Clinical deterioration of adult patients in acute medical-surgical wards continues to occur, despite a range of systems and processes designed to minimize this risk. In Australia, a standardized template for adult observation charts using human factors design principles and decision-support characteristics was developed to improve the detection of and response to abnormal vital signs.To describe the study protocol for the clinical testing of these observation and response charts (ORCs).We propose a two-phase multisite multiple-methods design to test the initial clinical utility of the charts in 10 hospitals of differing types and sizes across state jurisdictions in Australia. Data collection in the first phase includes user surveys, observations and field notes by project officers, handover de-briefs , and an audit of ORC documentation completion compared to the site’s existing observation chart. For the second phase, data will be collected using a retrospective audit of observation documentation from the previous hospital observation chart, prospective audit of observation documentation following implementation of the selected ORC, user focus groups, observational field notes, and patient outcome data from routinely collected organizational data sources.Site selection and preparation, project officer training, chart selection and implementation, participant recruitment, and data collection has been completed and the analysis of these results are in progress.This detailed description of these study methods and data collection approaches will enable a comprehensive assessment of the clinical utility of these newly developed track and trigger charts and will be useful for clinicians and researchers when planning and implementing similar studies. Potential methodological limitations are also noted. Widespread deficiencies in detecting and responding to clinical deterioration in adult patients in general wards at acute care hospitals continue despite a range of practice initiatives . One keyPaper-based observation charts remain the dominant approach for documenting clinical observations of adult patients in acute general wards of Australian hospitals. With the continued identified failure to recognize and respond to signs of clinical deterioration evident , developThe Australian Commission on Safety and Quality in Health Care (ACSQHC) implemented a program of work on “Recognizing and Responding to Clinical Deterioration” , focusinThe resulting adult deterioration detection system (ADDS) charts were designed with a multiparameter early warning scoring system (EWSS) using heuristic analysis  and wereThree additional observation and response charts (ORCs) were subsequently developed by the ACSQHC after simulation testing to account for different track and trigger systems (TTS) across the full range of health services in Australia . Each veEach version of the ORC is structured as a double-sided A3-sized form with a layout of a left binding margin and an off-center fold from the right. When folded, the cover page highlights to the user any other observation charts in use and modifications to parameter values for this patient. When folded out to the right, the inside left page contains the charting area for documentation of observations for nine specified parameters . All chart versions use the same graphing section . ImportaWhen graphing observations, users are instructed to place a dot (•) in the center of the box, which included the current observation in its range of values, and connect it to the previous dot with a straight line. For blood pressure, the “∨” and “∧” symbols are used for systolic and diastolic values respectively, and connected by a vertical dotted line. Pain score is the only parameter to use written numeric values, from 0 (none) to 10 (worst). When an observation is recorded in a shaded area, recommended actions are noted on the chart to guide clinicians to initiate an appropriate response, unless a modification has been documented previously on the ORC . Use of The inside right page provides information only for the user, including the response criteria and actions required (it is not for writing information on). The final page contains sections to record interventions associated with abnormal vital signs, clinical review requests, and additional observations .The aims and scope of our project are outlined in a competitive tender process from the ACSQHC. The first study aim is to test initial usability (ease of use) and clinical utility of the ORCs in general adult medical/surgical wards. The related objectives for this first phase are to examine whether the ORCs (1) are suitable for observations of adult medical-surgical patients and prompt a response for episodes of clinical deterioration, (2) have any sections that require modifications, and (3) could be introduced and applied in practice with minimal training.Five versions of the charts  are avaiThe scope for this phase from the ACSQHC is for the charts to be used in parallel with existing hospital observation charts and tested in a small number of hospital sites of different types and size.After modifications of the ORC templates (based on objective 2 above), the final study aim will be to examine whether the ORC templates demonstrated clinical utility when implemented into everyday clinical practice. The related study objectives are to investigate the (1) rate of completion of the ORC, (2) rate of abnormality in clinical observations, (3) rate of calling for assistance where indicated, and the response obtained, (4) preferences and comments of clinical staff, and (5) patient outcomes. The scope for this phase is to conduct a contained roll-out with site-customized ORCs implemented across a whole hospital/health service. As only one version is to be selected, implemented, and evaluated at each clinical site, no comparison of versions of the chart is planned. This paper describes the study protocol.A two-phase multiple-methods design was developed to examine usability of the selected ORCs in a range of adult clinical areas see . In PhasIn the second phase, a before-after multiple-methods design will be used, with the selected chart version permanently implemented as the site observation chart. Proposed data collection includes retrospective audit of vital sign documentation from the hospital’s previous observation chart, prospective audit of vital sign documentation following implementation of the selected ORC, user focus groups, observational field notes, and patient outcome data from routinely collected organizational data sources.Expressions of interest will be sought from hospitals across all state jurisdictions using the ACSQHC contacts list. In the response, interested sites will confirm their ability to support implementation and evaluation of the ORC in their facility. Ten clinical sites will be selected in consultation with the ACSQHC. A sample will be selected that reflects differences in hospital size and level of service, preferred chart template, and location.An executive from selected sites will be invited to engage as a champion for the project, liaising with key stakeholders, supporting the site-based project officer, and profiling the work with all relevant clinical staff. Site-based project officers will be seconded for the project and supported by training workshops, project manager site visits, teleconferences, telephone, and email assistance.Each site will select one of the five versions of the ORC that best matches their local escalation protocol and existing RRS for managing deteriorating patients. Each selected ORC template will then be modified to align parameter values with each site’s rapid response team calling criteria and RRS protocol and practices.A site information package will be developed and distributed to each of the site executives and project officers and will also form part of the ethics application for each site (discussed below). The document will provide details of the different stages in this phase, as well as guidelines and tools for data collection, and different resources for the site-based project officer. A training workshop is planned to be conducted centrally for all project officers. A full-day event will provide project orientation, including the context of patient deterioration and the ACSQHC’s program of work, exploration of the ORC designs based on human factors development, introduction to the ORC Project and project team, and description of the data collection approaches using short demonstration videos, patient scenarios, and practice sessions.Although training on completion of the chart for clinical staff is to be minimal as per the intent of the ACSQHC, staff preparation for data collection will be essential, and so each project officer will inform all relevant clinical staff (primarily nursing staff) about the new chart and the project. This is planned to include orientation to the design characteristics and components of the chart and the aims of the project and related data collection processes, specifically the need for dual-documentation of observations during the 24-hour data collection period. Given the issue of shift work and access to staff, this information will be provided in both written  and verbal forms .For the required double documentation of patient observations, clinical staff will be requested to document on the hospital’s current observation chart first as per usual practice, as this forms part of a patient’s medico-legal record. They will then document the observations on the trial ORC during the same documentation activity, to minimize any variations between the two charts. On the designated data collection day for that ward, the project officer will distribute the selected chart for commencement at the start of the observation day (planned to be early afternoon).The multiple-methods approach for this initial phase will comprise an audit of the ORC for completeness of documentation of observations, compared to the hospital’s existing observation chart, a self-report survey by users, handover debriefs , and observations and field notes from the site-based project officer.Any addition to workload of clinical staff is a risk to study compliance and feasibility, and therefore data collection is planned to minimize respondent burden by scheduling each ward to complete the dual-documenting of observations on the existing hospital chart and the designated ORC only within one 24-hour period. A continuous 24-hour cycle of observations in each ward is most appropriate for testing the clinical utility of the charts, including assessment on the use of charts at night, when ambient lighting is lower. A staged process will be developed for each hospital site, so that data collection for each ward can be undertaken in sequential 24-hour periods, separated by a data collation day to allow completion of data collection from the previous ward and preparation for the next ward.Dual documentation will be a requirement during this phase as the ORC will not be an approved medical record at this stage, and the current hospital chart will therefore remain in practice as part of the legal medical record during the trial. Following completion of the 24-hour period of dual-documentation data collection for each ward, each project officer will audit the ORCs for completeness of documentation of observations, compared to the hospital’s existing observation chart. These data will be entered via SurveyMonkey with guidelines provided to support the project officer. Compliance between the dual sets of documented observations will also be audited, comparing sets of vital signs on the ORC with sets of vital signs on the existing hospital chart to identify when (time of day) and where (variable on ORC) errors may occur. Any vital sign sets on the ORC that do not match the vital sign sets on the existing hospital chart will be considered as mismatched. Details of mismatched vital sign sets will be collected for a maximum of five sets per chart.A user-satisfaction survey will be completed by clinical staff at the end of their observation activities for the shift. The survey comprises 28 items relating to the design and components of the charts . For ADDBoth paper-based and online versions of the survey will be developed, with each taking approximately 5 minutes to complete. Each project officer will distribute the paper-based surveys to users at the beginning of their shift and then collect the surveys at the time of user completion, to ensure an optimal return rate and completeness of the survey. For staff that prefer and have access to Internet-enabled computers in their work area, a site-unique link to SurveyMonkey will be provided. Only one user survey per participant will be completed.At the completion of each shift (particularly after night duty), the project officer will conduct short interviews with a group of staff. These debrief sessions will be audio-taped with participant permission, for project officers to group or theme staff views and experiences. The aim of these interviews is to identify and explore the broad issues for clinical staff related to documentation in the ORC. Guidelines will be provided to support the project officer.Each site-based project officer will document field notes while observing practices relating to the use of the selected chart. During peak periods of observation , the project officer will observe staff observation practices and communicate briefly with users for any anecdotal comments on the clinical utility of the charts.Following Phase 1 analyses and discussion with the chart developers, applicable modifications to the ORCs will be implemented prior to Phase 2. Any information and training issues for Phase 2 will be addressed by a range of information resources such as a project plan, posters, materials for use during in-service sessions, and a Frequently Asked Questions sheet, and supporting site-based project officers during the preparation and the roll-out of the ORCs into their settings.The multiple methods to address this phase’s study objectives are a retrospective audit of current hospital observations charts and prospective audit of data following implementation of the selected ORC, user focus groups, observational field notes, and patient outcome data from routinely collected organizational data sources. After education and implementation of the ORCs in each site, clinical staff will use the charts routinely for observations for a minimum of 3 weeks, prior to data collection.For the two audits, a 72-hour admission period was selected: February in the previous year (retrospective) and February in the current year (prospective). For each participating ward, 60 admission episodes will be audited at each site. Sunday, Monday, and Tuesday were selected as the audit period to include data related to activity occurring out of hours.For the retrospective audit, observation charts in use prior to implementation of the ORC will be examined for rate of completion , rate of recognition of abnormal clinical parameters , and rate of triggered responses to a clinical deterioration . Abnormal clinical parameters will be identified retrospectively using trigger criteria from the site-selected ORC. Data collection will also include hospital length of stay, location of discharge or transfer at end of admission, resuscitation status, and admission outcome.During the prospective audit, the recently implemented ORCs will be audited for the same data as the retrospective audits, as well as extra items that will enable comparison with Phase 1 data on completion compliance according to the chart’s general instructions.After ORC implementation and a period of routine use, project officers will conduct short semistructured focus group interviews with clinical staff. Participant consent will be