Handbook of the Flora of Scandinavia by Carl Hartmanwas published in Stockholm by Zacharias Haeggström. TheHandbook was a successful project for both author andpublisher: similar enough to textbooks and academic publications to appeal ineducational settings, yet ostensibly written for the general public. TheHandbook went through eleven editions, becoming thestandard reference flora for Swedish botanists – academic as well as others –before being succeeded after 1879 by a range of specialized floras aimed atschoolboys, students, or academic botanists. The trajectory of Hartman’sHandbook through the nineteenth century highlights thechanging conditions of Swedish botanical publication. It draws attention toauthorship as a scientific career tool, and, conversely, the significance ofscientific texts in the emergence of commercial publishing in the first half ofthe nineteenth century.In 1820, a  Transactions ofthe Royal Swedish Academy of Sciences for his achievements as “anauthor, a calling to which he devoted every available moment, with restless energy,until his last days.” His biographer praised his contributions to botany – which hadearned him membership of the academy – while his activities as a physician weretolerantly described as “causing no disruption to his writing career,” despitemedicine being his main occupation and source of income.At his death in 1849, Carl Johan Hartman was eulogized in the Handbook of theFlora of Scandinavia, first published in 1820. The eleventh and finalcomplete edition was published in 1879, three decades after his death, and edited byhis son Carl Hartman. Hartman’s Handbook runs like “a green garland through mostof the nineteenth century,” in the words of Gunnar Eriksson, the foremost historianof Swedish botany. Eriksson’s imagery emphasizes the unifying qualities of theHandbook, drawing botanists of various backgrounds,occupations, and generations to a common standard. At the same time, each newrevised edition aimed to adapt to developments in publication practices, education,and career opportunities, and the trajectory of the Handbook chartsthe changing conditions of Swedish botanical publication in the nineteenthcentury.Carl Johan Hartman’s enduring credit as an author was his Handbook in the landscape ofscientific publication in nineteenth-century Sweden, examining it in the context ofcompetition in the small botanical book market. I will show that its successdepended on its relation to other botanical genres: similar enough to academic,Latin floras to merit serious consideration among botanists; accessible enough toappeal to a wider audience inside and outside Swedish schools; and benefiting, inits many editions, from the burgeoning botanical periodicals. In its inclusiveness,it profited from the problems of publishing science in Sweden, where scientificpublication was normally a matter of private or public subsidies. For its publisher,it provided profit and respectability; for its authors, a means of building andmaintaining positions, however different, in the Swedish botanical community. Iexamine its role in Swedish botany primarily as a matter of commercial competition –parallel to previous scholarship focusing on its role in contemporary debates aboutNaturphilosophie and Linnaean classification.In this paper, I situate Hartman’s Handbook throughreviews, official documents, and correspondence, foremost that between Carl JohanHartman and his editor Zacharias Haeggström, from the first edition of theHandbook in 1820 to the fifth edition and Hartman’s death in 1849. During this time, Hartman and Haeggström gradually carved a place for thehandbook among Swedish botanical publications. I conclude by outlining thetrajectory of the Handbook after 1849, as it went through six moreeditions under the editorship of Hartman’s son Carl.I approach the publication history of Hartman’s Handbook was a substantial volume. Alengthy preface, including references and instructions on collecting and preparingplants, was followed by a sixty-page introduction where the author explained theparts of plants, their classification, habitats, and seasons. The bulk of the book –almost 500 pages – consisted of descriptions of the plants of the Scandinavianpeninsula, arranged first by class and order, second by genus, mainly according tothe Linnaean system (with some modifications), and listing the characters, habitats,and localities of each species. There were no illustrations, apart from two diagramsshowing the shapes of leaves and flowers.The first edition of the Flora Lapponica (1737) and Flora suecica(1745), Linnaeus presented the species of a region or a country according to hissystem of classification and nomenclature, providing synonyms, habitats, andlocalities. “Floras” have a long history in botany, ranging from bare lists ofspecies to herbals and multivolume catalogs, yet are often discussed as a genre intheir own right. The format of Linnaeus’s floras was followed by many generations ofbotanists, particularly in his native Sweden. Bettina Dietz has shown how the multiple editions and translations ofLinnaeus’s central works, such as Systema naturae andSpecies plantarum, as well as his floras, depended on theadditions, corrections, and modifications of many naturalists. While this practiceestablished Linnaeus as the center of natural history, it also allowed naturaliststo shape his works to fit new audiences and contexts.In his Utkast til en svenskflora from 1791 was, in its turn, presented as a companion toHoffberg’s Linnaean outline. In later editions, Liljeblad’s Utkast outgrew itspredecessors as Liljeblad added species and simplified the Linnaean system. Headdressed it to “beginners and perhaps farmers” who had little time for Latin, butit also appealed to the students Liljeblad was teaching at Uppsala University as“botanices demonstrator” in the absence of the professor of botany, Linnaeandisciple Carl Peter Thunberg. Liljeblad published the book at his own expense, and it sold well enough togo to two further editions in 1798 and 1816.For Swedish readers, Carl Fredrik Hoffberg, a doctor, botanist, and contemporary ofLinnaeus, published a brief guide to the Linnaean system and nomenclature in 1763,expanding it in two later editions with descriptions of the uses of Swedish plantsfor medicinal and economic purposes. Samuel Liljeblad’s Utkast and its predecessors, Hartman’sHandbook may be regarded a direct descendant of thecomprehensive botanical works of Linnaeus. While Hoffberg’s and Liljeblad’s bookshad, at least initially, been cast as companions to the Linnaean canon, Hartmanbegan by announcing his cautious departure from certain Linnaean maxims anddiagnoses, for the purposes of “ease and certainty” in plant examination, and ofacquainting his readers with more recent scientific views. He was, however, carefulto distinguish it from more advanced botanical works that required a moreknowledgeable reader, not least by the fact that it was written in Swedish.“Nothing,” he wrote, “would have been easier than to turn this book into a learnedwork of several volumes,” but instead he aimed for “comprehensibility, exactitude,and brevity,” characterizing his book as a mere “index” compared to more voluminousand famous works. He still introduced the reader, at some length, to botanical science and itsphilosophical debates, and he described the book as a useful and up-to-date guide toplant examination for beginners. In the second edition, he further specified that it was “not intended forcontinuous reading, but for occasional use.”Through Liljeblad’s anwisning) and an “outline” (utkast),respectively, shying away from direct comparison with the Linnaean model. Hartman’s“handbook” suggested its use as a practical manual as well as a work of reference. It shares its multiple roles with many other handbooks, as recently pointedout by Angela Creager, Mathias Grote, Elaine Leong, and their collaborators. Drawingon book history as well as the history of science, they explore handbooks andmanuals across a wide range of disciplines, languages, and contexts, findingpamphlets, multivolume opuses, recipes, and encyclopedic tomes. But even thoughhandbooks resist easy characterization as a genre, they differ from othereducational genres, such as textbooks, in their focus on practical knowledge as wellas in their different paths on the book market.Hartman labeled his work a “handbook,” although it was frequently referred to as a“flora.” Hoffberg and Liljeblad had chosen to call their books a “guide”,a multivolume catalog of Swedish plants – and served as a hub of Swedish scientific publications. In the course of the nineteenth century, the scope of theTransactions – along with the academy itself – narrowed tofocus on academic science rather than the broad range of topics and scholarsincluded in the previous century. Although