Heat exposure can be a health hazard for many Australian workers in both outdoor and indoor situations. With many heat-related incidents left unreported, it is often difficult to determine the underlying causal factors. This study aims to provide insights into perceptions of potentially unsafe or uncomfortably hot working conditions that can affect occupational health and safety using information provided by the public and workers to the safety regulator in South Australia (SafeWork SA). Details of complaints regarding heat exposure to the regulator’s “Help Centre” were assembled in a dataset and the textual data analysed thematically. The findings showed that the majority of calls relate to indoor work environments such as kitchens, factories, and warehouses. The main themes identified were work environment, health effects, and organisational issues. Impacts of hot working conditions ranged from discomfort to serious heat-related illnesses. Poor management practices and inflexibility of supervisors featured strongly amongst callers’ concerns. With temperatures predicted to increase and energy prices escalating, this timely study, using naturalistic data, highlights accounts of hot working conditions that can compromise workers’ health and safety and the need for suitable measures to prevent heat stress. These could include risk assessments to assess the likelihood of heat stress in workplaces where excessively hot conditions prevail. Each state and territory in Australia has a work health and safety regulator to oversee workplace practices, educate, enforce laws, and ensure compliance . In the The present role of SWSA is to provide work health and safety and industrial relations services to South Australian workplaces and reduce the incidence of injury through engagement and action, and the provision of information, assistance, education, and compliance activities to promote safety. Inspectors are responsible for ensuring that safety standards are met and that appropriate enforcement action is taken if breaches of the laws are detected; while advisors provide information, advice, and support to meet individual workplace needs . One of The impacts of extreme heat on population health in Australia are well documented ,4,5,6,7.Whereas studies have inferred high heat-susceptibility in the aged, frail, isolated, and ill in SA ,11 thoseThat extreme heat poses a risk to the health and safety of people in the SA workforce has been asserted by Xiang et al., who have shown an increase in occupational compensation claims during days, and extended spells, of high ambient temperature ,14. OfteAnother less obvious but still concerning health and safety problem associated with working in hot environments is the propensity for heat-related occupational injuries. These can arise for reasons including fatigue, loss of concentration, dehydration, slippery hands, or impaired vision due to sweating, or tools being too hot to handle safely. Xiang et al. noted several types of heat-associated injuries during heatwaves including burns, lacerations, wounds, and amputations . In anotAlthough there are state and national guidelines for employers on thermal safety and the prevention of occupational heat stress in workers, there are no enforceable laws. Under the South Australian Work Health and Safety Act 2012, “A person conducting a business or undertaking at a workplace must ensure, so far as is reasonably practicable”, that “workers carrying out work in extremes of heat or cold are able to carry out work without risk to health and safety” . In effe“Dangerous” incidents including those causing death, serious injury, or illness, are “notifiable”, and national Work Health and Safety laws require they be reported to the regulator immediately. Penalties apply for non-compliance . HoweverWorkers can feel powerless or reluctant to approach management regarding grievances about work conditions and safety cultures. However, concerned members of the public and workers in SA are able to voice their concerns to SWSA regarding conditions they consider to pose a threat to workplace health and safety. During 2015–2016, there were a total of 44,631 contacts made to SafeWork SA, 10,357 notifications, and 22 formal complaints that were subsequently resolved through the formal customer feedback process . DetailsIn this unique study, we examined SWSA data garnered from calls about hot work environments. The aim was to provide insights into potentially unsafe or uncomfortably hot working conditions and work practices. This ‘naturalistic data’  has beenIn early 2006, SWSA established a Help and Early Intervention Centre (this later became the “Help Centre”), which members of the public could contact and be provided with advice on health and safety matters, or lodge a formal complaint. All official complaints and notifications to the regulatory safety agency that justified the creation of a record were kept; however, from 2009, a phone call logging system was put in place that allowed for a record of call details. Some calls are logged as enquiries and some are classified as official workplace complaints or notifications of injury or dangerous occurrence. SWSA offers callers an option for intervention for the latter. Notifications and complaints are assessed and triaged for response priority . Action Using the key word ‘heat’, the details of the lodged complaints and notifications from 2002 to 6 January 2017 were searched by an SWSA officer for those relating to concerns about thermal conditions. Excluded were approximately 450 “answered” calls where persons enquired about heat-related topics and, after speaking with SWSA, were satisfied that they could deal with the matter through their workplace risk management processes. For these calls—usually regarding cut-off temperatures to stop work or the number of breaks required in hot weather—only brief data is reported. All relevant records were extracted and compiled in a database, with identifying information of people or companies removed. The resultant dataset was sourced from SWSA.The data were imported into NVivo , a software analysis tool to aid in the analysis of qualitative data. Using descriptive statistics, and thematic analysis augmented by a content analysis , the datEthics approval for the study was sought from the Human Research Ethics Committee of the University of Adelaide , which deemed there to be no ethical issues raised. This study forms part of a larger study with ethics approved by the Human Research Ethics Committees of The University of Adelaide, Queensland University of Technology, Monash University, and the University of Western Australia.There were 118 records mentioning “heat” in the Help Centre dataset; eight in the period from November 2002 to March 2008, prior to the establishment of the “hotline”. Most (37) calls were logged in the month of January, 21 in December, 20 in February, 14 in November, and 12 in March. The remaining 14 calls were logged in the cooler months (April to October). An extreme unprecedented heatwave occurred in early 2009  coincidiThe data in the records were often of poor quality with details too scant to analyse—one entry comprised only two words, whereas the most comprehensive contained 506 words. A simple content analysis revealed the top 50 most frequent words of at least three letters in the dataset were, ‘heat’, “workers”, and “working” (data not shown). Thematic analysis of the data revealed three main themes: work environment, health effects, and organisational issues.Of the total 118 calls, more than half (63) related to indoor work, 38 to outdoor work, and 17 were non-classifiable due to limited information provided. The indoor workplaces included stores, kitchens, sheds, restaurants, factories, vehicles, workshops, a roadhouse, a glasshouse, and a warehouse. For some, the nature of the workplace was not stated, but details alluded to an indoor environment. Air conditioning (inadequate or non-existent) was a major subtheme of these calls. Some complainants rang with concerns that air conditioning was “not working properly”, had “broken down some time ago and has not been fixed”, or that evaporative cooling was ineffective. Another caller said that a once-working air conditioner had been removed for economic reasons. Additionally, some workplaces reportedly had “industrial fans”, some had “no ventilation”, and others had “no air conditioning or heating”.The air conditioner in the workshop has been tested with a thermometer in the vent and is alleging that the air blowing out is at 52 °C.(#1)The thermometer in the shed was reading 55 °C.(#26)The kitchen thermostat is reading at between 60–70 °C.