gained prior to data collection, and the focus groups will be audio-recorded for transcription of de-identified verbatim comments. Focus groups will be scheduled during shift overlap, staff development sessions, and education forums with the aim of capturing the views of as many staff comments as possible. Sample questions will be provided to each site project officer.Field observations are planned for the site-based project officers at negotiated times with each clinical area piloting the ORC, for a recommended minimum of six observation sessions per selected ward over at least 1-2 hours duration during the prospective data collection period. Observation sessions will range across different shifts on different days, to enable observation of activities related to use of the ORC in routine observation practices. Guidelines and a template for field notes will support project officers’ observation of practices. Ward staff will be informed that observations related to ORC usage will occur using normal communication processes and visible placement of ward posters. Individual staff members are able to refuse participation during the observation periods, by negotiation with their ward manager. Project officer interaction with clinical staff is permissible during the observation period to clarify or ask a question.To minimize data collection burden, patient outcome data will be collected using routinely collected organization-wide data systems for adverse events such as MET/arrest calls, unplanned intensive care unit admissions, unexpected deaths, and length of stay. These data will be collected for the months of the retrospective and prospective audit periods, as well as an annual summary for the previous year when available from sites.In Phase 1, the project officer at each site will assess all quantitative data for completeness, before data entry either locally or centrally (for de-identified paper-based user surveys). All data will then be cleaned and checked for errors centrally by the project manager prior to data analysis. Qualitative interview and field notes data will be transcribed for analysis at each site and transmitted to the research team for collation prior to analyses.Quantitative data from the user survey and audit will be analyzed descriptively using frequencies and proportions, for each site individually and for the total sample. Transcribed qualitative data from the field notes of observations, debrief sessions, and open-ended questions from the user survey will be entered into NVivo and examined initially via content analysis (where appropriate including counts of categories of text) and then thematic analysis. Coding of text will use categories aligned with the project aims; for example, clarity of text, chart format and layout, comprehensiveness, ease of documenting, and capacity to trigger a response for a deteriorating patient.For Phase 2, all site data will be sent to the research team for management and analyses. Audit data will be entered into Microsoft Excel, then cleaned and coded for analysis in SPSS (version 19). Patient outcome data will be sent in original form from the sites and then re-formatted and coded in Microsoft Excel. For quantitative data, frequencies will be examined for distribution. Descriptive statistics will be used to examine all data. For non-normal distributions of continuous data, medians and interquartile ranges will be used. Categorical data will be presented using proportions and frequencies.Focus groups will be audio-recorded, and sound files sent to the research team for transcription. Project officer field notes will be typed up as Microsoft Word documents and also sent to the research team. Qualitative data will be entered into NVivo 9 and analyzed for descriptive content and emerging themes.For Phase 1, we plan to submit the proposal to each clinical site as a negligible/low-risk project, given that clinical staff (not patients) are study participants and the level of risk entailed during data collection. Informed consent will be sought from participants  for the survey, observations, and interviews, as required, prior to data collection.For Phase 2, a proposal will be initially submitted to the Human Research Ethics Committee (HREC) of one selected lead site. Once approval is given, applications will be submitted to the HRECs of all other participating sites as required by the relevant jurisdiction for each site. The university HREC will then be approached for ratification. Clinical staff participants will be asked to provide informed consent for the focus groups, and observation periods by the project officer, using the provided participant information sheet and informed consent form. Confidentially of participant identity will be assured. All data will be stored as per national regulatory guidelines .Site selection and preparation, project officer training, chart selection and implementation, participant recruitment, and data collection has been completed and the analysis of these results are in progress.Clinical deterioration by adult patients in acute medical-surgical wards continues to occur, despite a range of systems and processes designed to minimize this risk. In Australia, the ACSQHC opted to develop a standardized template for adult observation charts using human factors design principles and decision-support characteristics to improve the detection of and response to abnormal vital signs.This study aims to use a cross-sectional and a before-after design with multiple-methods data collection approaches to evaluate the implementation, clinical utility, and user acceptance of an observation and response chart for use with adult general medical-surgical patients in clinical sites across Australia. This pragmatic methodological approach aims to balance collection of a diverse dataset with a manageable level of participant burden, within the scope of the project tender set by the ACSQHC.A number of potential limitations with these proposed methods are evident. The use of an onsite project officer seconded from the local organization’s staff will enable optimal communication and engagement with all relevant clinical staff. However, their involvement as data collectors, including facilitation of focus groups, has the potential to influence participant responses or behaviors (possible Hawthorne effect). The 24-hour cycle of data collection in Phase 1 is designed to enable involvement and feedback from night-duty staff. While data collection periods will be short, these are proposed to minimize participant burden in busy clinical environments.The before-after design in Phase 2 may limit causal inferences related to the chart implementation. While the use of control wards in sites may have improved interpretation, this latter design would also have other potential limitations, including differing ward cultures, case mix, and contamination bias.Within the context of the chart design characteristics, modifications to parameter values and response levels will enable alignment with local site needs, policies, and practices. This process of flexible standardization provides site input, but perhaps not from front line staff (the users). As noted earlier, while the three non-ADDS charts did not have any simulation testing prior to this clinical testing, the design characteristics and sections, including the graphing section, were similar across all versions . DiffereThis study plans to involve 10 sites from different Australian jurisdictions, including both public and private hospitals, with different levels of service and size, ranging from small rural facilities, to metropolitan and tertiary-level hospitals. This detailed description of the study methods will enable a comprehensive assessment of the clinical utility of these newly designed observation and response charts and will be useful for clinicians and researchers when planning and implementing similar studies.