Swedish remained the official language,the Transactions eventually allowed papers in other Europeanlanguages, as academy fellows increasingly sought their readers among scientistsoutside the country, rather than in the small Swedish scientific community.The dominant Swedish scientific publication in the early nineteenth century remainedthe periodical Botaniska notiser was theproject of Elias Fries, then recently appointed professor of botany at UppsalaUniversity, and Alexis Lindblom, nominally professor of philosophy at LundUniversity but a botanist by training and inclination, bringing experience ofediting and writing for a local liberal newspaper. They modeled their journal afterFlora oder Botanische Zeitung, published in Regensburg since1802, and similarly aimed to “expand the study of Botany as well as its interest andesteem” in Scandinavia by publishing primarily floristic and plant geographicalpapers as well as reviews, correspondence, and notices. The journal soon attracted papers from a wide range of Scandinavianbotanists. Hartman was a regular contributor, and used its publications for revisededitions of the Handbook.Despite the precarious conditions for publishing botany in Swedish, a commercialbotanical journal was launched in 1839. Botaniska notiser waspublished by academic botanists for the greater part of its run, and receivedintermittent government funding, keeping afloat despite repeated interruptions andchanges in management. Neither entirely academic nor commercial, Botaniska notiserillustrates the conditions for botanical publication in Sweden: benefiting in termsof funding and credentials from academic connections, but surviving as an enterpriseby attracting subscribers and contributors outside academic circles. It adds to thepicture of the strategies employed by editors of scientific periodicals in Britainand France in the early nineteenth century, as they navigated between politicalperiodicals and academic publications bolstered by the funds of scientific societies.Although launched as an independent project, Utkast as a youngboy. Raised in the provincial town of Gävle to take over the family glazier’sbusiness, he nevertheless gained permission to continue his education at UppsalaUniversity, studying botany under Liljeblad himself. Aiming for a medical degree, he supported his studies as a private tutor in aseries of well-to-do families in Uppsala and Stockholm. Alongside his medicalstudies and tutoring, and with the encouragement of his employers, he continued thepursuit of botany, building a network of friends and correspondents. Most importantamong these was Olof Swartz, Permanent Secretary of the Royal Swedish Academy ofSciences and curator of its natural history collections. Through Swartz, Hartmangained access to the academy library and collections, and in 1813 a travel grant tostudy the flora and fauna of northern Sweden, resulting in his first scientificpublication, an account of his journey published in the academyTransactions. Obliged to resume his medical studies, he graduated in 1822 and practicedmedicine in various positions before eventually returning to his birthplace, Gävle,as district medical officer in 1833.As recounted by his biographers, Carl Johan Hartman (1790–1849) discovered botanywhen he “happened to come across” Liljeblad’s Handbook of the Flora of Scandinavia while still a student.Haeggström soon commissioned Hartman for translations of two older works in naturalhistory (continuing his practice of publishing translations of foreign bestsellers),as well as another original work, the medical handbook Husläkaren, which caused considerable debate amongreviewers and fellow physicians, but appeared in three editions over seven years. The textbooks and, most importantly, the handbooks provided Hartman with asource of income during the lean years of studying, private tutoring, and precariousmedical positions.Somewhere in the circles of young botanists and scholars in Stockholm he metZacharias Haeggström, and wrote what was to become the first of many editions of theHandbooknonetheless caused controversy on its first appearance. The critical reviews of thefirst two editions in 1820 and 1832 revolved around its offenses against Linnaeanclassification, its use of the Swedish language, and its merits as a textbook.Significantly, the most vociferous critics were both publishing botanical works oftheir own at the same time. Göran Wahlenberg, lecturer and eventually professor ofbotany in Uppsala, wrote a series of scathing, anonymous reviews of the 1820Handbook while in the process of finalizing his own LatinFlora svecica, conceived as heir to Linnaeus’s own. The Uppsala printer Palmblad, who was taking a commercial chance on theFlora, also provided the forum for Wahlenberg’s disapproval:his own periodical Svensk Literatur-Tidning.A commercial success for both Hartman and Haeggström, the Handbook was critically reviewed by CarlAdolph Agardh, professor of botany at Lund University. He was publishing the secondvolume of his own Swedish botanical textbook in the same year, and objected stronglyto the Handbook as precisely a “textbook” exposing students to itseclectic approach to botanical theories. However, he praised it as a “handbook”summarizing the field for the scientist: “it is careful; it is complete; it is notcopied, but rather assimilated through the views of the author; and it meets a realneed in our educational literature.” In the small Swedish botanical book market, with its precarious footing inschools, the Handbook threatened both textbooks and scholarlypublications, and both reviewers had reason to fear for the success of their own,self-published works.The 1832 edition of the Handbook among Swedishbotanists seemed more secure. In contrast to Agardh’s criticism of the secondedition, Hartman’s friend Johan Emanuel Wikström, professor of botany at the RoyalAcademy of Sciences, stated laconically: “The work is widely known andoverwhelmingly used. A review is therefore superfluous.” However, the Swedish scholarly book market did not allow for complacency, andboth Hartman and Haeggström worried about competition. When Hartman was working onthe third edition, and simultaneously writing a textbook in natural history, helearned that Pehr Fredrik Wahlberg, acting professor of natural history at theKarolinska Institute of Medicine in Stockholm, was planning a textbook of his own.Realizing that two textbooks appearing at the same time would be “pointless,” bothWahlberg and Hartman were anxious to avoid a “collision.” Hartman was reluctant to abandon his book and suggested collaboration, butWahlberg declined. In the event, Hartman modified his plans and settled for arevised and expanded version of his own earlier translation of a German textbook.Wahlberg’s book on fodder plants appeared in 1835, seemingly without conflict.With each edition, the position of the Haeggström steadily cajoled and nagged Hartman to publish more, and more quickly.Hartman’s early translations of German textbooks remained successful in updated andexpanded versions, but a projected “Flora Oeconomica” and a geography textbook nevermaterialized, despite Haeggström’s coaxing.Handbook remained a dependable item in the Haeggström catalog,and sold “most admirably in Lund, Uppsala, and Stockholm” . New, revised editions appeared in 1832, 1838, and 1843, eachedition selling slightly faster than the previous one. Haeggström paid respectably: in 1845, he offered Hartman 500Riksdaler for a new edition, and 250 for subsequent printings. This was much more generous than the rate for textbook translations, butsubstantially less than the 3,000 Riksdaler offered by Haeggström’scompetitors P. A. Norstedt & Söner for a German textbook in 1849, indicating thestill precarious position of science in schools and universities.The Handbook tempted competitors. In1843, a young student, Johan Daniel Högberg, published a “Swedish flora” todevastating reviews and accusations of plagiarizing Hartman. Haeggström wasnevertheless concerned: It is scandalous that Öberg, or Sjöberg, or whatever his name is, should havecopied you; and it is not inconceivable that his book is being used, for Iseem to note smaller sales of the 4th edition than the one before, althoughI cannot say for certain before I complete my sales accounts at Christmas.Haeggström’s firm solidified its reputation as a publisher of textbooks andhandbooks, but the success of the  New textbooks and several local floras appeared, spurring Haeggström andHartman to capitalize further on the success of the Handbook. Theyissued two abbreviated versions: a textbook, or “botanology,” based on theintroduction to the Handbook in 1843, and a “pocket flora” in 1846,intended for excursions at a mere 191 pages, and including Swedish plant names atHaeggström’s behest.Högberg’s book was unsuccessful, but