structure, 4.1. parameter tunning, 4.2. results for known instances, 4.2.1. results for the fbs-dflp-1 instance, 4.2.2. results for the fbs-dflp-2 instance, 4.2.3. results for the fbs-dflp-3 instance, 4.2.4. results for the fbs-dflp-4 instance, 4.2.5. evaluation of results, 4.3. computational study, 4.4. sensitivity analysis, 5. conclusions, author contributions, data availability statement, acknowledgments, conflicts of interest, nomenclature.

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Erik, A.; Kuvvetli, Y. A Novel Approach for Material Handling-Driven Facility Layout. Mathematics 2024 , 12 , 2548. https://doi.org/10.3390/math12162548

Erik A, Kuvvetli Y. A Novel Approach for Material Handling-Driven Facility Layout. Mathematics . 2024; 12(16):2548. https://doi.org/10.3390/math12162548

Erik, Adem, and Yusuf Kuvvetli. 2024. "A Novel Approach for Material Handling-Driven Facility Layout" Mathematics 12, no. 16: 2548. https://doi.org/10.3390/math12162548

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• Published: 14 August 2024

Understanding the role of mobility in the recorded levels of violent crimes during COVID-19 pandemic: a case study of Tamil Nadu, India

• Kandaswamy Paramasivan   ORCID: orcid.org/0000-0002-8130-9266 1 , 2 ,
• Saish Jaiswal 3 ,
• Rahul Subburaj 4 &
• Nandan Sudarsanam 5  

Crime Science volume  13 , Article number:  21 ( 2024 ) Cite this article

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Purpose/Goal

This research investigates the potential link between mobility and violent crimes in Tamil Nadu, India, using an empirical study centred on the COVID-19 pandemic waves (2020–2022). The goal is to understand how these events influenced crime, employing a counterfactual approach.

The study employs the XGBoost algorithm to forecast counterfactual events across different timeframes with varying levels of mobility. The mobility data sources include historical bus and passenger records spanning a decade, along with Google Community Mobility Reports added during the pandemic phases. The foundation for crime analysis is built upon the univariate time series of violent crimes reported as First Information Reports from 2010 to 2022.

Results indicate a significant correlation between mobility and violent crimes when mobility drops below a specific threshold. However, no such correlation is observed when mobility is above this threshold during the non-pandemic periods. The COVID-19 pandemic had a major impact on people’s and vehicular mobility, especially during the complete lockdown periods of the first two waves, and also affected crime rates.

Conclusions

The decrease in recorded incidents could also be attributed to fewer criminal opportunities. Additionally, this could be due to unfavourable situational factors, such as victims’ limited access to appropriate health and law enforcement agencies to report crimes. Furthermore, frontline services were busy with pandemic-related commitments, which could have contributed to a lack of crime registration even when crimes were committed.

Introduction

Mobility holds a pivotal role in shaping crime dynamics by influencing spatial crime distribution and victimisation risks (Browning et al., 2021 ). It impacts opportunities for crime, either by bringing together potential offenders and targets or by disrupting social controls and fostering anonymity (Felson & Cohen, 1980 ). This understanding is vital for crafting effective crime prevention strategies.

In Tamil Nadu, India, human mobility is influenced by a multitude of factors. Public health crises, such as the COVID-19 pandemic, have led to lockdowns and social distancing measures, markedly altering mobility patterns (Paramasivan et al., 2022 ). Natural disasters, including cyclones and floods, particularly in Chennai, necessitate evacuations and disrupt travel, as observed by Narayan ( 2017 ) . Economic drivers also play a role, with certain cities experiencing an influx of guest workers (Ramesh & Ramya, 2023 ). Political events, like the deaths of prominent leaders, have drawn millions to urban areas, drastically impacting mobility ( The Asian Age , 2018 ; Times of Islamabad , 2016 ). Additionally, technological advancements have facilitated remote work, reducing the need for commuting (Mukherjee & Narang, 2023 ). Improved transportation infrastructure undoubtedly plays a role in influencing movement patterns. Overall even during non-pandemic times, there is considerable variation in the mobility pattern.

Extreme events like pandemics significantly disrupt mobility patterns, primarily due to imposed travel restrictions and social distancing measures. (de Palma et al., 2022 ). Such disruptions can cause disorientation and economic hardships, affecting people’s ability to move (Onyeaka et al., 2021 ). Grasping these effects is crucial for responding to crises and curbing their impact on public safety.

To capture this dynamic mobility landscape, the study utilises two key data sources. First, it leverages passenger and operational data spanning a decade (Jan. 2010 – Dec. 2022) from one of the largest bus transport corporations in the region that is responsible for all the public transport in Tamil Nadu. Second, the study incorporates Google Mobility Community Reports for Tamil Nadu, encompassing pandemic and post-pandemic periods across six land-use categories. This comprehensive data approach will enable a nuanced understanding of human mobility patterns within Tamil Nadu.

The COVID-19 pandemic’s unprecedented restrictions on movement offer a unique opportunity to examine the causal relationship between human mobility and violent crime rates. Taking advantage of a situation resembling a natural experiment, this study examines how changes in mobility patterns, especially during the three distinct pandemic waves with varying lockdown strictness, affect violent crime rates in Tamil Nadu (TN), India.

Directly comparing crime rates during the pandemic to pre-pandemic periods can be misleading due to factors like existing trends, seasonal variations, and holiday effects. To overcome this challenge, this research utilises a counterfactual approach that quantifies the impact of the pandemic on violent crime. The study employs a robust machine learning model, XGBoost, to perform a counterfactual prediction. This analysis estimates the crime rate that would have likely occurred in the absence of the pandemic. By comparing the actual reported crime rate with the predicted counterfactual rate, we can isolate the causal impact of the pandemic on crime.

To further elucidate the relationship between mobility and crime, the study replicates the counterfactual analysis using mobility data, specifically focusing on passenger volume and the number of buses operating. Although the primary emphasis is on the pandemic period and its induced mobility patterns in Tamil Nadu, the research spans nearly a decade, providing a broader context for understanding the dynamics between mobility and violent crime. This extensive approach enables a comprehensive assessment of how variations in mobility influence violent crime rates in Tamil Nadu, extending beyond the pandemic period alone.

Literature review and theoretical framework

Human mobility and crime.

Browning and colleagues ( 2021 ) highlight the growing importance of human mobility in understanding crime patterns. They propose three key perspectives: place and neighborhood approaches, which analyze how the concentration of potential offenders, victims, and guardians in specific areas influences crime rates; person-centered approaches, which focus on individual movements and interactions with places to assess personal crime risk; and ecological network approaches, which examine broader systems of connections based on shared activity locations to understand how these connections impact crime variations at both individual and spatial levels. These perspectives collectively underscore the increasing theoretical significance of mobility within the field of criminology. Studies have demonstrated that increased human mobility often correlates with higher property crime rates in large cities. This suggests that previous research on population size and crime rates might have been skewed by the presence of “floating populations” (e.g., tourists, temporary workers) rather than solely focusing on resident populations (Caminha et al., 2017 ). Furthermore, research indicates that the interconnectedness of human mobility networks plays a crucial role in predicting violent crime, even more so than geographical proximity alone. Neighborhoods experiencing significant changes in mobility patterns often see a rise in violent incidents, highlighting the importance of considering mobility dynamics in crime prevention strategies (Vachuska, 2022 ).Several studies have successfully used aggregated human mobility data from mobile networks, combined with demographic information, to accurately predict crime hotspots in cities like London (Bogomolov et al., 2014 ). Including mobility data in crime prediction models has demonstrably improved accuracy, with studies showing increases of up to 89% (Kadar & Pletikosa, 2018 ) and 70% (Wu et al., 2022 ).

It’s important to note that the influence of human mobility on crime likely varies depending on the specific crime type. Crimes like cybercrime, domestic violence, child sexual abuse, institutional crimes (e.g., corruption), and certain white-collar crimes are often driven by unique opportunity structures and may be less influenced by location compared to violent crimes like homicide, assault, and rioting.

Impact of COVID-19 on violent crime worldwide

The COVID-19 pandemic has undoubtedly impacted the occurrence and reporting of violent crime worldwide. A complex interplay of factors, including mobility restrictions, media coverage, mental health impacts, resource availability, and emergency response efforts, has contributed to these changes. Research findings indicate that the pandemic’s effects on crime varied significantly across countries and crime categories (Nivette et al., 2021 ).

As LeClerc and Wortley ( 2013 ) emphasise, it’s crucial to avoid overgeneralizing crime patterns in criminology. Understanding the specific decision-making processes of offenders is essential for developing effective crime prevention strategies.

This emphasis on specificity is crucial, especially within crime types, to grasp the nuances of shifting crime patterns. It becomes even more critical during pandemics, where understanding subtle changes, like opportunity structures, is paramount. For instance, pandemic-induced alterations in daily routines can lead to decreased populations in non-residential areas and increased populations in residential zones (Stickle et al., 2020 ).

The opportunity structure for a particular form of crime is not always the same. Most property offences, for example, have greatly dropped, as have road traffic accidents (Paramasivan et al., 2022 ). Murder, assault, and rioting, on the other hand, increased in certain places in the USA (Kim, 2022 ; Meyer et al., 2022 ) while remaining stable (Campedelli et al., 2021 ) or dropping in others (Calderon-Anyosa & Kaufman, 2021 ).

Regarding the pandemic, a few research works predict a drastic to moderate reduction in all crimes, including violent crimes (Abrams, 2020 ; Cheung & Gunby, 2021 ; Halford et al., 2020 ; Nivette et al., 2021 ). On the other hand, there are contradictory patterns of increased violent crimes in many places around the world (Hilsenrath, 2020 ; Kourti et al., 2021 ; Krishnakumar et al., 2021 ; Maji et al., 2021 ; Piquero et al., 2021 ; Raghavan, 2021 ).

According to Abrams ( 2020 ) , the theoretical framework of opportunity theory posits that a decrease in interpersonal connection during the various pandemic phases is likely to result in a corresponding decline in opportunities for the commission of specific violent crimes, including assault, rape, and robbery. The potential impact of implementing or removing restrictions on mobility is expected to have an effect on the incidence of reported criminal activities, either registering an increase or decrease in crime rates. The authors suggest that this discovery provides empirical backing for routine activities/opportunity theory, as there is a positive correlation between the incidence of violent crime and the increased mobility of potential victims and offenders across temporal and spatial dimensions (Lopez & Rosenfeld, 2021 ).