One of the major challenges health care systems face in modern time is treating chronic disorders. In recent years, the increasing occurrence of multiple chronic disorders (MCC) in single individuals has compounded the complexity of health care. In 2008, it was estimated that worldwide as many as one quarter of the population between the ages of sixty five to sixty nine suffered from two or more chronic conditions and this prevalence rose with age. Clinical guidelines provide guidance for management of single disorders, but not for MCC. The aim of the present study was the study of the prevalence, distribution and impact of MCC in a large Israeli health system.We performed a cross-sectional study of MCC in the Maccabi Healthcare System (MHS), Israel’s second largest healthcare service, providing care for approximately two million people. Data regarding chronic conditions was collected through electronic medical records and organizational records, as was demographic and socioeconomic data. Age and sex specific data were compared with previously published data from Scotland.Two thirds of the population had two or more chronic disorders. This is significantly higher than previously published rates. A correlation between patient age and number of chronic disorders was found, as was a correlation between number of chronic disorders and low socioeconomic status, with the exception of children due to a high prevalence of learning disabilities, asthma, and visual disturbances.MCC is very prevalent in the MHS population, increases with age, and except for children is more prevalent in lower socioeconomic classes, possibly due to the a combination of the structure of the Israeli universal insurance and requirements of the ministry of education for exemptions and benefits. A higher than previously reported prevalence of MCC may be due to the longtime use of use of integrated electronic medical records.To effectively deal with MCC health care systems must devise strategies, including but not limited to, information technologies that enable shared teamwork based on clinical guidelines which address the problem of multiple, as opposed to single chronic disorders in patients. In recent years, ageing of the world population combined with the effects of urbanization and globalization, an increase in communicable and non-communicable disorders, patients presenting with multiple complex diseases has occurred . To effeCare for the individual patient with MCC is often fragmented, split between providers leading to inefficient, incomplete and ineffective care. The individual with MCC is at risk for preventable adverse drug events , avoidabFrom a healthcare system perspective MCC is expensive  with a mFacing the complexity of MCC, and in order to plan an effective local strategy to deal with the issue of individual and organizational risk, the first step is to diagnose the extent and complexity of MCC at the local level. We therefore set out to examine MCC in the Maccabi Healthcare Service (MHS). Various measures have been used to define and measure MCC ,17. The This cross-sectional study was conducted in MHS, which insures approximately two million members. In Israel, universal healthcare services are provided by four health maintenance organizations that are obligated to insure every citizen who wishes to join them irrespective of age, sex, or medical history. Therefore every sector in the Israeli population is represented in MHS. MHS has used electronic medical records for over twenty years, and a unified patient chart now allows all providers to view patient information on a “need-to-know” basis. MHS’ central databases are automatically updated with every member transaction including all physician visits, prescriptions dispensed, laboratory tests, medical treatments, nursing care, physiotherapy treatment, hospital admissions, outpatient visits or any other medical service rendered to the insured individual through MHS, who is issued a unique identification number.The data for this analysis were collected from all active MHS members alive on August 6, 2012. The dataset included age, sex, and socioeconomic status. Socioeconomic status (SES) was categorized into ten levels according to the poverty index of the member’s enumeration area as defined by the 1995 national census based on several parameters, including household income, educational qualifications, crowding, material conditions and car ownership .To assess MCC, we followed the method presented by Barnett et al.  and seleWe calculated age-specific prevalence and frequency of MCC and compared them to the results published by Barnett et al.  for the The total study population included in the present analysis was 1,972,798 individuals. Children and adults younger than 25 years accounted for 43% of this population compared to 27% in the Scottish study  of the population had one or more chronic morbidities, and 38.1% (38.0%–38.2%) had two or more chronic disorders, i.e. MCC. These are significantly (P < 0.01) higher rates compared with 42.2% (42.1%-42.3%) and 23.2% (23.1%-23.3%) in the Scottish study population, respectively. In the age-specific analysis, the prevalence of MCC increased with age from 0.4% in infants and young children aged under five years to 28.1% in the 40-44 year age group, to over 90% after age 75 . Although in this paper we took the same approach in evaluating the data as Barnett et al. , differeIn comparison with the Scottish population described by Barnett et al.  our studThe prevalence of MCC presents challenges to modern health systems and providers. In this regard, the use of integrated electronic medical records made it possible for provider and health care system managers to comprehend the magnitude and complexity of MCC. The challenges to providers are significant, for example in trying to use the fewest necessary drugs possible, with the least side effects, to devise a personalized effective and safe treatment plan for each patient. Healthcare system managers are interested in optimizing the use of scarce resources efficiently in order to obtain maximal health of the population. In this regard the study of local patterns of MCC is of utmost importance.In order for healthcare systems to effectively approach the treatment of chronic disorders, the multidimensional Chronic Care Model (CCM) was developed by Wagner et al. . Though Management must provide caretakers with new, more complex educational tools and supportive information technology to help achieve best possible results. This should include seminars and lectures not only on discrete diseases but also on the efficient management of disease combinations such as diabetes mellitus, hypertension, hyperlipidemia and chronic renal failure. A recent Cochrane review which looked at studies examining interventions for improving outcomes in patients with MCC in primary care and community settings, concluded that though the research in the field is scarce, there are indications that interventions targeted at either specific combinations of diseases, or at specific problems for patients with multiple conditions may be most effective .General practitioners find consultations with multi-morbid patients demanding and not easily delegated to nurses , attestiA limitation to our study is the use of census data from 1995 in analysis of the association of MCC with socioeconomic status. It will be important to update our analysis as new and reliable census data becomes available.The current data indicates that MCC is highly prevalent in all age groups in Israel. A high prevalence of MCC has far-reaching implications in the planning of health care systems. As patients live longer lives and accrue chronic disorders, both mental and physical, the management of combinations of these disorders becomes more and more complex. There is therefore an increasing need for tertiary as well as secondary and primary prevention to prevent poor outcomes of combinations of chronic disorders. Finally, but most important, as succinctly pointed out to by Guthrie et al.  clinicalThe authors declare that they have no competing interests.JEA participated in the design of the study, interpretation of the results, drafted the manuscript and made critical revisions; GC participated in the design of the study, performed the statistical analysis, and helped to draft the manuscript; AG carried out the data extraction, participated in the statistical analysis, drafting of the manuscript and made critical revisions; AP conceived the study, participated in its design helped to draft the manuscript and critical revisions. All authors read and approved the final manuscript.JEA is Deputy Medical Director of the Southern Region of Maccabi Healthcare Services and Lecturer in Medicine at the Ben Gurion University of the Negev; GC is Head of the Epidemiology & Database Research Unit at Maccabi Healthcare Services, and Associate Professor at the Tel-Aviv University Faculty of Medicine AG, Data analyst in the Department of Medical Informatics Maccabi Healthcare Services; AP is Director of Maccabi Institute for Health Services Research and professor of medicine at the Ben Gurion University of the Negev.