the range of botany books available to Swedishreaders increased during the 1840s. The introduction of compulsory elementaryeducation in 1842 increased the potential market for textbooks, and, in thefollowing decade, new school statutes made botany mandatory for all secondary schoolstudents, although school science was slow to develop.Handbook first appeared, both its author and its publisherbenefited from the precarious scientific book market and the shaky status ofbotanical education. Ostensibly aimed at botanical beginners, it could be used inschools even though it did not conform to a specific curriculum. Written in Swedish,it appealed to a wider audience than the Latin works published by academicbotanists. But its flexibility also cast it as competition for a number of differentkinds of publication: for Wahlenberg’s scholarly Latin flora, for Agardh’s academictextbook and for Wahlberg’s economic one, and for the growing number of local florasappearing on the Swedish market.When the Handbook as a product, and Hartman himself as anauthor, were components in a business that relied on constantly updating its catalogof handbooks and textbooks to maintain long-term profitability in the emerging, butstill unreliable, Swedish market for scientific publications.To Haeggström, the My good friend! It is time to stop dawdling, and to take up your pen inearnest. Too long has she been idle. Remember how many years have passed,since we agreed on the plans for your great Natural Science, your FloraOeconomica, etc. If you are to have time for anything other than publishingnew editions of your works, you must hurry, because before you know it, youwill have to think about a new edition of your Flora.Handbook according to the commentsof his fellow botanists, as well as the promptings of his publisher. Thisquasi-serial character of handbooks and textbooks was an asset to Haeggström, withrecurring demand at the beginning of each school year or collecting season, and thepotential for ever new and revised editions. Haeggström also applied the serialmodel to his Library of Popular Science (Bibliothek ipopulär naturkunnighet), fourteen volumes of translations of works suchas the Bridgwater treatises, and published by subscription over several years. TheLibrary improved his status among Swedish scientists, whilealso emulating the practice of serial publication among publishers of popularnovels. By the mid-1840s, Haeggström’s was the largest publishing company in the country.Hartman continually revised the Handbook also increasingly relied on serial scientificpublications – Botaniska notiser in particular – for newinformation on observations, classifications, and publications, as well as foradvertising new editions. In its many editions, it resembled a serial publicationitself – kin to the multiple forms of periodicals in the nineteenth century: frommiscellanies to specialized collections of original papers; from serial monographsto weekly bulletins; from commercial enterprises to government and institutionalperiodicals; from semi-public newsletters to promotional publications. Toward the twentieth century, as Mathias Grote has pointed out, encyclopedichandbooks were often published serially as separate volumes or fascicles over time. The seriality of the Handbook also recalled the constantlyupdated and adapted editions of the Linnaean canon in the eighteenth century, but inHartman’s hands, Linnaeus’s universal project was recast as a national endeavor.The Handbook. On its pages, he cultivated the botanical networks hehad begun building as a student, paying lavish tribute to the contributions offellow botanists, and organizing his own last edition in 1849 according to thesystem of his influential friend Elias Fries. As the standing of theHandbook improved, Hartman still declared his business to be“editing” rather than “reforming” botanical systematics, treading the line betweentextbooks and academic botany. His duties as a district medical officer kept him in Gävle, at some distancefrom Swedish academic centers at Uppsala, Lund, and Stockholm, and he maintained hisposition mainly through correspondence and authorship. Nevertheless, he reached arespectable position in the Swedish botanical community, was elected fellow of theAcademy of Sciences in 1838, and attended the meetings of the ScandinavianAssociation for the Advancement of Science in 1840 and 1844.Hartman achieved both income and status in the botanical community through theThe authors of the growing number of botanical textbooks and local floras in thesecond half of the century rarely achieved such honors. In other respects, theirbotanical career prospects were more promising. As teachers in the expandingsecondary school system, they had an income as well as an audience, and Hartman’sbotanist sons Carl and Robert both followed this path.Handbook. His son Carl completed it and carried it through sixmore editions. It was more in demand than ever: a sixth edition was published in1854, with three more in the following decade and a tenth in 1870. By then, theHandbook had achieved standard status among Swedish botanists.Authors of province floras arranged their books in the manner of Hartman, andcollectors used it to organize their herbaria. As the eleventh edition was prepared for print, Carl Hartman was contacted byLeopold Neuman, secretary of the Lund Botanical Society. The Society served as a hubfor botanical specimen exchange in Sweden, and it published the most influential ofseveral plant lists, used by botanists to estimate the value of their specimens. Neuman was anxious to make sure that the Society’s plant list conformed tothe organization of the Handbook, and asked for advance copies ofthe new editions in order to adjust the plant list accordingly. The standards of practice established by the Lund Society were made tocorrespond with the arrangement of the Handbook.Carl Johan Hartman died in 1849, barely finishing the fifth edition of theHandbook, contributing botanical observations as well asexpertise on particular genera or species, thus gaining an audience without theeffort and expense of publishing a monograph.Botaniska notiser remained a crucial source of information, buteditorial ill-health and lack of both time and money made its appearance erratic.During its repeated interruptions, contributors to the Handbookcommunicated directly with its authors, among them the impressively named Uppsalastudent Thorgny Ossian Bolivar Napoleon Krok, who approached Hartman with the offerof canvassing his fellow students for botanical observations for the next edition. Along with an extensive list of cited authors (not least fromBotaniska notiser), contributing botanists were recognized inthe preface – in 1879 particularly for their authorship of specialist sections. Carl Hartman, on the other hand, styled himself the “editor” of his father’swork, the “corrections and additions” increasing with each edition, and culminatingin the “entirely reworked” eleventh edition of 1879.An increasing number of Swedish field botanists participated in theHandbook retained its inclusive character,appealing to botanists inside and outside academic institutions, as well as inschools. The school statutes of the 1850s initially added to the demand for ahandbook such as Hartman’s, and doubtlessly contributed to its continued success.But increasingly specific regulation of the science curriculum made itscomprehensive scope less appealing. In 1869, a commission was appointed to evaluatescience teaching and science textbooks in Swedish secondary schools. Krok –conscientious contributor to the Handbook, now teaching science ata Stockholm secondary school – was tasked with the section on botany and zoology,together with Hartman himself.Under Carl Hartman, the Handbook. Krok acknowledged its unparalleled positionamong Swedish floras and its great influence on later books: “Few floras haveachieved such great trust, such wide use, or stimulated such large interest fordescriptive botany as this.” However, his critical eye found many problems in theHandbook, in its account of characters, habitats, synonyms,sources; in what it included as well as what it left out.Of the eight textbooks, fifteen floras, and four illustrated volumes evaluated, nonegained full approval from Krok, the de facto author of the evaluation. Not evenHartman’s  Hartman’s Handbook may have seemed a blessing to teachers inthe 1850s, when the new school statutes suddenly required them to supervise theherbaria of their students, but by 1869 teachers and students were using localfloras: less cumbersome and more affordable, specifically targeted at students andplant collectors of particular regions. In their evaluation, the commissioners formulated a specific conception of thecontent and organization of school textbooks. But they also established “handbooks”as a separate category in all disciplines, subject to different requirements.Dictionaries differed from language primers, atlases from geography textbooks,collections of mathematical tables and scientific formulae from textbooks in physicsand chemistry. In botany, a “flora” was the stipulated handbook.Handbook now found itself sitting uneasily between categories.After the death of Carl Hartman in 1884, Krok himself attempted to take up the batonat the request of the family. His revised version was published in specialized installments and acclaimedby field botanists, but did not survive beyond the first few ambitious volumes; nordid a second attempt thirty years later. As envisioned by Hartman’s posthumous followers, theHandbook would resemble the encyclopedic latenineteenth-century chemistry handbooks examined by Mathias Grote. Often producedserially, and intended for practitioners rather than students, they differed notonly from textbooks, but from the multipurpose volumes produced by the Hartmans.Simultaneously too advanced and not comprehensive enough, Hartman’sHandbook) publishedtheir own “Swedish flora” explicitly intended for schools. Although some critics found it too elementary, it was more in line with therequirements stipulated by Krok in his evaluation, and soon achieved an unparalleledposition in Swedish secondary schools. The Krok–Almquist flora, too, was publishedby the Haeggström firm – but while textbooks remained central products, Zacharias’sson Ivar specialized in poetry and novels on the expanding Swedish book market ofthe late nineteenth century.At the other end of the spectrum, Krok and fellow teacher Sigfrid Almquist (anotherkey contributor to the final edition of the Handbook overlap with the earlyyears of George Bentham’s Handbook of the Flora of the BritishIsles, which went through seven editions and revisions in the hands ofseveral British botanists between 1858 and 1924. Bentham’s Handbookoffers contrasts as well as parallels with Hartman’s. Like Hartman’s, it wasoriginally addressed to “beginners” but eventually reached a wider readership,particularly after the addition of illustrations to the second edition. But itremained controversial among academic botanists, despite the credentials of Benthamand Sir Joseph Hooker, who revised it in 1887. David Allen ascribes its longevity,in the face of academic criticism, mainly to a lack of competition. British fieldbotanists longed for a book that could combine the features of an examinationmanual, a flora for students, and a comprehensive catalog, and in the absence ofalternatives, Bentham’s handbook filled the lacuna. In the same period, and in spite of its established position among academicbotanists as well as students and collectors, the task of navigating betweentextbook and catalog stretched Hartman’s Handbook too far. As anauthor, the industrious Krok attempted to bridge the divide, but he did so throughtwo separate publications.The later editions of Hartman’s Handbook reflects changes in botanicaleducation as well as in the Swedish book market. In its broad scope, it appealed toschoolboys, students, and established botanists, making it a profitable product in aprecarious book market with a small scientific readership, particularly in Swedish,and a limited demand for textbooks. Its success continued as science educationdeveloped, in schools as well as universities, underpinning a vigorous and growingamateur community. Its demise marks the divergence of scientific genres andpractices in the course of the nineteenth century, and partly – perhapsparadoxically – the strong position of botany in Swedish schools. By the second halfof the nineteenth century, handbook authorship in botany was the path to school,rather than to the Royal Swedish Academy of Sciences, for books as well as authors.Despite Hartman’s substantial revisions to the eleventh edition following thecriticism of the textbook commission, the Handbook lost itsposition in the profitable textbook market and was supplanted by local floras andspecialized handbooks intended directly for schools and mostly written by secondaryschool teachers. The particular role assigned to “handbooks” in Swedish botanicaleducation by the textbook commission was eventually filled by the Krok–Almquistflora for schools, to the great gain of its authors and publishers. Hartman’sHandbook had become the wrong kind of handbook.The trajectory of Hartman’s


Social isolation measures implemented in nursing homes during the COVID-19 pandemic generated occupational imbalance, discomfort, and mental health impairment in residents. We aimed to analyze the lived experience of elderly nursing home residents during the lockdown and social contact restrictions resulting from the COVID-19 pandemic. Methods: Exploratory qualitative study. Information was collected through in-depth interviews and field notes. An inductive thematic analysis was performed and international recommendations for the development of qualitative studies were followed. Results: Twenty-four participants residing in nursing homes were included. Two main themes were identified: (1) emotional impact of the experience of COVID-19 lockdown ; and (2) support as a therapeutic tool . Conclusion: Social restrictions by COVID-19 caused significant changes in residents’ occupations and routines, producing fear, loneliness, and abandonment of desired occupations; however, very important supports were also identified that helped to overcome the lockdown, such as social support, spirituality, and gratitude. SARS-CoV-2 is an acute respiratory illness, a causative agent of Coronavirus 2019 (COVID-19)  entered and nothing happened despite everything that could have happened’.(P.20)Other residents were not afraid of the disease, nor of death. From their perspective, it was necessary to be careful, cautious and respectful of the virus, and they had to live with this situation and deal with it in the best possible way.I have not been afraid, I have simply been cautious’;‘(P.4)I’m not afraid of the virus, no, I have to keep fighting’.‘(P.10)Residents thought about the possibility of becoming sick or even dying. Some felt prepared, while others described fear and worry. Some of the participants explained how they left it in God’s hands when their time would come, while also maintaining their drive to live:Life can go in a moment, and you have to be prepared”;”(P.1)[to die], I was very afraidI do not want to die because I love life very much…I am not prepared  [of the virus]”;”(P.13)…we have nothing left to say but let it be what God wants and let him have us when he wants us…I still want to live very much”.“(P.19)You cannot be afraid of death because it is something we cannot control, you can be careful, but not afraid, you have to face things”.”(P.16)In relation to the possibility that one of their family members might die, the residents said that they would prefer to die before one of their family members, especially among those participants with children and grandchildren:I was praying to God that I would be the first to die before my children. I couldn’t stand it [she gets emotional]. Even for my grandchildren I would give my life before anything happens to them”.“(P.23)It should be noted that the residents described how the meaning of the disease evolved throughout the pandemic. At first, in case of contagion, it was always certain death. Later, they found that it was survivable, and in many cases, it was mild or even asymptomatic: and the first days were horrible because of the fear, but then it was not so serious. There were only a few sick people here and as the days went by, I relaxed… we were not all going to die as I thought”.”… [the virus entered the residence](P.24)Residents recounted how their occupational routines were altered and changed by the pandemic, and the resultant feelings of frustration. Participants mentioned that changes in their routine included the addition of more scheduled activities such as cognitive training, psychomotor programs, and leisure programs. Above all, participants noted the loss of interaction with other residents, such as sharing meals. To this they added the loss of freedom of movement due to lockdown in the rooms, and the prohibition of visits from their families. They all wished to regain their previous routines, their pre-pandemic “normalcy”, which they associated with happiness and joy. However, they said they had been able to accept the new situation brought about by the pandemic:Routine makes you happy and you want to get it back”;“(P.1)Without my daily activities I was broken, I missed it a lot. The pandemic changes many things”;“(P. 10)I thought I was dying in there and at first, I thought it was going to be 2–3 days, but I watched the days go by with resignation and I got used to it, but it was horrible. For me, the freedom to move and relate to others is the most valuable thing a human being has and that was taken away from us”.