(#116)Some callers cited (unverified) indoor temperatures (in degrees Celsius), both estimated and measured. Examples are as follows:Comparatively fewer calls about outdoor work environments were received. One complainant worked outdoors “even though the temperature was in the high 30’s” and another “in the sun in 42 °C heat”. The main subtheme for outdoor environments related to the lack of sun protection such as hats, and no provision to seek shade or “get out of the heat”.Callers to the Help Centre cited a range of actual health effects and symptoms attributed to hot work environments. Some were merely raising concerns about potential health effects in workers or members of the public in current or upcoming situations—e.g., a scheduled sporting event in extreme heat, or young European fundraisers door knocking “in the searing heat of the Adelaide sun”. The health consequences mentioned by callers ranged from minor  to headaches, fainting, muscle fatigue, and exhaustion. Other, more serious cases were cited with individuals being dehydrated, vomiting, or losing consciousness. Some workers required transport in ambulances and visits to general practitioners or hospitals. There was also a report of a worker who suffered chest pains while working in extreme heat, was transported by ambulance to seek health care, returned to work, and later died.The next day when he returned to work he was suffering ill effects from heat stroke from the day before.(#108)…suffered heat stroke a week before Xmas, and thinks she may be suffering from it again.(#12)The term ‘heat stroke’ was used by some callers when something more minor on the heat-related illness continuum may have been intended. For example,…worker was admitted to hospital with extreme heat exhaustion (heatstroke).(#46)Nevertheless, actual cases of heat stroke were mentioned:Several issues were mentioned by complainants that related to organisational issues and management. In the majority of these, callers reported that, despite the hot conditions, workers were “required to work long hours in the heat” and requests for extra breaks were denied. In one case, there was a bonus incentive to keep working and in another there were threats of job losses for workers requesting breaks.…the foreman’s attitude was that, if he stops work, don’t bother coming back the next day.(#10)Some callers told of supervisors whose attitudes were seemingly unreasonable, as in the case of a worker in a rural area who had lost consciousness twice in the heat. The supervisor refused to let the worker be taken to an air-conditioned room and was then reluctant to assist in helping transport them to an awaiting ambulance some distance away. In other cases of poor management practices, a health and safety representative was temporarily suspended for filing a report, some workers were “forced to work installing insulation in house roofs in extreme heat”, and on one occasion management was “pushing people to work past their capacity”. Furthermore, some callers reported that on some worksites there was no “drinking water for employees” or that the water was “too hot to drink on hot days”. In some instances, workers reportedly had to supply or buy their own water.The safety culture of workplaces came into question in several calls to the Help Centre. Personal protective equipment (PPE), safety training, first aid, and hot weather policies were among the issues raised. Two callers complained about having to wear full PPE, but more said that PPE “to protect against the heat” was not provided by the employer. One frustrated worker in the transport industry clearly stated his/her views on employers’ responsibility for their workers’ health and safety:…time for drivers being responsible for their safety and their own PPE are done … it should be the companies [sic] responsibility to ensure my safety whilst on site without being put in heat/cold conditions that cause sickness … it’s unfair and wrong.(#15)There were also a small number of calls relating to a lack of first aid facilities or provider, and no or minimal, safety training. Several complainants raised the issue of no hot weather policies in place or that policies were not adhered to. It is particularly concerning that an insulation installation company reportedly had no hot weather policy. Views of policies were unclear, however, as one caller claimed that, although there was no heat policy, the workers could “start earlier and knock off earlier”. Acknowledgements of other heat stress mitigation measures included workers being provided with “ice packs and wet towels to keep cool”, powdered electrolytes, and “plenty of cold water”.This study summarises the calls to a safety regulator from members of the public with concerns about occupational heat exposure. It highlights some alarming and potentially harmful thermal environments in which employees work, and questionable safety cultures in some workplaces. Notably, there was an increasing trend in the number of these calls over the study period. However, it cannot be determined how much of this increase can be attributed to increasing knowledge of the existence of the Help Centre facility over this period.The majority of calls related to indoor work environments. This is in contrast to a considerable body of literature identifying outdoor workers amongst those vulnerable during extreme heat ,23,24. WUnder the South Australian Work Health and Safety Act 2012, employers need to ensure “so far as is reasonably practicable” that the thermal environment is such that workers “are able to carry out work without risk to health and safety” . The issSeveral studies across Australia ,15,23,27Mitigation and prevention strategies need to be available for those in occupations where excessively hot conditions prevail. Cool drinking water must be on hand, suitable PPE provided, a shaded area if possible, adequate and regular work breaks allowed, and training for supervisors and employees on how to recognise and respond to heat-related illnesses . Heat poIt is likely that most health and safety representatives are well aware of the risks of heat exposure on occupational health, yet heat stress continues to occur in workplaces, as a result perhaps of inadequacies in safety training to alert workers to heat as an environmental hazard, or a perceived need to keep working while ignoring physiological warning signs. Demographic issues such as an ageing workforce combined with an increase in individual and consecutive hot days may also be contributing factors. Another possibility is that compliance with organisational policies may diminish the autonomous or self-determined motivation of workers to reduce the risk of heat stress, consistent with the self-determination theory ; therefoRisk assessments can be undertaken by occupational hygienists or other qualified personnel to assess workplace conditions, the work being undertaken, and the likelihood of heat stress occurring. Workers, and health and safety representatives, need to be part of the consultation process when risk assessments are undertaken. Air temperature alone may not be a suitable indicator of heat risk as several factors may need to be considered . While cThe limitations of this study are acknowledged, particularly with regard to the data quality and quantity. The data comprised telephone operators’ brief notes outlining callers’ concerns, so there may be errors in, or misinterpretations of, the data. It should also be noted that callers’ claims about thermal conditions were unverified at the time of the call. Official notifications or complaints however, would have been followed up by the regulator. We cannot make assumptions about how widespread the problem is, as these heat-related calls only represented a small proportion of the total calls received by the regulator. Additionally, as the system was not specifically designed for reporting heat complaints, there would likely have been many unreported cases of occupational heat stress. Lastly, as a result of the search methods used, some trivial and uninformative records were included in the final dataset. Nevertheless, the data contained valuable “naturalistic” accounts and public perceptions of occupational heat risks unlikely to have been aired in any other forum and previously noted only by health and safety managers. The value of this type of data as a source of intelligence gathering on health and safety risks has been demonstrated.This unique study, accessing data from a safety regulator complaints database, provides an insight into the public’s and workers’ accounts of hot work environments where health and safety may, and in some cases was, compromised. Reports of thermal conditions perceived to be potentially unsafe to health, and poor management practices/organisational issues, featured strongly amongst callers’ concerns. This is despite regulations in place and a plethora of guidance material on heat risks available for persons conducting a business or undertaking. Hot indoor work environments featured strongly in the complaints possibly due to the high cost of operating cooling systems. For outdoor workers the provision of PPE for protection from the sun and heat was mentioned. Clearly, to mitigate the effects of heat, workers need to be able to autonomously undertake protective behaviours without fear of reprisals, and employers need to be aware of their responsibilities. This is particularly important in an era of rising ambient temperatures  and incr