The WONCA Special Interest Group on Health Equity was established in 2014 to provide a focus of support, education, research and policy on issues relating to promotion of health equity in primary care settings. In keeping with this remit, the group hosted a workshop at the WONCA Europe conference held in Istanbul in October 2015. The aim of the session was to engage practitioners from across Europe in discussion of the barriers and facilitators to addressing the social determinants of health at practice level and in the training of doctors. This commentary reflects on the main findings from this workshop and how these compare with existing work in this field. Despite overall improvements in population health in most countries over the last fifty years, deprivation-related health inequity remains a serious challenge worldwide. The World Health Organization defines the social determinants of health (SDH) as “the circumstances, in which people are born, grow up, live, work and age and the systems put in place to prevent and treat illness” . In ordePrimary care  is particularly well placed to support health equity, for a number of reasons. Firstly, it has population coverage, with most patients being registered with a general practitioner (GP) . SecondlThe WONCA Special Interest Group on Health Equity was established in 2014 in response to the Health Equity Workshop held at the WONCA World 2013 conference in Prague. The participants of this workshop expressed the importance of support, education, research and discussion on policy issues relating to promotion of health equity in primary care settings . In keepWhat are the barriers and facilitators to addressing SDH at the practice level?What can be done in the consultation to improve health equity?Can you think of good examples of training for primary care practitioners that address heath equity?Should all primary care practitioners receive training about SDH? And if so, what and how much training?The workshop was attended by General Practitioners and GP trainees from across Europe, including France, Spain, Italy, Belgium, the UK, the Netherlands and Ireland. It provided an opportunity to explore practical suggestions to improve health equity within primary care. An introductory presentation on the subject of health equity was given by a team led by Professor Sara Willems. As a group, we discussed each of the following questions in turn and simultaneously recorded the key points volunteered by individual participants onto whiteboards.The facilitators encouraged contributions from all workshop participants. This report gives a summary of the key points raised by the workshop participants.Before leaving the workshop participants were also asked to complete a survey consisting of fourteen questions about different inequity-reducing activities. They were asked to rate the priority of each activity on a scale of 1 to 5 . Ten completed surveys were returned. For each health inequity-reducing activity, scores were lower for the current state compared to what should ideally be the case. For example, one health inequity-reducing activity was ‘Reform of medical education to incorporate health equity and cultural competency training’. Participants gave a mean score of 2.11 (+/−SD 0.99) for current priority compared to 4.6 (+/−SD 0.52) for the ideal priority reflecting the difference between what is and what should be happening with regard to the incorporation of health equity issues in medical education.There were several barriers suggested by workshop participants, which will be considered in turn. First, poor health literacy was considered a significant obstacle. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” . In othewww.gla.ac.uk/deepend), representing the hundred most deprived practices in Scotland, published a report detailing the impact of austerity measures on patients [Austerity measures and other sequelae of the global financial crisis of 2007/8 were also mentioned as barriers to addressing health inequity. In 2012, the “GPs at the Deep End” group , which has been established to allow GPs, researchers, educators, health planners and policy makers to formally collaborate on a number of initiatives to improve the health of marginalised groups and those living in deprived areas.Some participants suggested that more effort should be made to involve frontline GPs, particularly those with experience of working in deprived areas, in creating health policies. One example of where this has been done is in England, where GPs now sit on local clinical commissioning groups which allocate funding and resources for health services. It remains to be seen, however, what the health equity impact of these primary care reforms will be. Another example is the Partnership for Health Equity in Ireland  were further suggestions. Longer consultations can only be achieved, however, by reducing the number of available appointments or increasing the GP workforce. The development of trusting relationships between GPs and patients was another facilitator raised at the workshop. A recent Royal College of General Practitioners report on health inequalities in the UK suggests incentivising ways of working which promote continuity, particularly in areas with high multimorbidity .Having good access to trained interpreters for patients was suggested at the workshop. Using interpreters requires additional time and resource for practices which are already over-stretched. Once again, patients and practices in deprived areas are most affected, as they are more likely to have immigrant and asylum seeker populations. Unfortunately, the provision of interpreters can be limited and underfunded. Improved resources and increased consultation time would help with this issue.The importance of covering health inequities in medical education was raised as a priority by workshop participants, repeating the conclusions of the WONCA 2013 Workshop . Recent The Istanbul workshop participants suggested allowing students to observe a patient or family from a deprived area over time and also encouraging contact with marginalised groups out with the medical setting. Published research has echoed these sentiments with suggestions that knowledge of the ‘lived experience’ of patients at the margins of society and the adversity they face are crucial skills for the development of conscientious GPs of the future . It was The health equity workshop at the 2015 WONCA Europe conference continued the work of the WONCA 2013 workshop by providing an excellent opportunity to further explore the barriers and facilitators for addressing the social determinants of health in primary care with participants of varying levels of experience from a wide variety of countries. However, as Julian Tudor Hart, who coined the term ‘inverse care law’, said: intellectual opposition to injustice is only the beginning of social understanding . Examplewww.globalfamilydoctor.com/groups/SpecialInterestGroups/HealthEquity.aspx.For further information on the WONCA Special Interest Group on Health Equity see GP, general practitioner; SDH, Social Determinants of Health; WONCA, World Organization of Family Doctors