“(P.24)Residents recounted the importance of occupational performance during the pandemic. Even though activities were suspended, feeling busy served to distract them from thinking about the pandemic. Being busy made them feel that time passed more quickly, and they found that fewer negative thoughts arose:I had the need to be doing things, when one was better occupied, the thoughts were softer. Doing nothing can make people crazy”.“(P.17)All residents were aware of the importance of keeping occupied. However, some described that they were not able to continue doing certain activities, due to a lack of concentration, motivation, or energy:I didn’t do them [occupations] because I didn’t feel like it, I wasn’t able to focus and there was no way to get me out of everything I was thinking. I think it would have been better for my head, but the spirit was lost”.“(P.23)The participants described religious beliefs as an important factor in coping with the experience of lockdown emotionally. Many of the residents noted that they feel grateful to God for not being sick, that there were no contagions in the residence, and that their family members were in good health:We have to thank God because our families are fine, I myself am fine. Thank God that we have not had any problems in the residence”;“(P.2)Blessed be God, nothing has happened to us”.“(P.3)In addition, residents reported that when they prayed, they saw God by their side. They felt comfortable and calm, and they felt heard when they were alone. Further, participants described how praying helped them to let off steam:Beliefs are very important because you feel listened to and even more so when you are alone”;“(P.9)Every night of this pandemic, but every single night, [my faith in God] made me feel satisfied and comfortable”.“(P.10)Residents emphasized the importance of the support they received from family members, fellow residents, and professionals. For them it was an essential treatment tool received in different formats.Phone calls from their relatives provided support to the residents, and helped them overcome sadness. They described how having someone listen lifted a sense of burden, that through conversation they reclaimed the will to live. Family support brought back a sense of happiness they had lost, and the will to keep fighting. Residents explained that talking to their family reassured them, made them feel supported, and increased their confidence and sense of strength to face lockdown:That is very sad, because to get over it a little I call my husband when I come home from breakfast, when I come home from lunch and at night before I go to bed, I call him”;“(P.1)They support you and tell you no mom, don’t worry because this [the lockdown] is like that. You already feel a relief with that support and that confidence. That’s what helped you to live, to feel listened to”;“(P.3)That really made me very happy, I let off steam with them”.”(P.14)Some of the participants described that while talking to their families they felt cheerful and encouraged. However, the end of the conversation was bittersweet: they felt uneasy, sad, and helpless:That time I was crying like Magdalena [Spanish expression that means to cry inconsolably] when I hung up with them, I felt like the worst of impotence, they tried to cheer me up, but I was very upset”;“(P.19)Notice how rare it was that they would call me, and it gave me a lot of joy, but when I hung up [the phone] I would get very sad and upset about being alone again. It was a bittersweet taste, I couldn’t wait for them to come, but when they left, I felt bad”.“(P.22)However, there were participants who felt the lack of support even more, in cases where their loved ones had passed away or where family members did not care about them:My sister’s support has always been missing from me and now even more so. I would have loved for my mother to have been there, she would have been my support, I have missed her much more”.”(P.9)They have barely called me on the phone, that is sad that your family does not bother to call you daily or anything”.”(P.21)Residents reported how the support received from other residents helped them to grow in the worst moments and to feel listened to. This support made them feel comfortable and made it easier to establish good relationships. The roommates in the residence were, on many occasions, the only contact they had, and served as a pillar of stability during the pandemic: My roommate’s support has been great and very important. We were both alone in the room”;“(P.14)The friendship I have had with my roommate has been very good for me because if it hadn’t been for her friendship, I would have died here of disgust… surrounding myself with her has taught me many things, the truth has been a very big support in this time because thanks to her I’ve gotten over her better [the lockdown]”;“(P.21)We told each other how we felt the stresses, the sorrows, and everything. If I had gone through it alone, I would have had a much worse time”.“(P.22)However, there were participants who did not feel supported by other residents. They described wishing they had had a companion to lean on more, share concerns, and avoid feeling alone. They explained how, with more support, the pandemic would have been easier to endure:It would have been nice to have been with someone with whom I could have talked and with whom we could have supported one another, I missed that a lot”;“(P.12)Another roommate would have been better, with my roommate it was very difficult because I could not tell her anything serious, she was like a wall, it was like being alone”.“(P.23)The residents appreciated the support given by the nursing home staff. They described how the professionals tried to create relaxed moments even though they were tired from work. The resident staff listened to them, stayed close by, and were always willing to help them. In addition, the residents described how the nursing home staff supplied the support that their family members could not give them, and some of the participants even reported that it was as if the professionals were their own family:They [the nursing home staff] came many times and listened to me and it suited me better”;“(P.10)I was very grateful for this support because my family could not be there, so they [the nursing home staff] were there”;“(P.12)During these days when they [the nursing home staff] were there, they were my brothers who sheltered me and took care of me, they listened to me. Having them as a family was very important, I felt good, and I felt understood”.“(P.16)There were also participants who described that, after contact with the staff, they returned to their previous state of discomfort. Others described how they wished the staff would have spent more time with them, sitting and talking quietly, without schedules: Those moments with [the nursing home staff] were like a breath of fresh air, but then they would leave, and I would get really sick again”;“(P.19)They would come and listen to us because they can’t say otherwise, but I have missed them sitting peacefully and talking to us because we needed that half-hour of patient presence and conversation”.“(P.17)The participants reported that they must be grateful for the great work carried out by the professionals despite their own emotional state. The participants understood that it was often difficult for the staff to care for them. This empathy for the professionals helped the residents feel better themselves:We understand the effort and work that they [the nursing home staff] do to keep us better and to heal us. It is very difficult and we must thank them for that after everything they have done”;“(P.10)I saw one of them [the nursing home staff] upset and I worried about them too, because I saw that they were very nervous. Even so, they always came with a smile to cheer us up, and for that we must thank them”.