Virologists. You might know a couple of them, but unless you are a virologist yourself, the probability that you have collaborated with one in the past is low. The community is relatively small, but they pack a heavy punch and are expected to play a leading role in the research into pathogens that lies ahead. You may ask why we think virologists are our future. Suffice it to say that it is not just because they have invented technologies that belong to the space age, including use of viruses as vehicles to shuttle genes into cells, organicBioinformaticians. You may know a couple of them, but usually you “just” need one to do proper math for your -omics experiments. Nowadays, nearly everyone in the life sciences has used BLAST  at leastIt is possibly not the problem of virologists but of bioinformaticians themselves. Although it was a virus that was the first organism to have its genome completely sequenced, bioinfoClearly virologists are well positioned to tackle some of the major disease threats that will inevitably face humans in the decades to come—but they are currently not the best equipped. In order to give virologists weapons, i.e., bioinformatic tools, we recently founded the European Virus Bioinformatics Center (EVBC).As alluded to above, this Center was developed based on our belief that we lack bioinformatical tools specifically designed for virology. We urgently need to develop algorithms for multiple genome alignments. It sounds trivial, but we still have no tool that can align, for example, 500,000 full-length coronaviruses . We cannot visualize such alignments that are clearly needed to rapidly identify mutational hotspots and compensatory mutations.Can you believe that there is not even a unified database for viruses? We only have good databases for Influenza (EpiFlu ), HIV 1, and humThese examples emphasize that we need to bring virologists and bioinformaticians together. Again, this seems obvious and, perhaps, trivial. But in reality, they speak different languages. We urgently need young scientists that understand both virology and bioinformatics so that they can bridge the gap between these two complementary yet different disciplines.The EVBC aims to develop bioinformatical tools for nearly all areas: (1) for detection of viruses, e.g., from high-throughput sequencing data; (2) virus assembly; (3) quasispecies reconstruction; (4) intraviral interactions; (5) virus entry, i.e., protein—protein interaction; (6) virus—host interactions; (7) phylogeny/cophylogeny; and (8) therapy. For the latter two areas, we have already established tools for HIV and Influenza A, but a large number of outstanding research questions remain. Finally, the EVBC will initiate and coordinate ring trials, undergraduate courses, graduate summer schools, and courses for principal investigators.evbc.uni-jena.de.Interested? Take a look here:


Histories of late nineteenth- and early twentieth-century medicine emphasise the rise of professional and scientific authority, and suggest a decline in domestic health initiatives. Exploring the example of weight management in Britain, we argue that domestic agency persisted and that new regimes of measurement and weighing were adapted to personal and familial preferences as they entered the household. Drawing on print sources and objects ranging from prescriptive literature to postcards and ‘personal weighing machines’, the article examines changing practices of self-management as cultural norms initially dictated by ideals of body shape and function gradually incorporated quantified targets. In the twentieth century, the domestic management of health—like the medical management of illness—was increasingly technologised and re-focused on quantitative indicators of ‘normal’ or ‘pathological’ embodiment. We ask: in relation to weight, how did quantification permeate the household, and what did this domestication of bodily surveillance mean to lay users? We explore how mechanistic approaches of self-surveillance were absorbed into a literature that already extolled moderate food intake, encouraged householders to take responsibility for weight management, and instructed them in the skills of exact measurement. After briefly introducing the rise and especially the commercial diffusion of quantitative approaches to health—and with them, the emergence of normative responses to weight variation—we turn to the role of the adult personal scales in particular. While the impacts of this health technology  in the United States have attracted some scholarly attention, little has yet been written about the different trajectory and meanings of the ‘personal weighing machine’ in Britain.Excessive weight has long attracted medical and lay attention; notable figures of vast girth and bulk generated public fascination, derision, mirth and admiration while their expanding waistlines were described and illustrated in paintings, novels, pamphlets and the press. By the end of the eighteenth century, routine corpulence had become a source of medical, literary and popular concern, exemplified by physician George Cheyne’s closely recorded and miserable battle with weight gain and equally impressive weight loss.In the mid- to late nineteenth century, diet products—from crackers and healthy cereals through to patent medicine products, including anti-fat pills such as ‘Figuroids’  and electric belts (to stimulate weight loss)—became widely available in Britain, reflecting the huge increase in the availability and promotion of health related goods.Domestic Medicine, first published in 1769, sold over 80,000 copies by the time of his death in 1805, with new editions appearing roughly every two years.Domestic Medicine remained popular during the nineteenth century, but was challenged as a brand leader by numerous other guides to health.Household medical guides illustrate the ways in which diet and attention to weight were introduced to the nineteenth-century home. The growth in the number of such publications and their frequent re-publication in large print runs testifies to the strong market for such guides, as part of a wider expansion of advice literature targeted at families.Modern Domestic Medicine recommended a temperate approach, carefully regulated according to age, gender and activity. ‘There can be no doubt’, Graham declared, ‘that the majority of the more respectable inhabitants of Great Britain eat and drink twice as much as is beneficial’, ignoring the physiological ‘alarm’ provided by their own sated stomachs.Gardner’s Household Medicine and Sick-Room Guide declared that obesity ‘was usually due to the amount of food being taken in access of requirements of the body’. He blamed ‘[h]igh living’, excessive drink, and ‘want of exercise’. To reduce fat, Gardner recommended active exercise, lowered starch consumption, avoidance of sugar and wine and the substitution of bread with thin, browned toast and hard biscuits.Household Physician devoted 100 of its hefty 1,000 pages to food types, diet, energy production, calories, cooking and the digestibility of food.Recommendations on diet were connected to instruction on regimen and ‘rules of health’ to be observed in householders’ daily practices, insisting on the necessity of paying attention to fresh air, exercise, clothing and adequate sleep.moral education, whereby the stomach was to be ruled by the head and regimes of moderation and regularity encouraged. Healthy living meant living naturally. The Olsens’ 1906 School of Health promoted hygienic practices, simple lifestyle, natural remedies, exercise and the ‘adoption of simple, natural [and vegetarian] diet’ as the ‘most powerful aid to pure living’.Good Health journal, the Olsens, spurned dairy products and beverages such as tea and coffee, and alcohol, and advocated ‘Fletcherism’ or chewing reform as a dietary aid.Health guides produced by advocates of new medical systems were equally unambiguous about the responsibility borne by individuals and householders in managing health, and concluded that gluttony produced poor health and illustrated moral weakness. Such texts offered guidance on eating as Lady’s Pictorial where they had first appeared. She described how ‘Julia’ was instructed to abandon her suicidal consumption of bread, potatoes, milk soup and tapioca pudding, and warned not to take pills for the mitigation of obesity. Instead, she was urged to become an early riser, to take brisk walks and exercise and to consume uncooked fruits, vegetables, white fish, lemon tea and rusks while avoiding farinaceous dishes, milk, sweets, pastry, cocoa and alcohol. Kingsford also forbad lolling in bed