This cross-sectional clinical study was designed to explore the relationships between family functioning, coping styles, and neck pain and neck disability. It was hypothesized that better family functioning and more effective coping styles would be associated with less pain and pain-related disability. It also was hypothesized that these relationships would be stronger in older people because they have fewer resources, more limited coping styles, and may depend more on their family for support. In this study, 88 women with chronic non-traumatic neck pain completed the Family Assessment Measure (FAM), Coping Inventory for Stressful Situations (CISS), Neck Disability Index (NDI), and a Visual-Analogue Scale (VAS) measuring the subjective intensity of neck pain. Zero-order and partial correlations and hierarchical stepwise regression were performed. CISS was not correlated with the NDI orVAS. Good family functioning was correlated with lower NDI and VAS scores. Age was found to moderate the relationship between the FAM and both NDI and VAS. This relationship was significant and positive in older patients, but non-significant in younger patients. It was concluded that better family functioning is associated with lower neck disability and pain intensity, especially in the case of older women suffering from non-traumatic neck pain. Neck pain is commonly reported. It tends to be chronic and results in prolonged disability –3. It isResearch on the association of psychological factors with neck pain and neck disability is relatively common. To date, this research has established that self-rated disability is positively related to depression , pain caThe importance of chronic pain has been strongly emphasized in the context of family functioning –16. LewaThe patient-family relationship can be bi-directional in that the pain patient may affect family functioning, while variables related to the family may affect various aspects of the patient’s life. Most existing studies concentrate on the first of these relationships; the patient’s effect on the family. It has been noted, among other things, that pain reduces full time employment and increases the amount of time spent doing housekeeping and household maintenance . Thomas In the present research, we were interested mainly in how family functioning affects pain and disability. Therefore, family functioning was the independent variable, or predictor, in our analyses, and neck pain and pain-related disability were the dependent variables. It should also be noted that, to our knowledge, there have been no studies on the family dynamics of patients with chronic neck pain. We hypothesized that better family functioning would result in less pain and disability. This could occur for quite simple reasons. For example, the members of the family may help patients with everyday activities, thus, enabling them to rest and concentrate more on treatment. Also, it is possible that a supportive family may encourage patients to start treatment.Coping style would seem to be an obvious predictor of pain: the better and the more adaptive the coping style, the less the pain should be. People struggling with prolonged pain naturally have to develop strategies to cope with it . HoweverIn addition, we investigated whether age acted as a moderating variable. We were unable to locate any study that examined our particular question: whether age moderates the effect of family functioning and coping styles on neck pain and neck disability. There is substantial research on the association of age with neck pain and the preponderance of these studies indicate that age is connected with both the prevalence and incidence of neck pain –3. Also,Despite the lack of relevant research, we believe the hypothesis that age moderates the association of family functioning and coping styles on pain is plausible. Moderation, in this context, means that family variables and coping styles influence pain and disability differently in people of different ages. It is possible that the relationship between the quality of family life and experienced pain is not as strong among younger people as it is among elderly people. This could be because young people may have a wider range of possible resources  at their disposal, and, thus, they may not be so dependent on family support. In contrast, older people may be more dependent on their spouse (or adult children); thus, there may be a stronger relationship between their quality of family life and pain and disability.We also were unable to find research on the relationship between coping styles and pain in which age was studied as a moderator. Nevertheless, a similar hypothesis may be tenable as in the case of family functioning: younger people may have sufficient available resources that may make them less dependent on the quality of their coping styles. Elderly people, on the other hand, may have fewer available resources, which makes them more dependent on the quality of their coping styles.Thus, this study tested the following hypotheses:The quality of family functioning is negatively related to neck pain and neck disability.Effective coping styles are negatively related to neck pain and neck disability.The relationship between the quality of family functioning and pain intensity and disability is stronger in younger people than in older people.The relationship between coping styles and pain intensity and disability is stronger in younger people than in older people.We restricted the sample to women in this study. This was done to avoid complications stemming from the fact that the gender roles of women and men differ in the family , and theThe study was conducted in 2009–2010 in an outpatient clinic in Cracow, Poland. This study was part of a larger study on the psychometric properties of the Polish NDI . The stuThe Neck Disability Index ,29 is a The Visual-Analogue Scale (VAS) is a reliable and simple self-rated index of the intensity of neck pain . We usedThe Coping Inventory for Stressful Situations (CISS) measures coping styles ,31. It iThe Family Assessment Measure (FAM) assesses the functioning of a family by family members ,32. The All the data analyzed in this article were obtained from the baseline measurements. Patients were examined by a medical doctor upon entering the study. The diagnosis was based on an interview, a physical examination, and imaging tests. Then, all the participants were informed about the aim of the project, its procedures, anonymity, and voluntary participation, and were asked to complete the NDI, CISS, and FAM; the level of neck pain was determined using the VAS. The study was conducted in collaboration with psychologists, and the measurements were performed by experienced physiotherapists who were blinded to the study.Zero-order and partial correlations (controlling for age) and a combination of hierarchical and stepwise regression models were performed, in which age was entered in the first model, and the remaining predictors (related to family functioning and coping styles) were entered into the subsequent models using the stepwise method to analyze moderation effects. The program PROCESS was used to analyze moderation effects .SD = 14.8; range 22–87). The mean of the NDI was 15.69  and the mean of the VAS was 47.96 . According to the criteria suggested by Vernon and Mior [In sum, eighty-eight women took part in the study. Their mean age was 54.5  with the FQ’s Control and Values and Norms subscales, and the SE’s Emotionality, Control, and Values and Norms subscales. The correlations were, at most, moderate, according to the standards proposed by Taylor .Controlling for age did not