“(P.14)The participants in our study described experiencing conflicting feelings during the social restrictions caused by the pandemic, placing high importance on occupations, disruption of routines, and social support.Our results show how residents exhibited contradictory feelings about illness, death, and occupation. Participants described feeling sad, feeling overwhelmed, and fearing death. Previous studies ,32,33,34The residents reported that despite the many negative experiences during lockdown, they were happy that they could continue to relate to each other. They were also happy to discover that the appearance of cases with COVID-19 did not mean death. Our results coincide with the study by Van der Roest et al. , where pOn the other hand, our results reveal that some participants concealed their true feelings from their caregivers and/or relatives. This could be due to the need for self-protection, or to protect those around them from suffering . IdoiagaOur results describe how residents frequently thought about the possibility of becoming ill or dying. These findings are consistent with previous studies ,38, whicThe studies by Gismero-Gonzalez et al.  and BoekAccording to our data, residents attached great importance to the religious role during the pandemic. This helped them to feel calm, confident, and accompanied. Religiosity and spirituality among residents is a theme that has already been addressed in other studies ,49,50,51To date, we have not yet found studies that investigated the importance of spirituality in nursing home residents during the pandemic, despite it being such an important part of the residents’ lives. However, we have found such topics among studies with disadvantaged communities ,52. For Our results show how social support was a key component of the residents´ experiences. The support received encouraged them to overcome sadness, and gave them the will to continue living. Our results coincide with previous studies ,53,54 whOur results show how the support received among residents helped them to feel listened to and protected. Zhao et al.  pointed A study by López et al.  describeIn comparison, other studies demonstrated other types of coping mechanisms employed by older adults. These included emotional eating , increasAdditionally, according to our data, residents were grateful. Gratitude can be of great benefit. In their study on gratitude, Büssing et al.  pointed The present study had limitations. Firstly, the results obtained cannot be extrapolated to the entire institutionalized population due to the nature of the qualitative methodology . SecondlIn conclusion, our results highlight the importance of occupation and routines during isolation. In addition, the support received from other residents, from professionals, and from their loved ones via telephone was an essential pillar for moving forward during the pandemic. These results may help in understanding the experiences of institutionalized persons during the major health crisis caused by COVID-19, to describe their feelings and the importance of occupation, routine, and social support. Future studies need to delve deeper into the experiences of older people in other contexts and their effect on occupation during the COVID-19 pandemic.


The UK Health Security Agency’s (UKHSA) Health Protection Teams (HPTs) provide specialist public health advice and operational support to NHS, local authorities and other agencies in England. The development of a three-year UKHSA Health Equity strategy creates a unique opportunity for HPTs to reduce health inequities within their work.This study aimed to understand current health equity activities and structures within HPTs, and to propose future HPT-led health equity activities.Between November 2021 - March 2022, HPT staff from the nine UKHSA regions were invited to participate in a semi-structured interview or focus group.Twenty-seven participants covering all nine UKHSA regions took part in a total of 18 interviews and two focus groups. There was enthusiasm to address health inequity, and many reported this as their motivation for working in public health. All HPTs routinely engaged in health equity work including, variously: liaising with other organisations; advocacy in case and outbreak management meetings; developing regional HPT health equity action plans; and targeting under-served populations in day-to-day work. HPT staff discussed the challenge of splitting their time between reacting to health protection incidents  and pro-active work . Although COVID had raised awareness of health inequities, knowledge of health equity among the professionally diverse workforce appeared variable. Limited evidence about effective interventions, and lack of clarity about future ways of working with other organisations were also shared as barriers to tackling health inequities.HPTs welcomed the development of UKHSA’s health equity strategy, and through this study identified opportunities where HPTs can influence, support and lead on tackling health inequities. This includes embedding health equity into HPTs’ acute response activities, stakeholder working, and staff management. This study also identified a need for health equity training for HPTs to improve knowledge and skills, utilising evidence-based approaches to health equity. Finally, we have identified areas where HPTs can lead, for example using brief advice interventions and through developing resources, such as standard operating procedures that focus on vulnerable populations. These findings will support a more integrated approach to addressing health equity through health protection work.The online version contains supplementary material available at 10.1186/s12889-023-15143-7. The World Health Organisation (WHO) defines health equity as the “absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality . Health is a fundamental human right. Health equity is achieved when everyone can attain their full potential for health and well-being.” .Health inequities may be driven by:different experiences of the wider determinants of health, such as the environment, income, or housing.differences in health behaviours or other risk factors, such as smoking, diet and physical activity levels.psychosocial factors, such as social networks and self-esteem.unequal healthcare access, experience, or outcomes .The COVID-19 pandemic has exposed and exacerbated inequities in society –14. OfteHealth protection issues, such as low vaccine uptake, infectious diseases  and Hepatitis C) and antimicrobial resistance (AMR), disproportionately affect inclusion health groups  or other at-risk groups who already experience health inequities  –18. In rAchieving health equity requires identifying and addressing inequities, wherever they exist. Narrowing inequities is complex and often described as a ‘wicked problem’ requiring system-wide solutions and innovative thinking .The 2010 Marmot Report  showed tCurrent strategies and approaches in England include:The NHS Long Term Plan (NHS LTP) which sets out an objective on prevention and health inequalities, with a focus on reducing local health inequalities and unwarranted variation , 23.NHS England and NHS Improvement’s Core20PLUS5 approach to support the reduction of health inequalities at both national and system level. The approach defines a target population cohort for action that includes the most deprived 20% of the national population (the ‘Core20’) and inclusion health groups and protected characteristic groups (PLUS). The ‘5’ refers to focus clinical areas requiring accelerated improvement .The government’s ‘Levelling Up’ White Paper which has a mission to: narrow the gap in Healthy Life Expectancy (HLE) between local areas where it is highest and lowest, by 2030; and raise HLE by 5 years, by 2035 .The 2021 public health reform dissolved Public Health England (PHE) , and crThe UK Health Security Agency’s (UKHSA) Health Protection Teams (HPTs) provide specialist public health advice and operational support to the NHS, local authorities, and other agencies. HPTs also prevent and reduce the effect of diseases, chemical and radiation hazards, and major emergencies, through: local disease surveillance; maintaining alert systems; investigating and managing health protection incidents and outbreaks; and implementing and monitoring national action plans for infectious diseases at local level .The UKHSA’s remit letter states that, to support delivery of the Department for Health and Social Care (DHSC)’s approach to health disparities, the organisation has a role in co-ordinating with partners to ensure all members of the community are, as far as possible, equally protected from health threats. As part of its core activities, UKHSA will develop and implement an internal UKHSA health equity strategy, supported by the newly established health equity division . This reThis study aims to collate the views of Health Protection Teams, and explores:Current health equity activities and structures within HPTs.Desired future health equity activities.The findings will be used to inform national and regional health protection strategies to tackle inequities.Initially, a named Health Equity Lead from all nine regional Health Protection Teams in England, were invited to either a 1–1 (interview) or group (focus group) discussion with the lead researcher (RA), depending on participants’ preference. Subsequently, any colleagues recommended by the Health Equity Leads were also invited to participate.The semi-structured interview schedule (Supplementary 1.), developed using the Theoretical Domains Framework (TDF)  , coveredRoles, responsibilities, and