and eating ‘stray cakes or cups of tea’ in favour of gymnastic exercise and Turkish baths.By the late nineteenth century, health advice was becoming ever more specialised. Guides catered for discrete audiences and no more so than for women and girls, many of whom were interested in regulating body weight for reasons of beauty and fashion as much as health. Health advice handbooks, health periodicals and magazines for women and girls elaborated increasingly on the ways and means of controlling weight, improving the figure and developing correct proportions. The problems of ‘thin’ or ‘lean’ girls and ‘fat’ or ‘obese’ girls were to be resolved by intense self-surveillance and rigorous regimes of body management; being overweight in particular was a sign of poor character and greed.In general, nineteenth-century health guides intended for the household reader did not yet emphasise surveillance by numbers. Not until the end of the century would they include straightforward tables relating ideal weight to gender, height, physical development, occupation and exercise, and cite hospital dietaries or diet tables drawn up by physicians as useful guides to what individuals should eat.méthode numérique and méthode anatomo-clinique of the Parisian clinic. Crucially, these techniques established the idea of ‘normal’ bodies.In contrast, specific quantification became an increasingly visible aspect of professional/expert responses to excessive weight or leanness in the mid-nineteenth century. Indeed, measurement had already come to professional medicine with a vengeance in the late eighteenth and early nineteenth centuries, via the New technologies of exact measurement played an essential—if controversial—role in this endeavour. As surgeon, physician and medical examiner to a large insurance company, John Hutchinson (1811–1861) wrote in 1846, ‘All we know is gathered from physical observation, through the medium of the senses’.But numbers alone, no matter what they measured, were useless. The rise of quantification in clinical practice required both the organised and systematic collection of the individual measurements of numerous individuals, and the correlation of those numbers with other quanta of embodiment: height, age, occupation, appearance—and especially weight. Speaking directly to his peers in the growing insurance industries of Britain and the United States, Hutchinson extolled weight as the most reliable predictor of health: ‘The weight is an expression of the whole man—the volume of his make; a measure of his general health . . .’.Review of Reviews in 1909, the editors remarked that ‘overweight universally shortens life. Overweight is a burden, not a reserve fund.’While the British government ignored Hutchinson’s pleas, the insurance industry on both sides of the Atlantic rapidly adopted the quantitative methodology. Companies would later publish much of this work in health promotion materials for their own clients, thus spreading the medical model of precise measurement into the domestic sphere.Simultaneously, the new maternal and child health clinics which sprang up in France, Britain and the United States in the late nineteenth and early twentieth century swiftly established similar procedures for assessing the health of infants and young children. The systems instituted to bring mothers and infants under medical and state surveillance provided ample means to gather and collate measurements establishing ‘normal’ height/weight ratios throughout child development.Letter on Corpulence, first published in 1863, went into its twelfth edition by 1902.sic] and knee joint, and been obliged to puff and blow with every slight exertion . . .Although no very great size or weight, still I could not stoop to tie my shoe, so to speak, nor attend to the little offices humanity requires without considerable pain and difficulty, which only the corpulent can understand; I have been compelled to go down stairs slowly backwards, to save the jar of increased weight upon the ancle ach past year’s record is compared with the present, so that at Carlsbad the fat man grows thin—and the thin man grows fat.Even so, the convinced and the curious alike had long found ways and means to weigh. In his 1856 diet book, A. W. Moore favoured weighing machines ‘found at a railway station, or at any place where they are used for commercial purposes’. The very public positions they occupied ensured heavy people would become a ‘source of amusement’; ‘the lean ones on these occasions, admiring the beauty of their lankiness, smile with a kind of self-complacency at the heavy ones, whilst making them the butt of their jokes’.Corpulency and Cure—a booklet promoting his weight-reducing vegetable preparation—insisted that the efficacy of his nostrum could be tested by ‘stepping on a weighing machine after 24 hours’.Though he was unclear about where actual weighing should take place, F. Cecil Russell’s, As we have seen, the adult personal scale took neither the doctor’s surgery nor the home by storm in the nineteenth century. Bulky, expensive and difficult to use, it was initially a specialists’ tool. However, the powerful new, and increasingly compact, compound technology embodied by the platform scale and the standardised height/weight table effectively severed the ties between experiential clinical knowledge and the diagnosis of health risks, enabling a lay fusion of health promotion and hobbyism. By the first decades of the twentieth century, the growing accessibility of adult weighing scales and the means by which to interpret weight readings would enable British laymen and women—just like the insurance assessors and medical practitioners so assiduously targeted by the scale’s early advocates—to form their own opinions of their weight ‘without being dependent on the opinion of another’. And as Katherine Vester has demonstrated for American consumers, this is exactly what they did.Encyclopaedia Britannica noted that an ‘automatic personal weighing machine’ was to be found ‘at most railway stations’.Moving the scales out of the public health clinic and the doctor’s consulting room and into the often cramped spaces of the middle-class home required innovations in equipment and manufacture that did not enter the mass marketplace until the 1910s. As we have seen, however, popular cultures of self-surveillance got a head-start from the 1885 emergence of the penny-scales as a form of entertainment and self-help. For adults, at least, self-measurement was often a public activity, appealing to both men and women. As early as 1910, humorous postcards depicting such scales were commonplace, and by 1911, the As ideals of precision and quantification entered public, domestic and professional understandings of health, what became of the home as a site of health care, consumption and decision making in the twentieth century? For decades, historians of medicine have told a story about the rise of science and the rise of the medical profession. That story usually plots an upward curve of professional status and power against a downward trend in patient agency, slowing only with the rise of ‘patient activism’ in the 1970s and 1980s. Closer attention to practices within the household, however, may challenge this implied correspondence between the growing cultural capital of biomedicine, and increases in its reach and impact on the ground—or in the home. How do the processes by which householders navigated the growing superabundance of readily accessible medical advice and goods relate to ideas and expectations about the home and its occupants in medical ‘modernity’? Drawing on the example of the bathroom scale in Britain, the remainder of this paper will explore the twentieth-century rise of quantitative, technologised self-surveillance as a domestic, home-based culture of health promotion, and an established health-seeking behaviour.Womanhood urged the overweight ‘patient’ to weigh herself regularly every fortnight to ascertain the progress of weight loss.Even after the invention of the (relatively) small spring-balance platform scale in the 1910s, the purchase of a domestic adult scale represented a significant investment in self-surveillance even for a middle-class household. Its cost notwithstanding, as early as 1901 the journal Health and Beauty for Women and Girls.normal weight of the body should be . . . try to keep to within a few pounds of that weight either way’; she advised weighing every month on the same machine.The Modern Woman, entitled ‘Cheating the Scales’, indicated their regular usage as well as the potential to assert superiority over the mechanical weighing apparatus through careful dieting.By the 1920s, personal scales were well established as useful aids in monitoring weight loss and gain, reinforcing self-surveillance, responsible healthful behaviour and holding back the ageing process. Margaret Hallam explained that ‘“too, too solid flesh” is a