The researchers of the present work seek to explain the role of mobility in the recorded levels of violent crimes on the basis of Crime Pattern Theory (Brantingham et al., 2016 ), Routine Activity Theory (RAT) (Felson & Cohen, 1980 ) and Crime Opportunity Theory (Hannon, 2002 ). Crime Pattern Theory, which is based on environmental psychology, emphasises the relevance of people’s habitual actions in raising awareness of criminal opportunities. First, offenders may be able to discover criminal opportunities more quickly and frequently near their points of activity, known as nodes. Qualitative research has established that the potential for crime opportunity awareness exists in the family, workplace, and other non-criminal settings (Curtis-Ham et al., 2023 ). Some quantitative research works (Brantingham & Brantingham, 1993 ; Menting et al., 2019 ; van Sleeuwen et al., 2021 ) suggest that offenders are more likely to commit crimes near their houses, the residences of close relatives, and the sites of previous offences than in other regions. On the other hand, because normal activities play a role in raising awareness of criminal chances, the likelihood of offending is highest near activity nodes and diminishes with distance. This decreasing distance pattern reflects the fact that people are more familiar with places closer to their activity locations than with areas farther away, and familiarity is a major component in crime location selection. All of this is also consistent with the concept of least effort: in theory, people will take the smallest distance possible to find a chance to commit a crime (Curtis-Ham et al., 2020 ). When mobility is severely hampered in the context of extraordinary circumstances such as a pandemic, there is a lower probability of crime occurrence due to fewer crime opportunities and a lower likelihood of committing offences near activity space where there is increased guardianship.

Building on the comprehensive discussion of human mobility’s influence on crime and the pandemic’s impact on crime rates, this literature review highlights a critical gap. While existing research explores these topics, there is a scarcity of studies examining the relationship between mobility and crime across an extended timeframe encompassing both pre-pandemic normalcy and the entire COVID-19 pandemic period (2020–2022).

This research aims to address this gap by investigating the potential link between mobility and violent crimes in Tamil Nadu, India, using an empirical study focused on the COVID-19 pandemic waves. This counterfactual approach will employ the XGBoost algorithm to forecast crime occurrences under hypothetical scenarios with varying levels of mobility.

The study employs counterfactual analysis using the rich datasets spanning a decade: historical bus and passenger records for mobility data and First Information Reports (FIRs) for crime data from 2010 to 2022. By analyzing these data in conjunction with Google Community Mobility Reports from the pandemic period, this research seeks to find the relationship between human mobility and violent crime.

Data and method

In response to the World Health Organization’s (WHO) declaration of COVID-19 as a pandemic, the Government of Tamil Nadu, under the National Disaster Management Act, 2006, issued emergency orders through the Revenue and Disaster Management Department to contain the virus by restricting movement. Throughout 2020–2022, the department released a series of government orders (GOs) that prohibited, restricted, or relaxed activities for individuals, organisations, and agencies. These GOs, available on the official government website, document the lockdown measures implemented during Waves 1 and 2 ( Government of Tamil Nadu. (2020). Order: Wave 1 ; Government of Tamil Nadu. (2021). Order: Wave 2 ). During Wave 3, although mandatory restrictions were not imposed, the government issued precautionary measures and advisories to encourage public safety.

The study investigates three pandemic waves that occurred from Mar. 23, 2020 to Aug. 31, 2020, Apr. 10, 2021 to Jun. 07, 2021 and Jan. 07, 2022 to Feb. 17, 2022, respectively, spanning 2020–2022. The region of analysis is Tamil Nadu, the sixth most populous state in India. Figure  1 illustrates the study’s timeline across various windows corresponding to the pandemic waves. Criminality was evaluated using time-series data, primarily focusing on crimes against individuals documented through First Information Reports (FIRs) — formal reports of cognisable offences initiating investigations.

The timeline for the different phases of lockdowns during the three pandemic waves (W1, W2, and W3) in 2020–2022

Lockdown severity fluctuated throughout the pandemic. Complete lockdown (CL) represented the most stringent measures, prohibiting all movement of people and vehicles. All institutions, markets, businesses, and shops, including those selling essential goods like alcohol, were completely shut down. People were mandated to stay indoors except for limited windows for purchasing medicines, essential groceries and vegetables. Social gatherings, including funerals and weddings, were heavily restricted. Exceptions were made for vehicles transporting essential goods and personnel involved in pandemic response, particularly healthcare, police, and local administration.

Partial lockdown (PL) introduced a gradual easing of these restrictions. Key industries and establishments reopened with limited staff and operating hours. Shops selling essential goods received extended opening times compared to CL. Alcohol sales were permitted for a limited daily window. Social gatherings of up to 50 people were allowed, but large venues like stadiums, theatres, malls, and major markets remained closed. Importantly, schools and colleges stayed shut, and private taxis and public transportation like buses, trains, and coaches remained non-operational.

The research relies on the First Information Reports (FIRs) registered in Tamil Nadu. Crimes are reported via FIRs in TN’s 1356 police stations, primarily governed by the Indian Penal Code (IPC) Chapter XVI (Sects. 299–377) for crimes against the human body. The analysis centres on frequently reported offenses within this category — including murder, attempted murder, aggravated assault, and rioting. The study employs univariate time series data of the state’s daily crime count spanning Jan. 1, 2010, to Dec. 31, 2022, for counterfactual analysis.

This research leverages mobility data from two sources to provide a comprehensive picture of the movement of people and vehicles in Tamil Nadu. The first source, encompassing daily bus and passenger frequency data from the Tamil Nadu State Transport Corporation (TNSTC) between Jan. 1, 2010 and Dec. 31, 2022, offers over a decade of pre-pandemic and pandemic period information. The second source, the Google Community Mobility Report, provides data on movement trends across six land-use zones within TN during the pandemic and post-pandemic period. By combining these two datasets, the study gains a richer understanding of mobility patterns throughout the region.

Google Community Mobility Reports (GCMR) that utilise user data — especially from handheld devices — are used to assess mobility trends for the pandemic phases. GCMR categorises user presence and time spent in domains like ‘retail and recreation’, ‘parks’, ‘groceries and pharmacies’, ‘workplaces’, ‘transit stations’, and ‘residential areas’ to gauge mobility changes. For each domain (e.g., retail, grocery stores), it calculates the relative change in visits compared to a pre-pandemic baseline (median visits from Jan. 3, 2020, to Feb. 6, 2020). This change signifies mobility trends within that domain. For example, a -20% change in retail visits signifies a 20% decrease compared to the baseline, while a + 15% change in residential time indicates a 15% increase in time spent at home.

The research starts with an exploratory analysis to determine if the pandemic caused significant changes in crime rates. Instead of merely comparing the mean or median of daily crime frequencies between pandemic and non-pandemic periods, it compares the distributions to identify any differential impacts. The Shapiro-Wilk Test is used to check for normality. Given that the population sizes differ between the periods, normality is likely violated, so the Mann-Whitney U test, a non-parametric test, is employed to check for statistical differences between the two distributions. To quantify the difference, Cliff’s Delta, another non-parametric measure of effect size, is used (Hess et al., 2014 ).

In the next level, to gauge the impact of the pandemic specifically and only on the major violent crimes, including attempted murder, murder, aggravated assault and rioting, the study deploys counterfactual analysis as the simplistic aggregated comparison done might be erroneous as likely it would have missed the trend, seasonality and holiday effects of the time series of the past historical data. This study utilizes XGBoost, a machine learning algorithm for time series forecasting and counterfactual analysis, to make predictions during the pandemic period based on a decade of historical data. The historical data is used to create lag and rolling features, capturing trends and patterns for accurate predictions. The variables include daily crime counts. The research involves creating and fine-tuning models through training, validation, and forecasting stages, as detailed in Table  1 .

During training, XGBoost sequentially trains decision trees, improving model accuracy by focusing on incorrectly predicted observations and predicting their residuals. The algorithm monitors performance on a validation set to avoid overfitting, using an early stopping criterion when validation performance stops improving.

The model’s accuracy is evaluated using the weighted mean absolute percentage error (WMAPE) metric, which avoids infinite errors by addressing zero crime days. WMAPE is calculated as the summation of absolute differences between actual and predicted values divided by the summation of actual values over the time period t from 1 to n.

To gain a more comprehensive understanding of the pandemic’s impact, the counterfactual analysis is replicated for mobility data. This analysis explores changes in both vehicular mobility (number of buses operated) and people’s mobility (passenger travel).

Next, a deeper investigation assesses the pandemic’s influence on four specific violent crimes. Utilising data from the Google Community Mobility Report (GCMR), the analysis examines these crimes across six land-use categories. This detailed exploration considers data from three distinct pandemic waves, further divided into nine phases with varying mobility patterns.

Similar to the crime analysis, the researchers compare actual and predicted distributions for mobility and crime data using appropriate statistical tests. Finally, Cliff’s Delta, a non-parametric effect size measure, is employed to quantify the magnitude of these effects.

In the last part of the investigation, the study evaluates Pearson’s correlation coefficient between mobility metrics and four categories of violent crime for various phases in the pandemic period. The mobility metrics in the results include transportation data (buses operated and passengers traveled) as well as the percentage change in mobility provided by GCMR. The carefully examined relationship between these factors becomes one of the major findings of the research.

Compared to non-pandemic periods, most crime categories – including violent crime, property offenses, and crimes against women and children – showed statistically significant declines during the pandemic. However, the decrease was negligible for these crimes. Road crashes, domestic violence, and theft saw substantial reductions with medium to large effect sizes. Notably, child sexual abuse cases exhibited a large effect size increase during the pandemic compared to non-pandemic times (see Table  2 ).

The counterfactual analysis performed using XGBoost prediction provided results within acceptable levels of accuracy for several time series forecasts (see Table  3 ). The investigation yielded two significant results. The first is about counterfactual analysis of the impact on crime and mobility during exceptional circumstances, and the second is about descriptive statistical analysis exploring the relationship between mobility and recorded levels of crime at all times.

Counterfactual daily counts of violent crimes represent incidents without an emergency. The observed/actual daily violent crime counts and predicted numbers in a non-emergency scenario were compared. The Wilcoxon test revealed no significant variations in distributions across violent crime categories throughout time frames, as highlighted in Table  4 , except during the complete lockdown in Wave-1 when all violent crimes reported a significant drop in recorded levels. During this severely restricted movement period, the effect size for aggravated assault, attempted murder, murder, and rioting was − 0.96, -0.4, -0.45, and − 0.28 compared to the counterfactual (refer to Table  5 ). The most noticeable effect was on aggravated assault levels. This trend is visually illustrated in Fig.  2 , which showcases a distinct decline in aggravated assault cases during Wave-1’s lockdown. The counterfactual analysis was extended to measure people’s mobility and vehicular mobility during the COVID-19 pandemic, and it revealed that only during Wave-1 of the pandemic was there a significant reduction in both mobilities, whereas during the non-pandemic period did not report any significant reduction as can be seen in the effect sizes which were negligible or small (See also Table  6 and Table  7 ). These findings mirror the analysis of the Google Mobility Community Report (GMCR) in Table  8 . The GMCR investigation, which is not a counterfactual analysis, is only applicable during the pandemic phases and compares pandemic mobility to pre-pandemic mobility.

A , B Plot of actual and predicted daily aggravated assault cases in TN during pandemic waves 1, 2, and 3

The study analyses the correlation between registered crimes and mobility (transportation department data) using Pearson’s correlation coefficient (r) based on daily crime counts and mobility data from Jan. 1, 2010, to Dec. 31, 2022. Table  9 indicates a negligible correlation between crimes and vehicular mobility, and the same for people’s mobility, except for aggravated assault (r = + 0.456) and child sexual abuse ( r = -0.577), moderately correlated to people’s mobility via passenger counts.