have any effect on the correlations with regard to the CISS. Most of the correlations with the FQ remained significant after controlling for age. In the case of the SE, some correlations became non-significant when age was controlled; namely, those between the NDI and the SE Communication, Emotionality, Affective Involvement, Control, and Values and Norms subscales.Next, hierarchical stepwise regressions were performed. To reduce the number of predictors, which would be relatively large in relation to the sample size, the coping styles were dropped from these analyses, as they were not correlated with the VAS or the NDI in bivariate correlations or the partial correlations, which controlled for age. Age was included in the first block, and the remaining predictors were entered in the second block of variables by means of stepwise elimination. Six analyses were performed, each with three groups of predictors: the subscales of the FQ, SE, and DR .As for the NDI, the FQ subscale Task Accomplishment proved to be a significant predictor, explaining about 7% of the variance in the NDI. Age was also present in the final model, explaining 15% of the variance in the NDI. Among the SE subscales, Affective Involvement was barely significant (4% of the variance explained). Age also was significant, accounting for 22% of the variance in the NDI. Finally, none of the DR subscales were retained in the final models, but age accounted for 23% of the variance in the NDI .Next, the moderator analyses were completed to assess whether age was a moderator of the relationship between coping and family functioning on one side, and VAS and the NDI on the other side. The significant results are presented in The pattern of results obtained was strikingly consistent across the different predictors and both dependent variables (NDI and VAS), with significant associations between the predictors and the dependent variables in the older participants, but not the younger ones. The association of the following predictors of the NDI interacted with age and were significant predictors of the NDI in older participants: (a) the FQ’s Role Performance, Communication, Emotionality, Affective Involvement, and Social Expectations subscales; (b) the SE’s Role Performance, Communication, Emotionality, and Control subscales; and (c) the DR’sTask Accomplishment, Communication, Emotionality, Affective Involvement, and Values and Norms subscales .Significant moderation effects were also found when the VAS was the dependent variable, in which the following predictors interacted with age: (a) the FQ’s Values and Norms subscale; (b) the SE’s Communication and Emotionality subscales; and (c) the DR’s Communication, Emotionality, and Affective Involvement subscales.negatively associated with the NDI in younger persons, but positively associated with the NDI in older persons. In both sets of analyses, only family-related variables proved to be involved in the moderating effects, not coping styles , and neck pain and neck disability on the other (the dependent variables). We also sought to determine whether this relationship is moderated by age; that is, whether this relationship is different at various ages.In sum, the relationships between family functioning and neck pain and neck disability were found to be statistically significant, with the vast majority of the scales of the FAM correlating with the VAS and NDI. The direction of the obtained correlations indicated that better family functioning is associated with less subjectively experienced pain and disability. This supports our first hypothesis that the quality of family life influences the experience of pain and disability, although it must be stressed that these results are based on correlational data, so one cannot infer the direction of causation.The number of significant effects found in our analysis was much larger in the correlational analyses than in the multiple regression analyses. This may be due to the fact that the intercorrelations among the subscales of the FAM were quite high see , which mGiven the lack of existing research in this area, we can only speculate about the reason for the negative correlation between family function and neck pain/disability. One currently and widely accepted mechanism—fear-avoidance beliefs—may help to explain these results ,39. The A second mechanism operating either separately or in conjunction with fear-avoidance beliefs may be the presence of depression. Depression has been found to be positively associated with higher levels of neck disability ,6. PooreThe results of the moderation analyses showed that the relationship between family functioning and pain and disability was significant in older women, but not in younger women. This finding is in line with the hypothesis that elderly people may be more dependent than younger people on the support of their families. Younger neck-pain sufferers may be able to seek help and obtain sufficient support regardless of whether such help is available in the family context, whereas older sufferers may be more dependent on family support. Thus, in the case of older people, aspects of the quality of family functioning, such as proper role performance, communication, emotionality, affective involvement, and social expectations, may help them handle their pain and disability.When interpreting these results, it should be borne in mind that only women participated in this study. It is possible that women are more dependent on the quality of family life than men are .Regardless of the actual mechanism underlying the moderating effect on the relationship between family functioning and neck-related problems, these results are important in that the population is aging in most countries ,42. In lIt was somewhat surprising that coping styles were not significantly related to either neck pain or the disability related to neck pain . Many studies have shown that coping is an important predictor of pain . HoweverWith regard to the specific topic of neck area, coping styles are often found to be unrelated, or at best weakly related, to pain. For example, Hurwitz et al.’s  analysisIt may be that the lack of significant effects of coping styles is related to the fact the present study used general coping styles related to coping with stress (as measured by the CISS), whereas most research of this kind has used coping strategies that are more directly related to coping with pain .Finally, it is worth mentioning that the present study found positive correlations between age and neck disability (as measured by the NDI), but not age and neck pain (VAS). This is somewhat surprising, as most studies of this kind have consistently found age to be unrelated to the NDI, in the case of both traumatic injury ,7–9, andPoorer family functioning may be connected with higher neck-pain disability and intensity, especially in the case of older women suffering from non-traumatic neck pain. Family functioning should be investigated in all neck-pain patients, especially those patients in their later years of life.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.S8 Table(DOCX)Click here for additional data file.S9 Table(DOCX)Click here for additional data file.S10 Table(DOCX)Click here for additional data file.S11 Table(DOCX)Click here for additional data file.S12 Table(DOCX)Click here for additional data file.S13 Table(DOCX)Click here for additional data file.