burden to everybody’ in her 1921 manual Nash’s and Pall Mall Gazette reminded its audience, presumed to be upper-middle-class men with sedentary occupations, that they might ‘readily regulate’ their diets and control their weight. They needed only to weigh each item of food and consult the newly available caloric tables, keeping in mind that the normal body required only ‘sixteen calories per pound of body weight . . . every twenty-four hours when you are not exercising’. The article, devoted to expounding the virtues of lower protein consumption for the human ‘machine’, presumed easy access to both kitchen and bathroom scales. For the man unwilling to commit to such a meticulous regimen for metabolic efficiency, it advised moderation and self-control at the table and to ‘check results now and again, weighing yourself to see whether you are gaining or losing weight, modifying your fuel intake in accordance with the record of the scales’. If men would not take ‘at least that much trouble in the proper fuelling’ of their ‘bodily machine’, they ‘should not complain of ill-health’ or foreshortened lives.The popular press swiftly incorporated the personal scale into its prescriptive canon of regimen and self-control. Bringing the latest scientific studies of physiology and dietetics to their readers in 1916, the British The greater seriousness with which private acts of self-help and surveillance, including private self-weighing, were imbued is also evident in the ways in which the ‘personal weighing machine’ was marketed in Britain. While UK advertising, like that of US manufacturers, stressed that ‘[w]eighing is now a daily practice’, the private bathroom scale in Britain was not represented in the same glamorous light. In the early 1930s, advertisements might combine images of kitchen balances  with representations of the massive public scales that still served as ‘personal weighers’ for most Britons—and would do until well after the Second World War.This focus on health, utility and the combination of kitchen and personal scales would continue through the war years and beyond. Even in 1947, when US scale makers had enthusiastically embraced the pursuit of beauty, Salter continued to focus on the scales as a tool ‘to keep a daily check on my health’ and ‘to get the utmost from the rations’this idea. [M.] is thrilled to bits because I am now 7 pounds heavier than her’.Times leader even celebrated the persistence of the ‘old English custom’ of ‘getting weighed’:[t]he number of weighing machines on our piers and promenades and railway platforms, in chemists’ shops and fun-fairs and snack bars is as large as, if not larger than ever it was. . . . There is always some small boy or stout middle aged gentleman or plump or pining maiden regarding that quivering pointer with glee or anxiety or complacency. . . . When customs are truly rooted in the hearts and lives of the people they need no subsidy for their survival.Even as personal scales themselves became smaller and more suited to domestic use, the idea that self-weighing was potentially a public and even a competitive activity persisted, at least in Britain. In 1952, two female visitors (G. and M.) to the Isle of Man sent Lancashire friends a typical saucy postcard. On the front, a scrawny, kilted man shared a railway platform scale with his buxom female companion under the text ‘Now Maggie, what’s half of 19 stone 3½ pounds?’ On the back, G. reported that they too had ‘all got weighed’, and regretted that she hadn’t thought of a similar scale-sharing scheme in time: ‘I should have thought of The editors ascribed the public scale’s enduring popularity not only to habit but to childhood training: ‘The child who in the first months of life is cradled on the scale, whose every ounce is charted with loving care, is father to the man who waiting on a train on any platform anywhere cannot resist the lure of the weighing machine.’ Unlike its serious domestic counterpart, public weighing was also cast as an act of harmless self-indulgence. The scales were a ‘temptation’, but an affordable and even a profitable one; ‘It is cheap . . . if it tells the slimming maiden that she has lost an ounce, she will not grudge the coin and if it warns the corpulent merchant that he has put on another pound or two, well he is getting more for his money.’ Self-weighing, the editors concluded, was universally appealing because it was ‘always about that subject of inexhaustible interest—us’.Family Doctor, published by the BMA for household consumption, stressed that dieting ‘demands regular use of the scales, preferably in the bathroom where we can judge ourselves naked, having first consulted a table of weights and heights and set ourselves a standard for our age’.Bathroom scales are a sound investment for health. It is important to weigh yourself regularly. It is much easier to check weight gains early than to slim after you have become overweight.By the 1950s, doctors too strongly advocated the use of domestic weighing scales, and urged their regular use to monitor weight gain and as ‘instruments of prevention’. An article in Dr Hutchin, author of the article, urged the use of bathroom scales as they enabled true weight to be established, without clothing, and for weighing to occur at the same time of the day with the scales in the same position.Lancet’s long-running ‘In England Now’ column another medical correspondent pondered the furtive use of his own bathroom scale by his would-be self-surveillant guests. Kept in the (fashionably upstairs) bathroom, his ‘weighing-machine’ was ‘the most irresistible fitting for the attention of our guests’. Guests, he noted with amusement, made ‘the most unconvincing excuses for slipping upstairs to weigh themselves’. Privacy—about both the practice and the results of weighing—was at the heart of the bathroom scale’s appeal. Despite manufacturer and medical invocations of the duty to weigh for health, the act itself was ‘a deadly secret’. Yet, of course, in a poorly soundproofed and small British home, the privacy self-weighers sought was largely illusory. Vividly, the author described the sounds of the inevitable struggle, if not with weight, then at least with weighing: ‘we keep the weighing machine tucked under the wash-basin. It has to be pulled clear for anyone to stand on its little platform: the job cannot be done without one loud metallic clank for the outward trip, and another one to hide the evidence.’ Why could ‘these women’ not weigh publicly, or at least ‘accept the truth more cheerfully’? The author offered no explanation, but he does reveal how high the stakes had become: the scale’s pointer (‘the horrid thing’) served as ‘the proper mark’ of ‘their conception of ideal womanhood’. His narrative suggested that women were not alone in investing the scale with the power to define their self-perceptions. ‘At the weigh-in last night, I registered 188 lb., the same as [professional heavyweight boxer] Floyd Patterson. Mind you the weight distribution looks a bit different, with a much lower centre of gravity’, he began—before hinting that he too might have ‘jumped up and down’ on the scale ‘to be a fair match’ for the boxer.Nonetheless, private weighing remained linked to the middle-class demographic of British scale ownership, and the bathroom scale remained a rarity even within this group. Writing in the In 1968 Salter finally moved to capitalise on demand for a cheaper domestic bathroom scale, bringing out the ‘Slimway’ scale. At the same time, the company replaced its rhetoric of health with the language of ‘modern styling and slim appearance’ . Here, too, for the first time the advertising copy promoted affordability.As the preceding discussion has illustrated, a multiplicity of providers and would-be advisors bombarded the household with suggestions, admonitions and an ever-expanding array of products and services all intended to moderate weight, produce health and encourage practices of self-monitoring. Evidence of the responses of individuals and households to this increasing range of advice on offer on weight loss, as well as detail about their interest in and ability to purchase diet aids, however, is patchy. We cannot be sure how far professional advice was taken up or whether householders proceeded to chart their own course towards weight loss, adapting or overriding the doctor’s guidance. Further research drawing on oral history might provide additional insight into approaches to diet and the balance between professional guidance and self-determination. However, the evidence we have found thus far suggests that, as consumers, but also as agents in their own right, individuals and families sifted the wealth of options to produce their own idioms of care and cure, their own regimens of healthy living. While medical professionals of all stripes perceived and expressed themselves as increasingly knowledgeable, powerful and authoritative, and