The investigation distinguishes between crisis (pandemic lockdowns) and non-emergency periods, particularly during 2010–2022. Analysis within these emergency periods reveals a significant correlation between mobility and violent crimes during severe restrictions, importantly in complete lockdown phases of the first two pandemic waves. Particularly, aggravated assault cases displayed a significant correlation during restricted mobility windows in pandemic lockdowns of Wave-1 and Wave-2. Noticeably, all categories of violent crimes exhibited moderate correlation during both waves of complete lockdown. People’s mobility and vehicular mobility showed no discernible difference concerning their relationship with registered violent crimes (Table  10 ).

The transportation department’s mobility data validation using GMCR data confirmed the relationship between mobility and violent crime. Figure  3 visually depicts the direct correlation between mobility changes across public spaces and reported crimes in the first six time windows from Wave-1 to Post-Wave-2. The percentage variations in mobility in different time frames follow the same trend, with the exception of the residential zone, where mobility increased as people stayed indoors more during the lockdown stages. However, the magnitude of such change expectedly varied, with the maximum occurring in the retail and recreation zone and the minimum in the spatial domain of pharmacy and grocery. In the most recent two periods, Wave-3 and post-Wave-3, there is no such correlation, as the percentage change in mobility increased across all land-use categories during these periods.

Relationship between mobility change and reported violent crimes during pandemic waves in TN. The top panels show mobility vs. attempted murder and murder, while the bottom panels depict mobility vs. aggravated assault and rioting

This section begins by highlighting the key findings presented in the previous section. Table  2 presents a straightforward comparative impact on general crimes, revealing a statistically significant difference between crime distributions during the pandemic and non-pandemic periods. However, the effect size for violent crimes, such as attempted murder, murder, rioting, and aggravated assault, is negligible. A more detailed counterfactual comparison dividing the pandemic into nine phases (Table  4 ) shows a substantial drop in all violent crimes during the complete lockdown in Wave-1 when mobility was severely restricted.

When examining the correlation between mobility (using passenger and bus data) and violent crime, significant correlation coefficients were observed during the complete lockdown periods of both waves (Table  10 ). Further analysis across the entire pandemic period, relying on the standards of the range of Pearson’s correlation coefficient (Ratner, 2009 ), found a moderate positive correlation between percentage changes or effect size metrics of mobility and violent crime (Table  11 ).

Unlike the transportation data, which does not categorise crime locations, the GCMR data provides percentage changes in mobility divided into six specific land-use categories, facilitating further analysis. The study reveals a high correlation between changes in mobility within these six land-use categories and four types of violent crimes, as shown in Fig.  3 . Notably, during post-wave-2, wave-3, and post-wave-3 periods, when mobility levels remained stable, this correlation disappeared across all land-use zones and crime categories (Fig.  3 ).

In summary, there is generally no correlation between mobility and violent crimes at all times. However, if mobility falls below a certain threshold, a relationship emerges, with substantial reductions in mobility leading to significant decreases in violent crime.

Recorded levels of crime rates are affected by other situational factors such as victims’ ability, willingness, and eagerness to report crimes (Stefanovska, 2019 ; Wittebrood & Junger, 2002 ) and law enforcement’s proficiency and responsiveness (Boateng, 2016 ). The second wave of COVID-19 was more lethal than the first (Tendulkar et al., 2023 ); India Coronavirus: Worldometer, 2024 ), but violent crimes decreased despite a relative increase in mobility during the complete lockdown during the second wave. This decline may occur due to a clogged crime reporting system and overburdened hospitals and other frontline agencies. Deterioration of the medical infrastructure impedes crime reporting and victim assistance.

During the complete lockdown in wave-1 of the pandemic, the decline in aggravated assault, attempted murder and murder, as reported by Cliffs Delta, were − 0.96, -0.4,-0.45, respectively. In the same period, mobility decreased most significantly in Retail and Recreation zones (-80.5%), followed by Workplace (-64.3%), Transit Stations (-62%), Grocery and Pharmacy (-51.2%), and Parks. Locations such as bars, recreational centers, street-side shops, and bus stations are particularly prone to the above violent crimes (Brantingham et al., 2016 ).

The substantial fall decline in mobility observed in retail and recreational, workplace, transit stations and parks may be attributable to a diminishing criminal opportunity for the offender due to limited activity space (Curtis-Ham et al., 2021 ). According to Brantingham and Brantingham ( 1993 ) , instances of crime arise when the awareness space of offenders, which refers to the areas they are cognizant of in proximity to their activity nodes, intersects with chances for criminal behaviour. The presence of potential targets and the absence of effective guardians create opportunities for criminal activity (Felson & Cohen, 1980 ), however, substantially reduced mobility during the strict stay-at-home orders did not pave the way for such circumstances for crime occurrences.

According to the researchers (Abrams, 2020 ), violent crimes, such as armed robbery, assault, rape, and murder, are declining because there are fewer possibilities for the crimes to occur. During the total lockdown, several locations were shut down. Bars, theatres, malls, restaurants, and concerts, which would ordinarily be locations where offenders would find targets to perpetrate crimes, were closed down. Similarly, there was an increase in mobility in the residential zone, implying enhanced guardianship and less opportunity for crime. The current study is predominantly in line with the work of Clarke ( 2012 ) , who suggests that rather than modifying offender propensity, situational factors facilitate or encourage the actual commission of criminal acts, explaining why some people are more likely to be delinquent or criminal (Clarke, 2012 ).

Whether considering the space-time convergence of routine activities or substantial changes in opportunities for committing crimes or place-based characteristics, these factors are affected only if mobility falls below a certain threshold. Similarly, situational factors that inhibit or impede the reporting and registration of complaints are impacted only when victims’ mobility is severely restricted, as the physical presence of the complainant at the police station is required for investigation. During the complete lockdown, there was almost complete cessation of all modes of transport except a few permitted.

Building on routine activity theory’s focus on the dynamics between offenders, victims, and guardians, research has highlighted the importance of spatial variations in crime at smaller scales, such as street segments and addresses (Eck & Weisburd, 2015 ; Hipp & Williams, 2020 ; McCord & Ratcliffe, 2007 ; Smith et al., 2000 ). Routine activities theory preconditions that a crime occurs when a motivated offender, a suitable target, and the absence of capable guardians converge in time and space. Offenders evaluate the costs and benefits of criminal acts based on immediate environmental conditions. This theory highlights the importance of mobility and the social composition of spaces in relation to offenders, guardians, and targets, leading to extensive research on place-based characteristics that inhibit or promote criminal opportunities (Wilcox & Cullen, 2018 ). It is important to discuss the corollary that during the same relevant time, the increase in mobility in residential zones was 32%. Increased mobility leads to a greater presence of capable guardians, such as parents, neighbors, and teachers, who monitor the area and deter potential offenders. Additionally, place managers who oversee the regular conditions of crime-prone sites are more likely to be present, further enhancing security (Eck, 2003 ; Weisburd et al., 2012 ). This present research empirically supports the exploration of mobility-related factors influencing crime at this “microplace” level.

Certain types of crimes are differently impacted by human mobility, as their opportunity structures may differ or the location may have no significance. These crimes often involve circumstances or motivations less dependent on human mobility, whether involving the offender, victim, or guardian. Cybercrimes, including hacking, phishing, and online fraud, occur in the digital realm and are not reliant on physical human mobility. However, due to reduced human mobility during the pandemic, people were more present in the digital world, either working or on social networking sites or retailing, which caused an increase in these crimes (Hawdon et al., 2020 ).

It can also be said that intimate partner violence typically occurs within private residences and is influenced more by interpersonal conflicts due to jealousy, finances, women’s gender role transgressions than by mobility patterns (Jewkes, 2002 ). Similarly, child sexual abuse often involves perpetrators known to the victim and typically occurs in environments such as homes or familiar settings, making it less influenced by general public mobility (Kaufman et al., 1998 ).

Human mobility will impact these offenses, such as intimate partner violence or child sexual abuse, differently. If mobility includes the presence of the offender for a longer duration, as increased mobility was during the pandemic stay-at-home orders, mobility indirectly impacts these occurrences. Regarding child sexual abuse, the prolonged closure of schools increased the possibility of abuse due to the opportunity for the offender to exploit the victim, while teachers, social workers, and others could not identify such cases and notify the appropriate agency for action (Paramasivan et al., 2023 ).

White-collar crimes, such as financial fraud, embezzlement, and insider trading, are usually conducted in the immediate environment where crime opportunities are discovered and evaluated by potential offenders. They are not significantly affected by the broader mobility of people (Benson et al., 2009 ).

While general human mobility may not directly impact these crimes, changes in societal conditions, such as lockdowns, can still indirectly influence the incidence or reporting of these crimes. For instance, lockdowns may increase domestic violence due to prolonged proximity and stress (Kourti et al., 2021 ), or reduce the reporting of child abuse due to a lack of access to external observers like teachers (Baron et al., 2020 ). As the present study primarily concerns the specific violent crimes discussed, no detailed investigation has been done on whether these crimes are impacted by human mobility. This is identified as a future line of investigation.

The study makes an intriguing observation: when mobility falls below a certain threshold, a strong correlation between mobility and recorded violent crime levels emerges. Otherwise, the research found no relationship between mobility and recorded levels of crime. Stay-at-home orders in certain countries have led to a reduction in violent crimes. During Wave-1’s complete lockdown in Tamil Nadu, both violent crime and mobility decreased, demonstrating a linear relationship.

The impact on vehicular and people’s mobility during the pandemic period experienced a significant decrease in mobility, particularly during the complete lockdown stages of the initial two waves of the pandemic, having a discernible impact on recorded crime levels.

There was an exceptional drop in recorded levels of crime during the complete lockdown period of Wave-1, when mobility across all land-use categories (except residential zones) declined phenomenally. The decline in reported incidents may also be attributable to diminished criminal opportunities. Additionally, this could be due to unfavourable situational factors, such as victims’ limited access to appropriate health and law enforcement agencies to report crimes. In addition, frontline agencies were preoccupied with pandemic-related responsibilities, which may have contributed to a lack of crime registration despite the fact that crimes were committed.

The significant decrease in crime during the lockdown, despite a potential increase in criminal motivation due to the pandemic, aligns with RAT principles. With drastically reduced mobility, offenders had fewer opportunities to encounter suitable targets and evade guardians. Additionally, the increased residential mobility suggests more potential guardians were present at home, further deterring crime. This empirical evidence from the lockdown strengthens the argument that opportunity, not social disorganization, played a major role in the observed crime decline.

Data availability

The authors do not have permission to share the data publicly in view of the confidential agreement between the authors and the departments of Government of India. However data will be made available upon reasonable request from the corresponding author.

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The Indian Institute of Technology Madras and the Robert Bosch Centre for Data Science and Artificial Intelligence (RBCDSAI) are thanked for their support of this work (SB20210605MSRBCX008658).