the structure of the team in relation to tackling health inequities.Use of strategies / guidance / tools / continuing professional development, aimed at tackling health inequities.Priority population / disease groups.Barriers and facilitators to tackling health inequities.In practice, the terms health disparity, inequality and inequity are often, albeit incorrectly, used interchangeably. At PHE the agreed terminology in this space was ‘health inequalities’, however, to better describe the ambition of the UKHSA, the term ‘health equity’ was adopted. As such, interviewees’ responses often shifted between these terms as these new organisations were formed and settled.Discussions were conducted by RA over Microsoft Teams at a time convenient to the participant(s). Participants were reassured that there was an understanding that the organisation was going through a period of change, and that there was no expectation regarding current health equity activities within their HPT. Participants were also reassured that the transcripts would be anonymised, so they could be as open with their opinion and share as much as they felt comfortable with. The interviewer (RA) was an experienced researcher, with a background in Public Health, but no experience of working in Health Protection Teams. On average, discussions lasted approximately 50 min.With the participants’ consent, the discussions were recorded and transcribed, verbatim. Transcripts were checked for accuracy by RA and anonymised. RA thematically analysed the transcripts  and mappAll UKHSA participants were invited to a follow-up workshop to review the main findings and discuss future priorities for national strategy and regional HPTs’ business plans.Between November 2021 – March 2022, twenty-seven participants from all nine UKHSA regions took part in the study  or fully agreed with the findings .Participants felt that the remit of the UKHSA was to achieve health equity by considering and accounting for health inequities in their health protection response work, but it was not felt that it was necessarily the role of HPTs to directly address the wider determinants of health inequities. Participants expressed that they felt their role was about finding the balance of reducing disease transmission compared to the risks of mitigation strategies required to do so. Participants felt that, although they were clear of the end goal, health equity was not always routinely considered in HPTs’ work.“Realistically, I think the majority of the time, actually what we’re really talking about is equity. So, if we’re looking at people who are intravenous drug users, or people who are homeless, we’re almost certainly going to have to go that additional mile. We’re going to be doing things with them that we wouldn’t do with other people, so it’s not equal, but it’s equitable to make sure that they’re getting the same experience as other people, and that we’re striving to have the best, the same health outcomes for them all.” (CCDC-I-17122021B).“I remember one of my colleagues saying to me that our job is just to reduce and stop infectious disease spreading. And I don’t believe my job is to stop infectious disease spreading at all costs, it is to balance the risks and reduce the risk of infectious disease against those other risks. So, in schools, the risk of reducing infectious disease by sending all the kids home is not worth it for the impact it has on inequalities.” .“…address the impacts rather than the underlying causes. Our service isn’t able to address the underlying causes of health inequalities… I mean, we can highlight the need for tackling the inequality from a Health Protection perspective, but we’re not the providers of accommodation or income or healthcare, so we can’t directly impact that; we could highlight that it’s an issue that needs to be addressed.” (CCDC-1-17122021 A).There was an appetite and enthusiasm among participants to address health inequity, and many participants reported this as their motivation for working in public health. Generally, participants felt that there was interest from other team members too, but some were concerned about staff time and capacity to focus on health equity.Although there were many differences, there was general agreement that HPTs have a role in:liaising with other organisations / agencies to tackle inequities.advocating for health equity in outbreak / incident management meetings.developing regional HPT health equity action plans.managing day-to-day incidents, with extra effort put into reaching under-served populations.pro-actively working with identified inclusion groups to understand their lived experiences and co-develop interventions to address inequities.HPT staff discussed the challenge of splitting their time between managing health protection incidents  and pro-active work , Sexually Transmitted Infections (STIs), migrants and asylum seekers, early years and school-aged children, people in contact with the criminal justice system). Staff members also had roles as geographical patch leads , managing local health protection incidents and strategic work with local stakeholders, such as local authority public health.“The core team, which is made up a mixture of consultants and practitioners…where we’re all providing an acute response, and we do that by a single acute desk. Practitioners are likely to spend the majority of their time ….on the acute desk, and then they will have a range of programmes that they feed into, and one of those programs is the inequalities programme… Sounds marvellous until you bring in the fact that our practitioners are constantly told to deprioritise programmes and prioritise the desk.” (CCDC-1-18012022).In relation to health equity activities, there was a full spectrum, in terms of progress, set-up and activities officially labelled as health equity projects. For example, where some HPTs already had a health equity team within their regional HPT, there was a desire from other HPTs to set this up, with a named champion within each patch. At the time, one HPT had a health inequities group which also included their OHID regional health and wellbeing team, which was considered advanced progress.“Within **[region] there are three Health Protection teams. There are periods of time and elements of work which we do across **[region]. So, for example all our SOPs around how we manage a particular infection or how we manage a particular situation are developed within a Pan **[region] group with representation from each of the three HPTs. However, each of the three HPT works a little bit differently and takes on different projects, and cover different populations, so there will be slightly different issues within each of those areas. And so, from the point of view of health inequalities, we hadn’t, across **[region], until late last year, really had a formalised health inequalities group and then the convening of that first national meeting, kind of pushed us to do that. So, all three of the HPTs had done various bits of work or had more, or less, formalised programmes of work with regards to health inequalities.” .“My honest opinion is that people are doing it and not realizing they’re doing work towards it… As an example, avian flu, we have had quite a lot of it in **[location], and there is a specific sort of population of people who end up doing a lot of the sort of nasty work with avian flu, picking up dead birds, and that sort of thing, and that population tends to have sort of worse health outcomes, they’re in poorer health, they’re less likely to take Tamiflu, they are managed by a different organization, no proper occupational health, disengaging… There’s a fair bit on health inequalities here that needs addressing, even if it’s not labelled as such, if that makes sense. And so, I think that that goes for health practitioners, business support as well, who are on the phones. Now, what I think, potentially we could do, is expand that and recognize what we’re doing, and in recognizing it and labelling it, you enable people to do it more.” .There were also differences in team staffing as some HPTs reported access to data and surveillance expertise that could provide intelligence, to inform action and decision making, which was considered beneficial.Participants acknowledged that health inequities were a clear thread in public health curricula, but recognised that, post-COVID, HPTs and the wider UKHSA were more professionally diverse than before the UKHSA formed, resulting in mixed awareness and knowledge of health inequities..There was a general agreement to move to a more holistic approach to support populations most in need, rather than siloed disease / hazard-specific working. Table Generally, participants found responding to questions about monitoring progress towards health equity challenging. Their