as obesity increasingly came to be described as a condition requiring expert management given the risks to health and longevity, householders were by no means passively compliant. Some adopted dietary and exercise regimes or alternative systems of health maintenance to preserve themselves in good health and weight; others adopted and adapted the advice of physicians, though often in their own homes and under their own daily self-surveillance—and some, perhaps, just jumped up and down on the scales. Either way, individuals and families charted their own paths to well-being and weight maintenance.Slimming for the Million Dr Eustace Chesser targeted patients and physicians and encouraged serious self-reflection on the part of the overweight: ‘Take a good look at yourself! Weigh yourself up! For your shape and weight are very closely connected both with your bodily health and your outlook on life.’By the late 1960s and early 1970s, the bathroom scale—and the culture of domestic self-weighing—was increasingly at home in Britain (as it had earlier become in the United States). In part this reflects changes both in household architecture and in weighing technologies. Both the scales and the self-monitoring they allowed, once proudly modern, invisibly melted into household routine over the course of the twentieth century. But does this illustrate the domestication of medicine, or the medicalisation of the home? Here medical reactions to the ‘personal weighing machine’ offer some insight. While the thriving manufacture of personal and public scales indicates that health-seekers and dieters actively sought out the new devices, the professional response was mixed. As we have illustrated, many practitioners incorporated precision weighing into health regimen advice, but expected—at least initially—to manage the quantification of adult body weight themselves. Guides to weight reduction produced in the interwar years stressed the need to consult a doctor , but also regular weighing at home and emphasised that success was ‘to be found in the willingness of the subject to submit himself to a disciplined diet’.Yet from the 1950s onwards, as the social prevalence, medical significance and political prominence of obesity grew, some doctors sought to reclaim their leading role in weight management and reduction. Perhaps unconsciously echoing his early twentieth-century peers’ distaste for fashionable ‘slimming’, in 1959, Alvan Feinstein  complained that ‘many attempts at weight reduction are based on aesthetic, cosmetic, or psychological factors rather than by physiologic concepts or the statistical features upon which the tables are based’. He insisted that ‘obesity cannot be defined in a strictly numerical fashion’, but could only be diagnosed by the expert medical use of clinical ‘inspection and palpation’.At the same time, many researchers have attacked the numerical relationships between body weight and height on which self-surveillance had been based since its inception: height/weight tables and the Body Mass Index have been regularly (and rightly) condemned as imprecise and unable to account for human variability in bone structure, muscle mass and fat distribution. Instead, specialists have advocated newer, more expensive, and importantly for our purposes, consumer-inaccessible technologies ranging from ‘novel handheld devices’ to ‘dual-energy X-ray absorptiometry’.


Eczema is common in children but adherence to treatments is poor. Written action plans (WAPs) have been shown to help in asthma but the potential value, format, and content of an eczema WAP is unknown.To explore the potential role of an eczema WAP, and to design an eczema-specific WAP.A qualitative study of parents of children with eczema, primary and secondary care health professionals, and other stakeholders.A total of 41 semi-structured one-to-one interviews and two focus groups were audiorecorded, transcribed, and analysed thematically.Reported challenges of managing eczema included: parental confusion about treatment application; lack of verbal and written advice from GPs; differing beliefs about the cause and management of eczema; re-prescribing of failed treatments; and parents feeling unsupported by their GP. An eczema WAP was viewed as an educational tool that could help address these problems. Participants expressed a preference for a WAP that gives clear, individualised guidance on treatment use, presented in a step-up/step-down approach. Participants also wanted more general information about eczema, its potential triggers, and how to manage problem symptoms.An eczema WAP may help overcome some of the difficulties of managing eczema, and support families and clinicians in the management of the condition. Further evaluation is needed to determine if the eczema WAP the authors have developed is both acceptable and improves the outcomes for affected children and their families. In the UK, the majority of children with eczema can be effectively treated in primary care with topical treatments: emollients and topical corticosteroids (TCS).1,4,1,11Research with patients and carers has identified barriers to effective treatment, including lack of understanding about the condition and treatments,8–WAPs have been shown to improve clinical outcomes in asthma,12The aims of this study were to work with health professionals, patients, and stakeholders to explore the perceived value of an eczema WAP, and to develop a WAP that could be used to support eczema self-management in primary care.The authors undertook 41 semi-structured interviews and two focus groups with parents of children with eczema, GPs, and a range of other clinicians and stakeholders between May 2016 and February 2017. They focused on children under 12 years with mild to moderate eczema because these represent the majority of eczema cases in primary care, and because the needs of adolescents and adults are likely to be different.1The authors identified five socioeconomically diverse practices in and around Bristol, UK. Each practice searched its electronic medical records and sent an invitation letter to around 100 randomly selected parents of children aged <12 years who had an eczema diagnosis. Primary care healthcare professionals  were recruited at participating practices and via personal and professional networks.Incorrect use of topical treatments is common in children with eczema, and contributes to poor clinical outcomes. Written action plans (WAPs), drawn up between healthcare professionals and parents and children, could support the self-management of eczema. The parents, GPs, and other healthcare professionals in this study felt that a WAP could improve parents’ knowledge and confidence in using and applying prescribed treatments. Using interviews and focus groups, the authors developed an eczema WAP, comprising individualised treatment guidance, generic eczema information, and a treatment log.Parents and healthcare professionals expressed interest in taking part in interviews and/or focus groups by completing an online or paper questionnaire, and their responses were used for purposive sampling. Parents were sampled by socioeconomic status , age, sex, ethnicity of their child with eczema, and self-rated eczema severity (POEM: patient-oriented eczema measure).Other stakeholders included secondary care clinicians , who were identified by snowballing and professional networks, and eczema charity representatives, school nurses, and nursery staff, who were identified via eczema charities and local school networks.In-depth interviews enabled the authors to collect data on the individual experiences and challenges of managing and treating eczema from the perspective of carers and healthcare professionals, as well as the elements that participants would find helpful in a WAP. They also provided the opportunity for participants to give feedback on the initial drafts of the WAP, which the authors developed and refined iteratively alongside the interviews. The interviews were held in participants’ homes, on NHS premises, or by telephone, and lasted 45–60 minutes. A semi-structured topic guide was developed for each participant group  and piloted . Topics Box 1.One of the authors, a GP with a specialist interest in dermatology, conducted the majority (13/15) of GP interviews. Another author, a non-clinical researcher, interviewed other participants. To facilitate discussion, early interviewees were shown three example WAPs, which varied in length, layout, and graphical content. Two were eczema-specific WAPs, one developed by the Hillingdon Hospitals NHS Foundation Trust, and the other by the Australasian Society of Clinical Immunology and Allergy (ASCIA). The third was a WAP for patients with asthma developed by Asthma UK. Sample WAPs were replaced in later interviews with successive drafts of the study WAP.n = 35) had been conducted, and the second group was the final part of data collection, when