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Paramasivan, K., Jaiswal, S., Subburaj, R. et al. Understanding the role of mobility in the recorded levels of violent crimes during COVID-19 pandemic: a case study of Tamil Nadu, India. Crime Sci 13 , 21 (2024). https://doi.org/10.1186/s40163-024-00222-w

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Case Study: Design of an Approach for Assessing a Novel Health Capability Maturity Model

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• 1 Deakin University, Information Systems and Business Analytics, Australia.
• 2 Deakin University, School of Medicine, Australia.
• 3 Victorian Department of Health, Australia.
• PMID: 38269848
• DOI: 10.3233/SHTI231010

Capability maturity models have been developed and are widely used within healthcare aiming to assess the degree of digitization of the organization, but empirical assessments of the models themselves has been undertaken infrequently. We present a mixed-method approach to assessing a novel health capability maturity model developed by a state government responsible for the management of 86 health services. The approach was designed to be suitable for system level assessment of services and pooled the wisdom and experience of subject matter experts and key stakeholders using a combination of survey and interviews to test and tune the proposed assessment approach and parameters. We applied the approach to assess the target capability model across a number of public health services in Victoria, Australia. The result showed sufficient validity to be able to generate recommendations for further improvement of the capability model and the assessment approach to enable broader application within Australia.

Keywords: Digital health; capability assessment; digital health maturity assessment; maturity model; validity study.

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Revising chronological uncertainties in marine archives using global anthropogenic signals: a case study on the oceanic 13 C Suess effect

Ulysses s. ninnemann, neil l. rose, david j. r. thornalley, tor l. mjell, françois counillon.

Marine sediments are excellent archives for reconstructing past changes in climate and ocean circulation. Overlapping with instrumental records, they hold the potential to elucidate natural variability and contextualize current changes. Yet, dating uncertainties of traditional approaches (e.g., up to ±  30–50 years for the last 2 centuries) pose major challenges for integrating the shorter instrumental records with these extended marine archives. Hence, robust sediment chronologies are crucial, and most existing age model constraints do not provide sufficient age control, particularly for the 20th century, which is the most critical period for comparing proxy records to historical changes. Here we propose a novel chronostratigraphic approach that uses anthropogenic signals such as the oceanic 13 C  Suess effect and spheroidal carbonaceous fly-ash particles to reduce age model uncertainties in high-resolution marine archives. As a test, we apply this new approach to a marine sediment core located at the Gardar Drift, in the subpolar North Atlantic, and revise the previously published age model for this site. We further provide a refined estimate of regional reservoir corrections and uncertainties for Gardar Drift.

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Irvalı, N., Ninnemann, U. S., Olsen, A., Rose, N. L., Thornalley, D. J. R., Mjell, T. L., and Counillon, F.: Revising chronological uncertainties in marine archives using global anthropogenic signals: a case study on the oceanic 13 C Suess effect, Geochronology, 6, 449–463, https://doi.org/10.5194/gchron-6-449-2024, 2024.

Among the most prominent features of 20th century climate in the circum-North Atlantic are the observed basin-wide multi-decadal variations in the Atlantic Ocean sea surface temperatures (SSTs) – the Atlantic multi-decadal variability, AMV. This has impacts on the North American and European climate (Sutton and Hodson, 2005), the frequency of Atlantic hurricanes (Goldenberg et al., 2001), the extent of Arctic sea ice (Miles et al., 2014), and rainfall patterns in the African Sahel (Wang et al., 2012). However, instrumental SST records are limited to the last ∼  150 years (e.g., Kaplan et al., 1998), and only in a few location has widespread coverage existed since the 1950s onwards. Yet longer records of climate and ocean circulation are required to understand and assess the mechanisms behind its variability. For example, it is still debated whether AMV is driven internally, linked to multi-decadal variations in the Atlantic Meridional Overturning Circulation (AMOC) (Zhang et al., 2019), or driven externally, e.g., due to solar and volcanic forcings (Otterå et al., 2010) or the timing of anthropogenic forcings (Booth et al., 2012); it is even debated whether or not such an oscillation exists at all (Mann et al., 2020). Annually laminated mollusk shell archives offer the excellent chronological constraint required to investigate such questions; however, they are limited to shelf locations, and the range of proxies that can be applied in these archives is limited (Reynolds et al., 2016). Also overlapping with and extending the instrumental records further back in time, marine sediments hold the potential to resolve these issues and contextualize current changes. New high-resolution proxy records, particularly from North Atlantic sedimentary drift sites, are now emerging, closing the time gap between modern and paleo-observations (e.g., Boessenkool et al., 2007; Mjell et al., 2016; Thornalley et al., 2018; Spooner et al., 2020). For instance, Mjell et al. (2016) found that AMV and deep-ocean circulation varied on similar timescales over the last 600 years; however, due to age model uncertainties as high as the duration of half an AMV cycle, determining the precise phasing was not possible and required independent age constraints. Hence, integrating nearly continuous but shorter observational records with longer (but with relatively lower resolution) marine archives still poses one of the major challenges for the (paleo)oceanographic community.

Recent marine sediments are dated using an array of approaches, all of which have their own limitations and uncertainties. Radiocarbon ( 14 C ) dating is one of the most common methods for dating marine sediment cores. The uncertainties with this method can exceed 50 years and include several caveats and assumptions such as uncertain and variable reservoir effects and confounding influences such as the effect of fossil fuel emissions on atmospheric radiocarbon and the H-bomb 14 C spike, which further increases the uncertainties when dating recent sediments (Reimer et al., 2004; Hughen, 2007; Graven, 2015). In the latter case, the 14 C bomb spike can serve as an additional high-resolution dating tool in marine settings, yet this requires annually resolved archives (Scourse et al., 2012). Geochemical composition of tephra shards and fingerprinting these to known volcanic eruptions can also provide absolute age markers. The precision of these age markers can be 1–2 years, yet this method is only regionally applicable and the occurrence of multiple, closely spaced eruptions with similar geochemistry can lead to greater uncertainty (Lowe, 2011). Radionuclide dating ( 210 Pb , 137 Cs , 241 Am ) (Appleby, 2008) and more recently the increases in mercury (Hg) concentrations (i.e., as an anthropogenic (pollution) indicator) are used as chronostratigraphic markers on recent marine sediments (Moros et al., 2017; Perner et al., 2019). For instance,  210 Pb dating is widely used for dating recent sediments (0–150 years), while chronostratigraphic markers such as fallout from testing nuclear weapons in 1963 and Chernobyl fallout in 1986 can also be determined from the presence of 137 Cs (Appleby, 2008). Still, 210 Pb -based age models also involve multiple assumptions and are ideally validated using an independent age marker (e.g., 137 Cs or 241 Am ) to assess the influence of post-depositional remobilization or bioturbation. Yet, it remains difficult to confirm to what extent the assumptions for dating are met (Smith, 2001). 137 Cs profiles are often used to partially validate 210 Pb chronologies, but this can only be undertaken for specific periods (e.g., bomb testing, Chernobyl). In addition, 137 Cs is also prone to post-depositional remobilization and is not always above the detection limit – depending on core locations (e.g., Barsanti et al., 2020). Although the application of 210 Pb dating in combination with 137 Cs in lacustrine environments is well established, delayed input from 137 Cs fallouts highlights the need for care in using 137 Cs as chronostratigraphic markers even in lake sediments (Appleby et al., 2023). The situation is considerably more difficult in marine environments (e.g., Appleby et al., 2021). Indeed, a recent review highlights the continuing importance of, and need for, independent age control markers to corroborate 210 Pb -based age models (Barsanti et al., 2020). Clearly progress is needed to improve age constraints in the 20th century in a way that will allow us to calibrate proxies using observational time series and, ultimately, reliably extend these observational records. Anthropogenic signals, such as the oceanic 13 C  Suess effect and spheroidal carbonaceous fly-ash particles (SCPs), are evident in high-resolution marine archives and hold the potential to provide a means for improving age control over the 20th century.

Atmospheric CO 2 has been increasing due to human activities, such as fossil fuel combustion and deforestation, since the beginning of the industrial period. Due to preferential uptake of the lighter isotope (i.e., 12 C ), increased anthropogenic CO 2 emissions cause the 13 C / 12 C ratio ( δ 13 C ) and the 14 C /C ratio ( Δ 14 C ) to decline. The decreasing trend in the radiocarbon ( 14 C / C ) content of CO 2 was first named the “Suess effect” by Suess (1955). In 1979, due to its similarity, Keeling (1979) extended the Suess effect terminology to the shifts in the 13 C / 12 C ratio of the atmospheric CO 2 . The 13 C  Suess effect propagates into different reservoirs of the Earth system; for instance, the addition of low- δ 13 C anthropogenic CO 2 from the atmosphere to the surface ocean also affects the natural δ 13 C gradients (Eide et al., 2017; Olsen and Ninnemann, 2010). Foraminiferal δ 13 C records (planktonic and benthic) from high-resolution marine archives capture this accelerating decline in δ 13 C over the last century (e.g., Mellon et al., 2019) and thus hold huge potential for refining age control for recent sediments.

Another new and promising approach for dating recent marine sediments is the use of spheroidal carbonaceous fly-ash particles (SCPs) (Spooner et al., 2020; Thornalley et al., 2018). SCPs are only produced from high-temperature industrial sources, such as coal and oil, and are thus purely anthropogenic in origin. They are emitted to the atmosphere along with combustion flue gases and are therefore transported to and recorded in many natural archives worldwide – including regions that are remote from industrial sources (e.g., Rose et al., 2004, 2012). In lake sediment records, SCPs were first observed during the mid-19th century in the UK, Europe, and North America and show a very distinct concentration profile. The SCP concentration trend starts with a gradual increase from the beginning of the SCP record until the mid-20th century, followed by a rapid increase at ca. 1950 linked to the increased demand for electricity following the Second World War (Rose, 2015). The beginning of the SCP record may vary regionally because it depends on the regional developments in industrial history as well as the sedimentation rates. However, the rapid increase observed in the mid-20th century has been considered to be a global signal (Rose, 2015) – making SCPs a robust and ideal stratigraphic marker for a mid-20th century Anthropocene. The first applications of the SCP method to marine sediment archives (Thornalley et al., 2018; Spooner et al., 2020; Kaiser et al., 2023) have been shown to follow similar trends to those established from lake records (Rose, 2015), providing an independent means to improve marine-based chronologies over the last 150 years.

Here we combine these two novel chronostratigraphic approaches that use anthropogenic signals (i.e., oceanic 13 C  Suess effect change and spheroidal carbonaceous fly-ash particles – SCPs) to reduce age model uncertainties in high-resolution marine archives. As a test, we apply this new approach to a high-resolution site at the Gardar Drift, off southern Iceland, to revise the previously published age model at this site (i.e., Mjell et al., 2016). We further provide refined regional 14 C reservoir corrections and uncertainties for Gardar Drift using a combination of accelerator mass spectrometry (AMS) radiocarbon dates and oceanic 13 C  Suess effect estimates for our core location.