reasoning for this was that health equity objectives had not previously been explicitly set within health protection, and therefore, it had probably never been measured before in their work. They recognised that demonstrating progress on defined outcomes  would take time and that data was crucial to monitor it. Participants suggested that looking at the existing metrics on published data sources e.g. OHID’s Fingertips , would b“The best thing to do, for the start, would be to review what metrics we already have nationally, and so using the fingertips, etc. and saying, which of these indicators do we have an impact on? So, you know, we don’t have an impact, for example, on number of children in poverty. That’s not something really that the Health Protection team can add any weight on. But we do have an impact on immunization rates… And let’s review them more regularly for our boroughs. So, you know, that tool is really good, actually, isn’t it, for being able to compare geographies? And we could just, as a matter of routine, once every six months, or once a year, look at where our boroughs sit, compared to other things, and come up with a sort of action plan about where we focus our attentions according to those metrics. I think that would be the start. Don’t reinvent the wheel. Those metrics have been thought out very carefully, but there are probably new metrics also and some of them are probably quite easy to think about, and sort of more audit type metrics. I mean, even reviewing the number of situations that we’ve managed over a time period which affect a specific group.” .Other suggestions for ways to measure and monitor progress in the HPT health equity arena was through auditing HPTs’ case and incident management against agreed standards to understand whether cases were managed according to guidance and whether standard operating procedures (SOPs) could be improved to better consider health inequities. Participants suggested that the relevant fields to facilitate this and other quality improvement activities and research should be built into the new HPT electronic case and incident management system currently being developed (CIMS).“In terms of measuring impact, proving that impact, I think there does need to be quantitative measure… And actually, it’s made a real difference… as a result of doing what we’re doing, we’ve got this many people in to stop smoking services.… this is the percentage change in intravenous drug use and homeless people with TB adhering to treatment. I think the difficulty is that the baseline for that doesn’t exist at the moment, so it’s around kind of getting some of that baseline. And maybe it is around kind of recording that, but it has to be done in a simple way… maybe looking at things like CIMS [UKHSA’s Case and Incident Management System] for example. I’m thinking about like really quick checkboxes for example, that people could do within the programme that says, you know, have you done XY&Z and then we could kind of have a look at the outcomes of that. Working perhaps with local authorities around gathering, so if we are referring into services, for example kind of trying to get some of that information back. So how many times have Health Protection referred into our services and what has that resulted in? I guess, kind of linking up some of those data streams.” (CCDC-I-17122021B).Participants suggested that they would consider that their actions had made a difference to health inequity if there were changes in national guidance, such as national guidance on diagnosing measles, rash in pregnancy, chicken pox, hepatitis B etc., to include how rashes or jaundice will appear on various skin types or amending the population groups recommended Hep B vaccinations Resources, staffing levels, time constraints and organisational barriers, were mentioned as factors that impact the ability of staff to tackle health inequity. Participants reflected on these issues and suggested solutions to overcome them.See Tables UKHSA Health protection teams see that they have a role in addressing health equity going forward, both within their reactive management of health protection incidents and outbreaks, as well as with their pro-active project and stakeholder working. At the time of data collection, challenges to this included: time and capacity to put the processes in place to embed health equity; lack of evidence about effective interventions for health protection; challenging systems, data collection and access to data; mixed awareness / knowledge of health equity in the professionally diverse, post-COVID HPT workforce; uncertainty in the UKHSA and HPTs’ health equity remit, and future ways of working between key organisations.It is known that public health agencies have a fundamental role in understanding the health needs of deprived communities and inclusion health groups, identifying interventions to improve their health and providing leadership at local and national levels . HoweverHPTs identified a role in pro-actively working with inclusion health groups to understand their lived experiences and co-develop interventions to address inequities. This community-centred approach is consistent with the published place-based approach to tackling health inequalities . HoweverThe King’s Fund state that “now is the time to embed work to address health inequalities” ; these vThere is agreement in the literature that population health concepts should sit at the core of health curricula , with a The main strengths of this study are the robust methodology, underpinned by behavioural science; and the timeliness of the discussions, to capture the views of HPTs shortly after transition from PHE to UKHSA, which can be used to inform development of the UKHSA health equity strategy. Further studies could go further to address and unpack some of the themes and the relative impact HPTs might make addressing health inequalities through different mechanisms e.g. on wider determinants.Furthermore, although there were more participants from London and the West Midlands, these teams covered some of the largest populations, and had many smaller areas within their regions; therefore, it was appropriate to collect the views from colleagues across the region, as recommended by the regional health equity lead. Moreover, participants from health protection teams from all nine UKHSA regional teams in England participated in the study, implying that we can be confident that the findings provide a true picture of current approaches to health equity across HPTs. However, the findings are limited to reflecting the English health protection system, and therefore may not be generalisable to other countries. It could also be argued that there were bias in findings as the primary participants were the nominated health equity lead(s) for their health protection team, suggesting that they were already engaged, and could therefore bias the results. However, all health equity lead(s) were given the opportunity to suggest as many other colleagues as they thought could input into the discussion, and every suggestion was invited to participate in the study.Acknowledging that resources, staffing levels, time constraints and organisational barriers, following re-organisation of Public Health agencies, all impact the ability of staff to tackle health inequity is important; to overcome them requires leadership, a focus on the most impactful interventions, and efficient cross-organisational working.Although many challenges, there was an appetite and enthusiasm to address health inequity within health protection, and UKHSA’s HPTs have a role in this. Recommendations include:development of a Health Equity Strategy which sets out the remit and expectations of HPTs and the wider UKHSA.take a more holistic health protection approach to support populations most in need, rather than siloed disease / hazard-specific working.embed health equity into business-as-usual e.g., including / considering in SOPs, guidance, audit, clinical reviews, outbreak report, risk assessments, job roles, commissioning contracts. Approaches to embedding in health equity in national guidance, could include ensuring that all guidance and supporting resources are inclusive in their language and descriptions and promote equitable public health action across all population e.g., national guidance on diagnosing measles, rash in pregnancy, chicken pox, hepatitis B etc., to include how rashes or jaundice will appear on various skin types.develop the workforce through skills audit and health equity training to improve knowledge and provide specific skills relating to evidence-based approaches to health equity.These findings will support a more integrated approach to addressing health equity through health protection work.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3