data saturation from one-to-one interviews had been reached. Representatives were recruited from across the different participant groups to each focus group to promote a balanced discussion. For the first focus group discussion (FGD1), the authors invited primary care healthcare professionals  and parents who had been interviewed, because they understood the research aims and lived locally enough to travel to the university premises where the groups were held. For the second focus group discussion (FGD2), all those who had taken part in the first focus group were asked again, with the invitation being extended to a further four GPs, nine parents, and local secondary care healthcare professionals who had expressed interest in taking part, or who had already participated in an interview.Focus groups were employed to further refine, and reach a consensus around, the draft study WAPs. The first group was held towards the end of data collection, when the majority of the individual interviews . Data were analysed thematically.The authors developed and refined an eczema WAP over the course of the study. The final draft was produced with the assistance of a professional graphic designer, to maximise its visual appeal and usability.All participants were given written information about the study, and written informed consent (or assent for children) was received prior to the interview or focus group. All participants were nominally reimbursed for their time.n = 37). The four other stakeholders were self-selected from the organisations approached. ‘It was just, stick it on his legs. It really was just a kind of “here you go, this is it, and off you go”.’(Parent [P]10)Parents voiced frustrations at feeling unsupported by GPs in terms of treatment, and felt their information needs were not met. The absence of specific verbal advice on how to apply emollients and TCS in terms of when, where, how often, and how much was either absent or unclear, leading to uncertainty with treatment application:ad hoc manner:‘No, I don’t tend to give written information unless I think, “OK, this person really doesn’t know much about what they’re doing,” In which case, I might print out the patient information leaflet from Patient UK.’(GP4)GPs reported not providing written information to patients with eczema regularly. If they did, it was usually a generic leaflet printed from their clinical system or website. When individualised guidance was given, it tended to be in an ‘I think they expect that, if they can find the one trigger for the eczema, they can make it all magically go away, so you have to unpick that.’(GP14)‘They’re going to give me the same thing they’ve been giving me for about a year, so it doesn’t really make any sense if there’s nothing to cure my daughter of the eczema.’(P9)Several parents held views about the causes and best method of treatment for eczema that differed from the approach expressed by healthcare professionals. Some parents believed eczema had a root cause, such as an allergy, which needed to be identified and avoided, rather than it being an inherent condition that needs to be managed with emollients and TCS. GPs recognised this issue, which they said got in the way of successfully treating and managing the condition:‘It’s [name of treatment] in the notes, but what you get is, it’s unclear whether the treatments worked and they stopped using them, or it hasn’t been effective and they’ve never used it again.’Many parents and healthcare professionals agreed that treatment tended to be on a trial-and-error basis. However, finding a treatment regime that works for the family is difficult because parents reported difficulty in remembering names of treatments tried. Also, the reasons for stopping a treatment are not routinely recorded by GPs, meaning failed treatments may be re-issued:Box 2.Participants were generally positive about the role that WAPs could play in addressing barriers to eczema management. Potential benefits identified included a documented treatment plan, patients and carers empowered and confident to use treatments, an eczema information resource, and improved clinical outcomes.‘how to get between the two’ steps . Early interviewees who were shown the Hillingdon and Asthma UK example WAPs that take this approach thought they were a good model to follow:‘I really liked that they had four, you know, they had sections on when the skin was kind of manageable, and what to do just to kind of maintain the skin, and then when there was actually a flare.’(Eczema charity representative 2)Participants wanted a treatment plan that was individualised and specific. Also, plans should be presented in a stepped approach, that is: step 1, what to do when the condition is stable; step 2, what to do when there is a flare; and ‘There’s not a lot of support from doctors, and it’s hard to know when to take him back. I don’t want to be like a fussy parent, “oh, they’re back again with a bit of eczema”, but like I said, you know, it’s his skin.’(P3)All groups wanted an additional third step indicating action to take if the condition does not respond to advised treatment:Participants agreed that the WAP should be specific about what to use and when, including volume, frequency, and duration. It was also suggested that web links to videos demonstrating how to apply treatments be added.‘If I ring up the doctors and say “can I get another, you know, that one”, I couldn’t remember the name of it, so I was like “hang on, I’ve got to find the thing”, and have to go and rummage. So, yeah, if I had it all on there, I’d probably keep that on my fridge or something, and it’d just be all there then, in front of me.’(P3)‘What I like, from my perspective as a GP, is the log of previous treatments tried. It’s really common that you ask what’s been used, and it’s difficult to know because the creams look the same, they have names that are unfamiliar and, really, why would people remember unless they’ve logged it down?’Some also felt that providing space for a treatment log to document parents’ experiences would help either prevent re-prescribing of failed treatments, or facilitate re-ordering a successful treatment:Generally, this was described as a log completed by the parent, rather than the clinician.Participants also wanted the eczema essentials  to allay parental fears.‘The fingertip full thing’s quite good, I find. That’s what I quite often say to people, “a fingertip full for this crease”, and if that could be written down, then it’s clear.’(GP8)For TCS, healthcare professionals felt it important to explain the fingertip unit :‘J is constantly scratching, like, even in his sleep he does it. He obviously doesn’t know he’s doing it. It would be nice if there was a way to, like, stop him doing that.’(P3)Parents, notably, also wanted non-medical information on how to stop their child scratching, as this was often described as one of the most distressing behaviours related to eczema:Another suggestion was to include a reminder about re-ordering creams, as a delay in ordering repeat prescriptions was identified as a common problem.‘in an ideal world’ (P7), would appreciate an electronic copy as well, which would facilitate sharing — such as e-mailing it to school — and retention, as a single paper copy is easily damaged or lost. GPs were focused on ease of access and speed of use. The prevailing opinion was that they wanted the tool to be embedded in their clinical system and pre-populated as much as possible, for example, with patient details and treatments:‘If it could somehow be integrated into the software of the GP consultation … we have to make some notes in the records, so, if in some way when we’re saying to a patient “put the emollient on morning and the evening and the steroid on in the middle of the day”, or whatever, that typing in types into the form that you can just print off with the one click.’(GP9)In terms of format, most parents wanted a paper copy of the WAP to display around the house. Others, Once agreed and completed electronically, GPs envisaged it being saved in the medical records, and a printed copy given to the patient (and e-mailed if possible).‘on the fridge’ (P7), or ‘on a wall’ (P5). A traffic light colour coding system, to highlight the different steps, was also favoured: green for clear skin, amber for a flare, red for seek help. GPs cautioned that, as most surgeries do not currently have the resources to print in colour, the WAP needed to be usable in black and white as well.The draft WAP had the individualised action steps on the front page, because parents wanted something they could refer to ‘I’m a bit overwhelmed in terms of the amount on the page, or the amount in each box. I don’t know why, but that’s my — I can see myself handing this to someone … and then it would have to take time to explain what it all means.’The interviews identified a tension between having enough information to guide and support the parent, but not so much that it overwhelms or puts off the user. The first focus group felt the balance between these elements was not right in the authors’ draft WAP:The authors modified the WAP to make it less detailed and, based on the suggestion of the focus group, moved video links to demonstrations of treatment application from the back ‘information page’ to the front ‘action page’.