Table 1 14 C AMS dates from GS06-144-09 MC-D.

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In this study we use sediment samples from the Gardar Drift multicore, GS06-144-09 MC (60°19 ′  N, 23°58 ′  W; 2081  m water depth), recovered during the University of Bergen cruise no. GS06-144 on board the research vessel (R/V) G. O. Sars . Four successful identical cores (GS06-144-09 MC A-D) were recovered at this station. The 44.5  cm long GS06-144-09 MC-D has been sampled at 0.5  cm intervals. Each sample was soaked in distilled water and shaken for 12  h in order to disperse the sediment before they were wet-sieved and separated into size fractions of  >  63 and  <  63  µm . The fine fractions ( <  63  µm ) were used for mean sortable silt grain size analysis (Mjell et al., 2016), whereas the  >  63  µm fraction was used for selection of foraminifera for stable isotope analysis and 14 C AMS dating (Table  1 ). The 44  cm long GS06-144-09 MC-C was sampled at 0.5  cm intervals. Each sample was dried and weighed. Dry bulk sediment samples from GS06-144-09 MC-C were used for SCP analysis.

Samples from GS06-144-09 MC-D have previously been analyzed for the activity of 210 Pb , 226 Ra , and 137 Cs at the Gamma Dating Centre, Department of Geosciences and Natural Resource Management, University of Copenhagen, Denmark (Mjell et al., 2016). The initial age model of GS06-144-09 MC-D was based on 210 Pb excess dates from the top 7.25  cm and two 14 C AMS dates (Mjell et al., 2016). The presence of 137 Cs in marine sediment cores is often used to validate the 210 Pb chronologies and can also provide additional information (e.g., an independent tie point) for the onset of atmospheric weapon testing (e.g., Perner et al., 2018). In core GS06-144-09 MC-D, the content of 137 Cs was very low and below the detection limit except in the top 4  cm of the core. This may indicate that the top 4  cm could be younger than ∼  1950 CE. However, for core GS06-144-09 MC-D, traces (near detection limit) of 137 Cs were also episodically present below this depth (Fig. S1 in Mjell et al., 2016). Hence, here we choose not to include the information provided by 137 Cs in our age model, and we also do not include the 210 Pb dates, as it will not be possible to validate with 137 Cs .

In general, an ideal approach to build the best possible chronology is to integrate all available information. However, here we aim to demonstrate the potential utility of two novel approaches, oceanic 13 C  Suess effect change and SCPs, in building robust marine sediment chronologies. Therefore, we focus on these two novel techniques in a more stand-alone manner to assess their utility independently and their consistency with each other. Our methods include stable carbon isotopes of planktonic foraminifera ( δ 13 C ), 14 C AMS dates, SCP analysis, and time series of oceanic 13 C  Suess effect change computed for our core location.

2.1  Stable isotope analysis ( δ 13 C )

Stable isotope analyses ( δ 13 C ) were performed on the planktonic foraminifera Globigerina bulloides , Neogloboquadrina incompta , and Globorotalia inflata every 0.5  cm throughout the core. G. bulloides was picked from the 250–300  µm size fraction, while N. incompta was picked from 150–250  µm and G. inflata was picked from the 250–350  µm size fraction. Approximately 5–7 shells of G. bulloides , ∼  5 shells of G. inflata , and ∼  10 shells of N. incompta from each sample were used for stable isotope analysis. Foraminifera were ultrasonically rinsed for 20  s in methanol to remove any contaminants prior to analysis. Stable isotope analyses were measured using a Finnigan MAT 251 and a MAT 253 mass spectrometer in the FARLAB (Facility for Advanced Isotopic Research) at the Department of Earth Science, University of Bergen. All samples were run in two replicates whenever foraminifera were sufficiently abundant. The stable isotope results are expressed as the average of the two replicate measurements and reported relative to Vienna Pee Dee Belemnite (VPDB), calibrated using NBS-19. Long-term analytical precision (1 σ ) of the standards over the analysis period was better than 0.04 ‰ for δ 13 C .

2.2   13 C  Suess effect estimates

Recently, Eide et al. (2017) calculated globally gridded surface-to-seabed 13 C  Suess effect estimates for the industrialized era. These estimates were based on the two-step back-calculation technique of Olsen and Ninnemann (2010) for waters deeper than 200  m , while for waters above they were determined by combining the 200  m level estimate with values of the surface ocean 13 C  Suess effect as evident in coral and sclerosponge records. The two-step back-calculation approach first takes advantage of the relationships between preformed δ 13 C and chlorofluorocarbons (CFC-11 or CFC-12) in the ocean to quantify the 13 C  Suess effect since CFCs first appeared in the atmosphere (the 1940s). In the second step, these estimates are extended to the full industrialized era under the assumption of transient steady state (Gammon et al., 1982; Tanhua et al., 2007), which states that after an initial adjustment period, the response in tracer concentrations at depth will be proportional to the change in boundary concentration in exponentially forced systems. This means that we can expect that the ratio of the 13 C  Suess effect at any point in the ocean to that in the atmosphere will remain constant in time, i.e.,

where Δ t 1 and Δ t 2 represent two time intervals since the preindustrial. In the case of Eide et al. (2017) these are the periods 1940 to 1994 and preindustrial (defined as atmospheric δ 13 C   =   − 6.5) to 1994.

Figure 1 Planktonic δ 13 C records from Site GS06-144-09 MC-D plotted vs. depth ( cm ). Yellow highlighting marks the sharp decline in δ 13 C due to the Suess effect. (a)   G. bulloides δ 13 C record (blue) with five-point mean (bold line), (b)   N. incompta δ 13 C record (green) with five-point mean (bold line), and (c)   G. inflata δ 13 C record (pink) with five-point mean (bold line). The five-point mean is extended into the core top by taking the mean of samples at 0 and 0.5  cm , shown as dashed bold lines to highlight the large abrupt δ 13 C decrease at the core top.

Here, we use Eq. ( 1 ) to derive time series of the Suess effect since the preindustrial at 10 depth layers from the surface to 200  m (e.g, δ 13 C SE_0 , δ 13 C SE_50 ) above the Gardar Drift core site. This depth interval covers the depth habitats of the planktonic foraminiferal species we have used for stable isotope analysis. The time series were determined by taking the ratio between the Suess effect determined by Eide et al. (2017) at each of the 10 depth levels we consider in the grid box covering the Gardar Drift (60–61° N, 23–24° W) and the atmospheric δ 13 C decline until 1994 and multiplying this by the atmospheric δ 13 C history since the preindustrial provided by Rubino et al. (2013). The thus calculated marine Suess effect time series are presented in Fig.  2 . We set the starting point in time to 1800, as an appreciable decline in atmospheric δ 13 C is only visible after that year.

Figure 2 13 C  Suess effect estimates at the Gardar Drift (60.5° N, 23.5° W) for the 10 different depth layers from the surface to 200  m , plotted together with the atmospheric δ 13 C record provided by Rubino et al. (2013).

2.3  SCP analysis

We followed the SCP method outlined by Rose (1994). Approximately 0.2  g of dried bulk sediment was weighed into 15  mL polypropylene tubes. One SCP reference standard (Rose, 2008) and a blank were included for quality control purposes and treated exactly the same as the samples. The SCP extraction method included nitric acid ( HNO 3 ), hydrofluoric acid (HF), and hydrochloric acid ( HCl ) stages to respectively remove organic matter, silicious material, and carbonates. Following the acid digestion stages, a known fraction of the final residue was evaporated onto a cover slip and mounted on a microscope slide using Naphrax mountant. A light microscope with 400 × magnification was used to identify and count the total number of SCPs on each slide. SCP identification followed the criteria described in Rose (2008) based on morphology, color, depth, and porosity. SCP concentrations are reported as the number of SCPs per gram of dry sediment ( gDM −1 ). SCP analyses were performed at the Department of Geography, University College London. The concentration of the SCP reference material was 5318  gDM −1 ( ± 1022, 90 % confidence level), close to the reported concentration of 6005  ±  70  gDM −1 (Rose, 2008). No SCPs were observed in the blank.

3.1  Planktonic foraminiferal δ 13 C vs. the oceanic 13 C  Suess effect

In the subpolar North Atlantic, G. bulloides calcifies in the upper 50  m of the water column over the late spring and summer, depending on food availability (Jonkers et al., 2013; Schiebel et al., 1997; Spero and Lea, 1996; Chapman, 2010). On the other hand, the habitat depth of N. incompta is highly variable, ranging from the surface to deeper thermocline, most likely calcifying between 50 and 125  m water depth (Chapman, 2010; Field, 2004; Pak and Kennett, 2002; Pak et al., 2004; Von Langen et al., 2005; Nyland et al., 2006; Schiebel et al., 2001). G. inflata is a deep-dwelling foraminiferal species, living at the base of the seasonal thermocline or deeper in the main thermocline if the base of the seasonal thermocline is warmer than 16  °C (Cléroux et al., 2007). In the North Atlantic, G. inflata calcifies between 200 and 400  m south of 57° N and between 100 and 200  m north of 57° N (Ganssen and Kroon, 2000).

To calculate the age estimates based on the 13 C  Suess effect, we assume a calcification depth of 50  m for G. bulloides and compare our G. bulloides δ 13 C record with the 13 C  Suess effect change at 50  m ( δ 13 C SE_50 ) at our core location. In order to avoid any uncertainties regarding planktonic foraminiferal depth habitats, we also present a stacked planktonic δ 13 C record ( δ 13 C stack – i.e., the average of G. bulloides , N. incompta , and G. inflata ) and compare it with the average 13 C  Suess effect change over the top 200  m of the water column ( δ 13 C SE_0–200 ), which spans the depth habitats of all three planktonic species (i.e., G. bulloides , N. incompta , and G. inflata ) used in this study (Figs. S1 and S2 in the Supplement).

3.1.1   G. bulloides δ 13 C vs. oceanic Suess effect change at 50  m ( δ 13 C SE_50 )

The G. bulloides δ 13 C record shows large natural variability over the 10–44  cm core interval, varying between ∼  0.08 ‰ and ∼   − 0.6 ‰. However, the most prominent feature occurs towards the core top. δ 13 C  values reach a peak of 0.27 ‰ at 7.5  cm , then start to gradually decrease and reach 0.05 ‰ at 1  cm . This is followed by a very sharp decline of ∼  0.8 ‰ centered at 0.5  cm . The gradual decrease observed in G. bulloides δ 13 C , with a sharper decline at the core top, indicates the presence of the 13 C  Suess effect. Compared to the 13 C  Suess effect change at 50  m , the relative change in G. bulloides δ 13 C seems to be very similar (Fig. S3 in the Supplement). Does the δ 13 C SE_50 curve provide a means to narrow down chronological uncertainties over the industrial period? To explore this, we objectively matched our G. bulloides δ 13 C record with the δ 13 C SE_50 curve to find the starting point (1800 CE) of the Suess effect curve on the G. bulloides δ 13 C record.