‘I think they look central and they look important, simply because there’s not much other information. It makes you think that these videos will have important things.’Subsequent participants felt that this invited users to look at them:‘I think images are sometimes more powerful … most people can, you know, this is the step and this is the arrow so you use this much, and then if it doesn’t improve, then you use — and you keep following the arrows until you get to where you want to be.’.This first focus group also helped to reconcile varying views on whether the WAP should be aimed at older children (between 7–12 years old) as well as parents. The group agreed that the authors should adopt a more pictorial approach, because pictures were seen as important, not only for engaging children, but also in terms of simplifying the action steps, and overcoming language and literacy barriers:‘Within a couple of weeks you’re saying “oh my gosh, I can’t stand my child being so greased up, I’m stopping using the hydromol, it’s a right pain”, and maybe you don’t remember to write that down. But then, almost the next time you go back to the doctors, and you’re taking this with you, and … you’re only looking at the four things [four treatments written in the log in the WAP], and the doctor’s like, “well, do you want the repeat of those?” And you go “oh, hang on; we’ve stopped using that one ‘cos I hate it”.’It was not possible to include a treatment log and keep the document to two sides of A4. GPs were sceptical that parents would have the time or inclination to complete it. This view also emerged in the second focus group. However, it was agreed that, although parents may not complete it at home, it may trigger conversations about treatment acceptability during eczema consultations:Because of its potential to promote the discussion and documentation of parents’ treatment preferences, the log was included in the final version. The final WAP, excluding the treatment log, is shown in The management of eczema in children is often impeded by parents being confused about the treatment plan. They often felt that they had received insufficient advice and information from primary care. Healthcare professionals highlighted parental belief around eczema causation leading to differing treatment expectations. All participants noted problems around the documentation of treatment preferences.A patient-held, written self-management plan that provides clear and simple individualised treatment guidance and educational information was seen as a means of overcoming these barriers. The authors developed an eczema WAP based on the views and preferences of parents and healthcare professionals. Consistent views about format and content enabled the authors to develop draft WAPs. Focus groups helped in finalising the WAP in relation to balancing the level of detail needed for effective self-care while ensuring users are not overwhelmed with information, deciding whether the target audience should include children as well as parents, and weighing up the value of including a log of treatments.The final, three-page eczema WAP comprises a stepped approach to treatment , eczema essentials , and a parent- completed log of previous treatments and patient preferences. It favours brevity over detail and aims to minimise completion time for healthcare professionals. Pictures are used to engage children and aid communication and understanding.As far as the authors are aware, this is the first qualitative study with a range of stakeholder perspectives investigating the potential value and desired content and format of a WAP on eczema. A breadth of viewpoints, drawing on interview and focus group data, has enabled the authors to develop a user-led WAP. Having clinical and non-clinical research team members aided reflexivity during discussions throughout data analysis. The unbalanced ratio of healthcare professionals to parents in the first focus group (4:1) may have been intimidating for the lone parent and could have resulted in a biased discussion. This was countered, however, by the facilitator, who ensured all voices were heard, and the balance (4:3) in the second group was more equal. The voices in this study are predominantly those of GPs and parents, rather than those of secondary care clinicians and stakeholders, with a focus on children with eczema aged <12 years. This reflects the authors’ decision to focus on this age group/disease of mild–moderate severity, because they both represent the majority of children managed in the primary care setting. The authors sought views from the other groups, primarily to check acceptability and content of a WAP from their viewpoint, but it is possible that they failed to identify relevant opinions from these other potential users.The difficulties in treating eczema in children highlighted by this research reflect the findings of work previously undertaken with parents and carers. This includes dissatisfaction with, and confusion about, treatment plans,National Institute for Health and Care Excellence guidance on eczema treatment highlights the importance of parental education to improve adherence and outcomes.One of the difficulties the authors faced was how to include all of the content desired while still making it visually appealing and user friendly. A previous study looking at the readability and suitability of asthma WAPs exposed some of the common pitfalls: too many check boxes for medications and doses, lack of visual cues, such as boxes and arrows, practitioner-centred wording, and lack of white space.A qualitative systematic review looking at the design and use of WAPs in asthma and eczema depicted a preference for pictures for universal communication.The authors have developed a WAP for children with eczema, using input from a wide range of parents, clinicians, and stakeholders. The draft WAP has been improved by a professional designer without changing the core aspects identified by the study participants. Further research is needed to trial the WAP in practice, to establish whether it can empower parents, children, and healthcare professionals to improve the management and treatment of childhood eczema in primary care.


ICB) antibodies, which antagonize inhibitory receptors on T cells and their ligands and thus unleash the cellular immune system against the tumor. ICB showed tremendous effects in several types of cancer. However, only a proportion of the patients suffering from tumors, which are in principle sensitive, benefit from this treatment and other kinds of neoplasia are completely resistant. Great effort is currently being undertaken to distinguish responders from non‐responders, and concepts to turn the latter into the former are urgently required. One approach is to combine ICB with already well‐established treatment strategies, that is, the other mainstays of cancer therapy such as surgery, radiation therapy (RT), and chemotherapy. Depending on the circumstances, both chemotherapy and RT may act either immune suppressively or immune stimulatingly. In this issue of EMBO Molecular Medicine, Azad et al (ICB monotherapy, becomes responsive to this treatment by simultaneous RT or chemotherapy.Immunotherapy has evolved as a new pillar of cancer treatment during the last decade. The main breakthrough was the development of immune checkpoint blocking (ad et al  show tha Tumors hijack these mechanisms to evade immune response, and blocking these so‐called immune checkpoints  with therapeutic antibodies generated impressive results in a variety of tumors. These include malignant melanoma, Hodgkin lymphoma, Merkel cell carcinoma, and head and neck, breast, lung, gastric, hepatocellular, renal cell, ovarian, and colorectal cancer . The outcome of this trial will put the findings of Azad et al (Clinical research on combined treatments is rapidly progressing, and although few results have been published, about 40 clinical trials are already listed on ad et al  to the tClearly, the take‐home message, which was already well received in the field, is to hit the tumor simultaneously with as many different weapons as possible. The older strategy was overcome, to treat sequentially with first‐, second‐, and third‐line treatment while waiting each time until resistance occurred, and only after that try immunotherapy or other experimental treatments. The combination radiation and ICB treatment brings new hope, especially for those malignancies for which the current standard of care is not significantly efficacious.