To objectively place the start of the δ 13 C SE_50 curve (1800 CE) on the G. bulloides δ 13 C record, first we computed the curvature of the δ 13 C SE_50 curve. We use a third-degree polynomial fit using the polyfit function in MATLAB. Secondly, we apply third-degree polynomial curve fits to the G. bulloides δ 13 C record for different core depth intervals ( n =12 ) starting from 12  cm to cover the whole industrial period. We apply curve fits to 12–0, 11–0, 10–0, 9–0, 8.5–0, 8–0, 7.5–0, 7–0, 6.5–0 6–0, 5.5–0, and 5–0  cm intervals. When applying curve fits, we use G. bulloides δ 13 C , as well as its three-point running mean and five-point running mean, assuming the overall trends might be better represented in the smoothed data. Goodness-of-fit results for each curve fit are presented in Table S1 in the Supplement. Finally, we compared the curvature of the δ 13 C SE_50 curve with the various curve fits applied to G. bulloides δ 13 C records to find which curve fit is the most similar to the curvature of δ 13 C SE_50 . To do this, we calculate the correlation coefficients between our target curve (in this case, the curvature of δ 13 C SE_50 ) and each of the third-degree polynomial curves using their individual polynomial coefficients (i.e., p1, p2, p3, p4; Table S1). The curvature of the G. bulloides δ 13 C record for the 7.5–0  cm interval is the most similar to the curvature of our δ 13 C SE_50 curve ( r   =  0.73), suggesting 7.5  cm could be 1800 CE. We further do the same test using the three-point and five-point running mean of the data. Although the correlation is poorer, the same result is also reached (i.e., best fit when the record starts at 7.5  cm ) when three-point running mean ( r   =  0.46) and five-point running mean ( r   =  0.22) of G. bulloides δ 13 C are used. Placing the start of the oceanic Suess effect change ( ∼  1800 CE) on our G. bulloides δ 13 C record is one of the main challenges of our approach as the most prominent δ 13 C decline does not happen until the most recent years or core top. This is also evident from our correlation analysis results (Table S1). For instance, a close second-best fit occurs when we place 1800 CE at 5  cm ( r   =  0.69) instead of 7.5  cm ( r   =  0.73). A comparison between the two correlation coefficients using the Fisher's z transformation suggests that the difference between the correlation coefficients is not statistically significant ( z   =  0.064, p   =  0.949). This indicates that 5  cm could also be 1800 CE.

3.1.2   δ 13 C stack vs. the 0–200  m average oceanic Suess effect change ( δ 13 C SE_0–200 )

N. incompta and G. inflata δ 13 C also followed a very similar trend as the G. bulloides δ 13 C record – with the most prominent decline towards the core top, indicating the presence of the 13 C  Suess effect. To cross-check our approach described in Sect.  3.1.1 and to avoid any uncertainties that may be caused due to habitat depth variability, we use the stacked planktonic δ 13 C of G. bulloides , N. incompta , and G. inflata ( δ 13 C stack ). Considering the habitat depth range of all three planktonic species, we then compare the δ 13 C stack with the 0–200  m average of the 13 C  Suess effect ( δ 13 C SE_0–200 ) (Figs. S1 and S2). Similarly, to place the start of the δ 13 C SE_0–200 curve (1800 CE) on our δ 13 C stack record, first we find the curvature of the δ 13 C SE_0–200 curve. We use a third-degree polynomial fit using the polyfit function in MATLAB. Secondly, we apply third-degree polynomial curve fits to the δ 13 C stack record for the same core depth intervals as in Sect.  3.1.2 . Finally, we compare the curvature of the Δ 13 C SE_0–200 curve with the various curve fits applied to our δ 13 C stack record and find which curve fit is the most similar to the curvature of Δ 13 C SE_0–200 . To do this, we again calculate the correlation coefficients between our target curve (in this case, the curvature of δ 13 C SE_0–200 ) and each of the third-degree polynomial curves using their individual polynomial coefficients (i.e., p1, p2, p3, p4; Table S1). In this case, we get similar results for intervals 5–0, 5.5–0, and 7.5–0  cm ( r   =   − 0.60). Although the negative correlation coefficients indicate that the similarity approach used here may not capture the complexity of comparing third-degree polynomials, it gives us a rough estimate of which curve is most similar to our target curve (i.e., Δ 13 C SE_0–200 ) and overall agrees with our initial finding based on G. bulloides that 7.5 or 5  cm may in fact be 1800 CE.

Figure 3 Overview of core-top age calculation. (a)   G. bulloides δ 13 C record (blue, with five-point mean; bold line) vs. depth ( cm ). The five-point mean is extended into the core top by taking the mean of samples at 0 and 0.5  cm , shown as dashed bold lines to highlight the large abrupt δ 13 C decrease at the core top. The dark gray line and gray shading respectively mark the mean and standard deviation of the 1–7.5  cm and 0 and 0.5  cm intervals. (b)   δ 13 C SE_50 curve (pink). The arrow and dashed lines mark when a 0.57 ‰ magnitude decline occurs in the record.

3.2  Core-top age

In paleoceanographic studies it is common to use the year a sediment core was retrieved as the core-top age. However, this is highly dependent on the sedimentation rates of the region and may not always be the case. The core-top (0  cm ) 14 C AMS date for GS06-144-09 MC-D indicated the presence of bomb carbon, confirming that the top should be younger than ∼  1957 CE (Mjell et al., 2016). Therefore, based on high sedimentation rates at the site, Mjell et al. (2016) assumed 2006 CE to be the core-top age, i.e., the year core GS06-144-09 MC was retrieved. Here we explore this further considering the new information provided by the relative change in our oceanic 13 C  Suess effect curve. For this, we use the G. bulloides δ 13 C record and the δ 13 C SE_50 curve.

Based on our previous curve fits, we place 1800 CE at 7.5  cm . The most prominent change in the G. bulloides δ 13 C record occurs at 0.5  cm . Hence, first we find the mean and standard deviation of the 1–7.5  cm interval ( − 0.05  ±  0.2; n =14 ), i.e., the mean δ 13 C over the industrial period and secondly the core top (two data points at 0 and 0.5  cm ; − 0.62  ±  0.17; n =2 ), of the G. bulloides δ 13 C record, i.e., where the sharpest decline due to the Suess effect occurs. We then calculated the difference in means using a t test (0.57 ‰) and found the magnitude of the sharpest decline in G. bulloides δ 13 C due to the Suess effect. Finally, we used the δ 13 C SE_50 curve to find when a 0.57 ‰ magnitude decline relative to the preindustrial value occurred. Based on our δ 13 C SE_50 curve, a decline of 0.57 ‰ occurs in ∼  1972. This would then place 1972 CE at 0.25  cm (i.e., the mid-point of our two samples at 0 and 0.5  cm ), suggesting a much older core-top age than previously assumed for GS06-144-09 MC (Mjell et al., 2016).

We repeated the same approach and evaluated how the core-top age would change if we placed 1800 CE at 5  cm (i.e., our second-best fit). We computed the mean and standard deviation of the 1–5  cm interval ( − 0.09  ±  0.2; n =9 ) and calculated the difference in means (0.53 ‰) between the 1–5  cm interval and the core top (0–0.5  cm ). Finally, we determined when a magnitude of 0.53 ‰ decline occurred in the δ 13 C SE_50 curve. Based on our δ 13 C SE_50 curve, a decline of 0.53 ‰ occurred in ∼  1969, placing 1969 CE at 0.25  cm . This suggests that placing 1800 CE at 7.5  cm vs. 5  cm changes our core-top age (or our tie point at 0.25  cm ) by 3 years. When building our age model, here we choose 7.5  cm as 1800 CE (i.e., based on the best curve fit) and 0.25  cm as 1972 CE, and we introduce 3-year uncertainty to the selection of these tie points.

3.3  Revising regional reservoir corrections ( Δ R ) at Gardar Drift

To build an age model for the marine sediment cores based on radiocarbon dating it is necessary to convert 14 C dates into calendar years. Surface ocean 14 C is depleted relative to the atmosphere, which is known as the marine reservoir effect. Global marine radiocarbon calibration curves, e.g., the latest Marine20 curve (Heaton et al., 2020), account for the global average offset between the marine and atmospheric reservoirs; however, there are temporal and spatial deviations from this offset. Marine reservoir ages range from 400 years in the subtropics to more than 1000 years in polar oceans (Key et al., 2004). Therefore, the accurate calibration of 14 C ages depends on knowledge of the local radiocarbon reservoir age of the surface ocean, i.e., the regional difference ( Δ R ) from the global marine radiocarbon calibration curve. The marine reservoir database within CALIB ( http://calib.org/marine/ , last access: 1 November 2023) is the most extensive and valuable source for Δ R values for the modern ocean (Reimer and Reimer, 2001; Stuiver and Reimer, 1986). This online platform provides the user with an average Δ R value for their core location based on the information provided on coordinates and number of nearest points. The Δ R values within the marine reservoir database are determined based on the known-age approach, i.e., when the death date (in calendar ages) of a pre-bomb marine sample (e.g., a mollusk shell) is known. However, as a consequence of nuclear tests in the 1950s and early 1960s the Δ R calculation with the known-age approach can only be applied to samples collected before 1950 CE; hence, the majority of the samples within the marine reservoir database are not homogenously distributed – making them temporally and spatially limited (Alves et al., 2018). Therefore, deriving a Δ R using the nearest points to a core location is problematic for many regions, where the closest Δ R is either not available or located in a different oceanographic setting (e.g., Hinojosa et al., 2015). When selecting samples for Δ R calculation, it is also important to review the ecological information on the taxa from which the Δ R value is derived, as some studies find species-specific values due to habitat, feeding mechanisms, and food sources. For instance, suspension feeders are thought to be the most suitable for dating, whereas deposit feeders, omnivore species, or carnivorous species are generally excluded due to their greater uncertainty in 14 C ages as they incorporate old carbon (Pieńkowski et al., 2021; England et al., 2013; Forman and Polyak, 1997). However, some studies find no difference in 14 C ages due to feeding mechanisms when the mollusks are derived from areas with no carboniferous rocks or local freshwater inputs to the surface ocean (Ascough et al., 2005).

Table S2 in the Supplement shows the Δ R values for our core site (GS06-144-09 MC; 60°19 ′  N, 23°58 ′  W), located south of Iceland, derived from the nearest points available in the marine reservoir database (Reimer and Reimer, 2001). When the 10 nearest points are used (i.e., based on the distance (km) from core location), the Δ R for our core site is − 72  ±  64  14 C yr . However, when we exclude carnivore and deposit feeding species, the Δ R value becomes − 80  ±  54  14 C yr . It is also important to note that even the individual samples have a large range of Δ R values, varying between − 23  ±  45 and − 220  ±  85  14 C yr , suggesting there might be other factors influencing the Δ R . For instance, considering the oceanographic setting, another approach could be to only select samples located around southern Iceland – i.e., those potentially under the influence of the Irminger Current, where our core site lies. Then, the Δ R  value would be − 92  ±  93  14 C yr (or − 126  ±  66  14 C yr when carnivore and deposit feeding species are excluded). This suggests that the available Δ R values within the CALIB marine reservoir database (Reimer and Reimer, 2001) for the region are highly variable and highly dependent on the selection criteria used by the investigator.

Global Ocean Data Analysis Project (GLODAP) radiocarbon observations (Key et al., 2004) provide an alternative approach to estimate the spatial variations in the reservoir ages (Gebbie and Huybers, 2012; Waelbroeck et al., 2019). For instance, Waelbroeck et al. (2019) extracted the pre-bomb surface mean (upper 250  m ) reservoir ages from re-gridded (4°  ×  4°) GLODAP data. Following the Waelbroeck et al. (2019) approach, we extract the reservoir ages (443  ±  75.8  14 C yr ) at our core site (60° N, 24° W) from GLODAP data. Waelbroeck et al. (2019) note, however, that the error for their reservoir ages should be at least 100  14 C yr if the computed GLODAP standard deviation is less than this value (i.e., in our case 443  ±  100  14 C yr ). Considering the global average marine reservoir age of ∼  600 years based on Marine20 (Heaton et al., 2020), this would suggest a Δ R of − 157  ±  100  14 C yr for our region. The large difference (and/or uncertainties) in regional reservoir corrections extracted using two independent methods (e.g., CALIB vs. GLODAP-based) highlights the need for additional approaches to further constrain regional reservoir ages.

Figure 4 G. bulloides δ 13 C (7.5–0.25  cm , light blue line plotted with the five-point mean; bold dark blue line) vs. the δ 13 C SE_50 curve spanning the 1800–1972 CE interval (bold pink line). Gray triangles on the depth axis mark the three 14 C AMS samples at 2.5, 4, and 5  cm depth intervals, while the dashed gray lines and triangles on the age axis mark their corresponding “known ages” based on the Δ 13 C S E _ 50 comparison.

Here we suggest an alternative approach for calculating the Δ R for marine sediment cores that is independent of uncertainties such as the distance between core sites and sample locations, different oceanographic settings (e.g., coastal and fjord regions vs. open ocean), or the feeding ecology of the species used for dating. Based on our comparison of the G. bulloides δ 13 C record and the δ 13 C SE_50 curve we obtain two tie points, placing 1972 CE at 0.25  cm and 1800 CE at 7.5  cm . Figure  4 shows the G. bulloides δ 13 C record on a depth scale spanning the 7.5–0.25  cm core interval, plotted together with the δ 13 C SE_50 curve spanning the 1800–1972 CE interval. First, we estimate the “known ages” for depths 2.5, 4, and 5.5  cm (i.e., where we have 14 C dates) by reading the corresponding ages from the δ 13 C SE_50 curve. Next, we calculate the Δ R  value for each sample using the known-age approach in the online application deltar (Reimer and Reimer, 2017) based on the most recent Marine20 curve (Heaton et al., 2020). Finally, we calculate the weighted mean (Eq.  2 ) and standard deviation of Δ R following Reimer and Reimer (2001) and provide a revised Δ R estimate for the Gardar Drift. The uncertainty of Δ R is determined as the maximum value of either the weighted uncertainty in the mean of Δ R or the standard deviation of Δ R , as in Eqs. ( 3 ) and ( 5 ). Our refined Δ R estimate ( − 69  ±  38  14 C yr ) is similar to the value obtained from the marine reservoir database when the 10 nearest points are used ( − 72  ±  64  14 C yr ) – although with better uncertainty estimates.

Table 2 Revised Δ R estimate for Gardar Drift. “Known ages” are derived from the 13 C  Suess effect comparison, as shown in Fig.  4 . The weighted mean and standard deviation of Δ R are calculated following the method outlined in CALIB using Eqs. ( 2 )–( 5 ) (Reimer and Reimer, 2017, 2001).

3.4  Revised age model for GS06-144-09 MC

We use Bacon (version 2.5.0), the age–depth modeling approach that uses Bayesian statistics (Blaauw and Christen, 2011), operated through R (version 4.0.3) – free software for statistical computing and graphics. A total of 10  14 C AMS dates (Table  1 ) are calibrated through Bacon using the most recent Marine20 curve (Heaton et al., 2020) and a Δ R value of − 69  ±  38 (this study) – assuming a constant Δ R  value throughout the core. Since our Δ R  estimate is based on the comparison with the 13 C  Suess effect curve, we can only calculate a Δ R  value for the last ∼  200 years with this approach. Although we assume relatively stable conditions over the last millennium (e.g., compared to glacial–interglacial changes), changes in ocean circulation and ventilation before this period will also effect the Δ R in the region (e.g., during the Little Ice Age; Spooner et al., 2020).

Figure 5 Age–depth plots of GS06-144-09 MC (a)  when additional tie points for 0.25  cm (1972 CE) and 7.5  cm (1800 CE) are used and (b)  when “known” calendar ages for samples at 2.5, 4, and 5.5  cm that were derived from the δ 13 C SE_50 comparison are used as additional tie points.

Additional tie points for 0.25  cm (1972 CE) and 7.5  cm (1800 CE) are used based on the information obtained from the Suess effect curve. Based on the core-top (0  cm ) 14 C AMS date ( >  1950 CE) and the year the core was retrieved (2006 CE) the core-top age should be between ∼  1950 and 2006 CE. As the core-top age cannot be younger than 2006 CE, we use this information as a prior in Bacon to set a minimum age limit for the core top. According to the revised age model, the date for the core top (0–0.5  cm ) is 1977 CE. The average uncertainty for the last ∼  200 years (i.e., the 0–7.5  cm interval) is ∼   ±  42 years and for the whole core (i.e., the 0–44  cm interval) is ±  90 years. The resulting age–depth plot is provided in Fig.  5 a. Although Bacon selects the best age–depth model (i.e., dotted red lines in Fig.  5 ), considering the sedimentation rate profile based on the prior information, the tie points at the core top and 1800 CE play a crucial role, providing a basis for sedimentation rates. This is also seen from Fig.  5 a, illustrated by the large range of 14 C AMS dates that exceeds the calibration range of Marine20 due to bomb carbon. This further underscores the need for independent chronological approaches, particularly for the last century.

As a comparison, we also include the “known” calendar ages for samples at 2.5, 4, and 5.5  cm that were derived from the δ 13 C SE_50 comparison, together with their uncalibrated 14 C dates, in the Bacon input file. For all the tie points derived from the δ 13 C SE_50 comparisons we add a ±  3-year uncertainty. Including the known calendar ages does not change the overall age model, but as expected, it highly decreases the age model uncertainties for the last ∼  200 years (Fig.  5 b). Based on this, the core-top age (0–0.5  cm ) is again 1977 CE. The average age model uncertainty for the last ∼  200 years (i.e., the 0–7.5  cm interval) is ±  17.5 years. Below this point, the uncertainty increases (average of ±  84 years for the 0–44  cm interval) and is highly dependent on the uncertainty of the 14 C AMS dates. The average sedimentation rates for the top 0–7.5  cm interval are 43 and 63  cm kyr −1 for the 7.5–44  cm interval. The average sedimentation rate of the core (0–44  cm ) is 59  cm kyr −1 , giving a sample spacing of ∼  8.5 years per 0.5  cm sample.

3.5  SCP analysis

To cross-check the validity of our Suess-effect-derived age model, here we use another independent approach: spheroidal carbonaceous fly-ash particles (SCPs).

SCP concentrations at GS06-144-09 MC are generally very low, varying between 152 and 616  gDM −1 . Based on our revised age model, SCP concentrations start to gradually increase during the 1930s. A more marked increase in SCP concentrations occurs after 1954 and reaches peak values in 1966, followed by a decline towards the core top. Figure S4 in the Supplement shows a comparison of the GS06-144-09 MC SCP concentrations with previously published SCP profiles from Apavatn Lake, Iceland (Rose, 2015), and Nunatak Lake, Greenland (Bindler et al., 2001; Rose, 2015). Despite similarly low concentrations, both lake records show the same increase after ca. 1950 as the Gardar Drift marine sediment core. This suggests that the SCP concentrations at Gardar Drift follow a similar temporal pattern to the lake sediments in the region. Although the low SCP concentrations at GS06-144-09 MC result in considerable uncertainty for the SCP profile, the rapid increase after the 1950s at GS06-144-09 MC is consistent with the SCP trend in the region and is consistent with our Suess-effect-based revised age model.

Figure 6 SCP concentration profile of GS06-144-09 MC plotted vs. the revised age model (as shown in Fig.  5 b). The dashed red line marks 1950.

Figure 7 Age–depth plot for the top 10  cm of GS06-144-09 MC to highlight the differences (e.g., in sedimentation rate) between the original 210 Pb -based chronology (Mjell et al., 2016) and the tie points derived based on anthropogenic signals (this study). 14 C dates are calibrated with CALIB (version 8.2) (Stuiver and Reimer, 1993) using Marine20 and Δ R   =   − 69  ±  38  14 C yr .

Figure 8 Sortable silt mean grain size ( SS ‾ ) as a proxy for Iceland–Scotland Overflow Water vigor (Mjell et al., 2016) vs. the AMV index (Gray et al., 2004), plotted on the (a)  original age model (after Mjell et al., 2016) and (b)  revised age model using anthropogenic signals (this study).

Our case study off Gardar Drift demonstrates the utility of two novel chronostratigraphic approaches that use anthropogenic signals (i.e., the oceanic 13 C  Suess effect change and SCP concentrations) in reducing age model uncertainties of recent high-resolution marine archives. In addition, using a combination of 14 C AMS dates and oceanic 13 C  Suess effect estimates, we further provide refined regional 14 C reservoir corrections and uncertainties for Gardar Drift. Despite the similarity of our refined Δ R estimate to those available in the marine reservoir database (Reimer and Reimer, 2001), it is also important to note the shortcomings of our approach. For instance, by reading the corresponding known ages from the 13 C  Suess effect curve to calculate Δ R , our approach assumes constant sedimentation rates and no bioturbation or reworking at the core top. Although we do not see any visible traces of bioturbation in our core, we acknowledge that this is often not the case, and we rarely have sites with true known ages. One exception to this, with potential to overcome this limitation, would be to use absolute age markers derived by identifying tephra layers and fingerprinting these to known volcanic eruptions. Yet this method is also only applicable in specific geologic settings and can also be affected by bioturbation – a limitation shared by all dating methods.

Bioturbation is one of the main sources of uncertainties of our approach as it will typically influence the age distributions and smooth the record. Generally, the smoothing, or attenuation, is greater when the sedimentation rates are low ( ∼  10  cm kyr −1 ) (Anderson, 2001). For instance, according to Anderson (2001) minimum attenuation (i.e.,  <  5 %) is observed only when sedimentation rates exceed 50–70  cm kyr −1  – a range often observed at sedimentary drift sites, such as the Gardar Drift. Given the average sedimentation rate of ∼  43  cm kyr −1 for the top 0–7.5  cm interval of our core (i.e., spanning an interval from ca. 1977 to 1800 CE) and sampling resolution of 0.5  cm , our ultimate chronological precision potentially achievable using these methods would be ∼  12 years.

We further compare our revised age model based on anthropogenic signals with the previously published age model for Site GS06-144-09 MC-D. Figure  7 shows the 210 Pb dates (Mjell et al., 2016), 14 C dates, and information provided by the anthropogenic signals (i.e., 13 C  Suess-effect-derived tie points and the interval where the SCPs are present). The significant mismatch between the 210 Pb and 14 C dates once again highlights the need for independent approaches, as well as the potential of using anthropogenic signals to improve age model constraints over the last 2 centuries.

One of the main differences between our revised age model and that of Mjell et al. (2016) is the core-top age (1977 vs. 2006, respectively). This once more emphasizes the need to validate 210 Pb -based chronologies as well as the common assumption of the year a sediment core was retrieved as the core-top age. Here we suggest and assume that the significant decline in our foraminiferal δ 13 C records over the last century is mainly caused by the oceanic 13 C  Suess effect. This is particularly the case for our G. bulloides δ 13 C , where the actual decline in foraminiferal δ 13 C is the same as the 13 C  Suess effect decline at 50  m depth. However, this may also be registered differently in other species. It is important to note that, although difficult to distinguish, our foraminiferal δ 13 C signals are also subject to natural climate variability. For instance, there are significant changes in the subpolar gyre circulation over the 20th century; more specifically, the observed productivity decline in the region (Spooner et al., 2020) will also be registered by our foraminiferal δ 13 C . Here, we have focused on the relative difference between average G. bulloides δ 13 C values over the industrial period vs. the core top (i.e., sharpest 13 C decline due to the Suess effect) and demonstrated the potential utility of the 13 C  Suess effect approach in recent marine sediment chronologies. However, further sensitivity studies are needed to distinguish the effects of natural vs. anthropogenic climate variability in foraminiferal δ 13 C records.

The scale of the, ongoing, Suess effect is now starting to exceed the entire range of δ 13 C exhibited through most open-ocean environments (Eide et al., 2017), and, as such, it should be a dominant feature in records able to resolve short timescales. Indeed, the lack of this signal in a core-top record suggests that modern sediments were not recovered and/or that sedimentation rates and bioturbation may confound sub-centennial-scale interpretation of foraminiferal isotope records at a given core site.

Finally, Fig.  8 shows the sortable silt record of Mjell et al. (2016) on its original age model that is based on 210 Pb and two 14 C dates vs. the revised age model (as shown in Fig.  5 b) for GS06-144-09 MC-D, plotted together with the AMV index (Gray et al., 2004), to illustrate how our proxy-based interpretations for the 20th century might change with revised marine sediment chronologies.

Although marine based uncertainties over the last 2 centuries might still be too high ( ∼   ±  18 years in average) for a significant lead–lag comparison with observational records, our new approach based on anthropogenic signals provides an independent and valuable first step in refining age models and for validation of existing age model approaches and their assumptions.

High-resolution (i.e., decadal to multi-decadal) marine sediment records from North Atlantic sedimentary drift sites are now emerging, with the potential to extend instrumental records further back in time, distinguish natural climate variability from anthropogenic variability, and contextualize current changes. However, age model uncertainties, particularly over the 20th century, pose major challenges, especially for integrating shorter instrumental records with those from extended marine archives. Recent sediments are dated using an array of methodologies, yet all have their own limitations (e.g., bomb carbon, local reservoir corrections for radiocarbon); they are either not applicable to all locations (e.g., tephrochronology) or can be below the detection limits and require another independent approach to confirm (e.g., 210 Pb , 37 Cs ). Here we propose a new chronostratigraphic approach that uses anthropogenic signals to reduce age model uncertainties over the last 2 centuries. As a test application, we use the Gardar Drift sediment core GS06-144-09 MC and revise the age model at this site. Comparing planktonic δ 13 C records of GS06-144-09 MC with oceanic 13 C  Suess effect changes above the core location, we assign the beginning of the industrial period (i.e., 1800 CE) in our core and similarly derive the core-top age. We further use a combination of 14 C AMS dates and the 13 C  Suess effect change estimates at our core location to calculate regional reservoir corrections at Gardar Drift. Our refined Δ R estimate for Gardar Drift ( − 69  ±  38  14 C yr ) is similar to the value obtained from the marine reservoir database when the 10 nearest points are used ( − 72  ±  64  14 C yr ) but with better uncertainty estimates. Furthermore, to validate our 13 C  Suess-effect-based age model we use another independent approach: spheroidal carbonaceous fly-ash particles (SCPs). The rapid increase in SCP concentrations after the 1950s at GS06-144-09 MC is consistent with the SCP trend in the region and our 13 C  Suess-effect-based age model. Our new approach, based on anthropogenic signals, provides an independent and valuable first step in refining age models and for validation of existing age model approaches and their assumptions.

Data are available as information files in the Supplement.

The supplement related to this article is available online at:  https://doi.org/10.5194/gchron-6-449-2024-supplement .

NI and USN conceptualized the study. NI refined the new age model approach together with USN, FC, and AO. TLM processed the multicore samples and performed stable isotope analysis. NI processed samples for SCP analysis and conducted SCP analysis together with NLR and DJRT. USN led the efforts on stable isotope analysis. AO led the efforts on oceanic 13 C  Suess effect estimates for Gardar Drift. NI led the writing effort and coordinated input from all co-authors.

The contact author has declared that none of the authors has any competing interests.

Publisher's note: Copernicus Publications remains neutral with regard to jurisdictional claims made in the text, published maps, institutional affiliations, or any other geographical representation in this paper. While Copernicus Publications makes every effort to include appropriate place names, the final responsibility lies with the authors.

We thank the crew of R/V G. O. Sars , the Institute of Marine Research (IMR), the University of Bergen, and the scientific party of UiB cruise no. GS06-144. We thank Marie Eide for her help with calculating oceanic 13 C  Suess effect estimates for our core location at Gardar Drift. Stable isotope data were produced at the Facility for Advanced Isotopic Research and Monitoring of Weather, Climate and Biogeochemical Cycling (FARLAB; Research Council of Norway grant 245907).

This study was funded by the Bjerknes Centre for Climate Research (BCCR) – Centre of Climate Dynamics (SKD) Strategic Project PARCIM (Proxy Assimilation for Reconstructing Climate and Improving Model). Nil Irvalı received additional support from the University of Bergen Meltzer Research Fund.

This paper was edited by Richard Staff and reviewed by James David Scourse and two anonymous referees.

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• Introduction
• Material and methods
• The new age model approach
• Summary and conclusions
• Data availability
• Author contributions
• Competing interests
• Acknowledgements
• Financial support
• Review statement

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c Department of Chemistry, University of Puerto Rico, Río Piedras Campus, San Juan, Puerto Rico 00931, USA

d Department of Pharmaceutical Sciences, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico 00936, USA

e WEL Research Institute, Avenue Pasteur 6, B-1300 Wavre, Belgium

This study reports efforts toward the integrated advanced manufacturing of the anti-narcoleptic drug modafinil. It showcases a holistic approach from flow synthesis to purification via continuous crystallization. The integration strategy included a necessary optimization of the reported flow synthesis for modafinil, enabling prolonged operation and consistent crude quality. The reactor effluents were subsequently processed downstream for purification utilizing two single stage mixed suspension mixed product removal crystallizers. The first stage was an antisolvent cooling crystallization, providing refined modafinil with >98% yield. The second cooling crystallization delivered crystalline modafinil with >99% purity in the required polymorphic form I suitable for formulation.

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Continuous flow synthesis and crystallization of modafinil: a novel approach for integrated manufacturing

D. V. Silva-Brenes, S. Agrawal, V. López-Mejías, J. Duconge, C. P. Vlaar, J. M. Monbaliu and T. Stelzer, React. Chem. Eng. , 2024, Advance Article , DOI: 10.1039/D4RE00273C

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Precisely defining and quantifying hallucinations in natural language settings remains challenging due to language ambiguity and unclear knowledge content in training data. Despite advancements in generative capabilities, hallucinations persist as a significant challenge for LMs. The research addresses the gap in understanding how hallucinations depend on model scale. Knowledge graphs offer a structured approach to LM training, enabling straightforward fact verification against the dataset and providing a quantifiable measure of hallucination.

Traditional language models (LMs) trained on natural language data often produce hallucinations and repetitive information due to semantic ambiguity. The study employs a knowledge graph (KG) approach, using structured triplets of information to provide a clearer understanding of how LMs misrepresent training data. This method allows for a more precise evaluation of hallucinations and their relationship to model scale.

The study constructs a dataset using knowledge graph triplets (subject, predicate, object), enabling precise control over training data and quantifiable hallucination measurement. Language models (LMs) are trained from scratch on this dataset, optimizing auto-regressive log-likelihood. Evaluation involves prompting models with subject and predicate, and assessing object completion accuracy against the knowledge graph. Token tasks and head detectors evaluate hallucination detection performance. The methodology focuses on hallucinations where correct answers appear verbatim in the training set, exploring the relationship between the LM scale and hallucination frequency.

The research trains increasingly large LMs to investigate scale effects on hallucination rates and detectability. Analysis reveals that larger, longer-trained LMs hallucinate less, though larger datasets may increase hallucination rates. The authors acknowledge limitations in generalizability to all hallucination types and the use of smaller-than-state-of-the-art models. This comprehensive approach provides insights into LM hallucinations and their detectability, contributing to the field of natural language processing.

The study reveals that larger language models and extended training reduce hallucinations on fixed datasets, while increased dataset size elevates hallucination rates. Hallucination detectors show high accuracy, improving with model size. Token-level detection generally outperforms other methods. A trade-off exists between fact recall and generalization ability, with extended training minimizing hallucinations on seen data but risking overfitting on unseen data. AUC-PR serves as a reliable measure of detector performance. These findings highlight the complex relationship between model scale, dataset size, and hallucination rates, emphasizing the importance of balancing model size and training duration to mitigate hallucinations while addressing challenges posed by larger datasets.

In conclusion, the study reveals that larger, longer-trained language models exhibit reduced hallucination rates, but achieving minimal hallucinations requires substantial computational resources. Increased dataset size correlates with higher hallucination rates when model size and training epochs remain constant. A trade-off exists between memorization and generalization, with extended training improving fact retention but potentially hindering adaptability to new data. Paradoxically, as models grow larger and hallucinate less, detecting remaining hallucinations becomes more challenging. Future research should focus on enhancing hallucination detection in larger models and exploring the practical implications of these findings for language model applications.

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Shoaib Nazir

Shoaib Nazir is a consulting intern at MarktechPost and has completed his M.Tech dual degree from the Indian Institute of Technology (IIT), Kharagpur. With a strong passion for Data Science, he is particularly interested in the diverse applications of artificial intelligence across various domains. Shoaib is driven by a desire to explore the latest technological advancements and their practical implications in everyday life. His enthusiasm for innovation and real-world problem-solving fuels his continuous learning and contribution to the field of AI

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