The world population is aging, with the proportion of older people (65+ years) expected to reach 21% in 2050 and to exceed the number of younger people (aged 15 or less) for the first time in history. Because cancer is particularly a chronic disease of older people, a large increase in the number of elderly patients with cancer is anticipated. The estimated number of new cancer cases worldwide among people over 65 is expected to grow from about 6 million in 2008 to more than 11 million during the coming decade. By 2030, individuals over 65 are expected to account for 70% of all cancer patients in the Western world. Along with the increase in oncology patients, the number of older people caring for their ill spouses or other relatives is also growing, with the ensuing toll on these caregivers causing major concern, especially in western countries. In different societies the characteristics of family caregiver stressors, cultural norms concerning caregiving, and the availability of support have a huge impact on those providing care. Any study of older caregivers of older cancer patients requires an integrative evaluation of aging that takes into account cultural, social, psychological, and behavioral variables. This review proposes a critical discussion of the multidimensionality of the caregiving and of the impact that age, culture, and gender have on it. Culture may be viewed as a mechanism through which people learn how to “be” in the world – how to behave, how to respect social norms and how to infuse their existence with meaning. Interpretation of culture provides the context for living under free normative conditions in society and across individual lifecycle events .While It could be described as “the integrated pattern of human behavior that includes thoughts, communication, actions, beliefs, values, and institutions of an ethnic, religious, or social group” .Cultural identification may include, but is not limited to: race, ethnicity, national origin, migration background, gender identity, sexual orientation, marital or partnership status, and spiritual, religious, and political affiliation. Moreover, culture underlies priorities in healthcare services as it is one of the foundations for well-being, survival, human interactions, and quality of life and care .Dimensions of cultural variables form a background to human interaction across various life stages, and health and illness come to the foreground when people face the realities of an imminent threat to life. The meaning of tradition, rituals, and family values becomes increasingly relevant within the context of illness and health. It is then that patients, families and physicians negotiate the complexity of care within their perception of the reality of each normative culture.Although much of the extant work on cultural diversity in healthcare has focused on issues of ethnicity, social disparities and religion, the perspective should be broadened to acknowledge differences and similarities between and within groups.Cross-cultural encounters in healthcare present a challenge with respect to economic, education and health inequalities as well as differences in gender and race . AcknowlStudies of elderly patients explore the way societal and cultural development affect attitudes toward older people and their family caregivers. In traditional societies old age is often highly valued, with the elderly personifying a source of knowledge and experience. However, in western societies, as the number and percentage of older people increase, they may be seen as a liability and a burden to both their families and society .This is not the case in all cultures, especially non-Western ones, where relatives continue to provide care and total support. At the most fundamental level, perceptions of aging and care are reflections of religious beliefs, traditional family hierarchies, and patriarchal norms of obedience. Attitudes toward caregiving are based in part on cultural and family systems, which shape how caregivers are perceived and whether or not they are treated with respect.In traditional countries, such as those in the Middle East, the debate concerning knowledge and consent with respect to illness and healthcare revolves around family norms based on the holy books and the family unit is responsible for decisions about treatment and care. These and many other cultures based on community rather than individual rights and responsibilities, value non-maleficence (doing no harm) and strives to protect patients from any emotional and physical harm caused by directly addressing illness and end-of-life care .For example, within Islamic culture, the total involvement of caregivers is natural, in the context of the long-held value of respect for unconditional solidarity which is intrinsic to the normative religious-cultural tradition. The integrity and cohesion of relatives as caregivers are understood solely within the dynamic of the family, and not in terms of institutions that provide treatment for illness or terminal care .In the Western world, individual autonomy, truth, and open communication are the core of the dominant bioethical framework. However, the perception of autonomy and openness as empowering and providing a sense of control tends to be blind to the fact that the decision-making process of the individual is involved in a complex relationship with the social surroundings. In Islam, families prefer caregivers to live with uncertainty about the fate of one of its members rather than to confront a poor prognosis or “death threat” .The number of older people (65+) across the globe is expected to more than triple by 2100, increasing from 784 million in 2011 to 2 billion in 2050 and 2.8 billion in 2100. The more developed regions of the world have been leading the process of aging and, by 2050, the proportion of older people in these regions is expected to be double that of children (under 15 years): 31.9 vs. 16.3% respectively .With a decline in mortality and fertility rates, populations in European countries are aging, leading to the expectation that the demand for healthcare and care for the elderly will rise accordingly. The proportion of individuals aged 65 and over in the 25 member countries of the EU is expected to rise from about today’s 16–30% in the year 2050 .Following this trend, populations in developing countries will also be aging rapidly in the coming decades. The number of older people in less-developed countries is expected to increase from 249 million in the year 2000 to 690 million in the year 2030. Since the elderly are at high risk for co-morbidities and disabilities, urgent demands will be placed on developing countries’ healthcare systems – most of which are ill-prepared to handle such pressure.Inasmuch as cancer is essentially a chronic disease of the elderly, an upward spiral in the number of older individuals with cancer is expected. The incidence of cancer worldwide among people over 65 is expected to grow from about 6 million in 2008 to more than 11 million in the coming decade. By 2030, individuals over 65 will probably account for 70% of all cancer patients in the Western world .The proportion of malignant tumors, combined with demographic factors, will potentially translate into increasing numbers of diagnoses of cancer, or a high risk for developing cancer .According to the , “FamilyAn estimated 44 million Americans ages 18 and above provide unpaid assistance and support to older people and adults with disabilities who live in the community. Care is provided to someone who is elderly and ill by 65.7 million caregivers who make up 29% of the US population .The value of unpaid family caregivers will likely continue to be the largest source of long-term care services in the US, and the aging populations (65+) will more than double from 2000 to 2030, increasing to 71.5 million from 35.1 million in 2000 .More women than men are caregivers, with an estimated 66% of caregivers being female. One-third (34%) take care of two or more people, and the average age of a female caregiver is 48.0 .Many caregivers of older people are themselves growing older. Of those caring for someone aged 65+ the average age is 63 years with one third of these caregivers in fair to poor health .Furthermore, the percentage of caregivers caring for individuals over 85 years of age has increased across all surveys of informal caregivers conducted by A Gallup survey found 72% of caregivers cared for a parent, mother-in-law, or father-in-law, and 67% of caregivers provided care for someone aged 75 or older .Most care recipients live in their own home (58%) and one in five (20%) live in their caregiver’s home .All the preceding facts and figures have social, medical, psychological, economic, and political implications for families and the community as a whole. Society increasingly recognizes that advanced age is a quantitative reality, and that older adults will have to contribute significantly to caregiving for elderly people and aged communities. At the same time, many people face multiple bio-psychosocial challenges as they age. These may be related to physical and cognitive abilities or may be manifest in barriers to accessing mental/behavioral healthcare; decreased economic security; and loss of meaningful social roles and opportunities that allow them to remain engaged in society. These challenges affect entire families, who struggle to provide physical, emotional, financial, and practical support to their aging members.Healthcare research clearly indicates that caregiver appraisal should be multidimensional, reflecting culturally competent practice. Studies have shown that cultural beliefs and social norms play a part in influencing family emotions and behavior with respect to cancer perception and in their appraisals of illness and health.Outcome research shows that access to care may be compromised in some cultures by the family’s reluctance to discuss the disease among its own members, deriving from a belief that “silence should prevail” . Asian AMultiple social, psychological, and biological factors determine the level of functioning of each caregiver at any point in time. As well as the typical life stressors common to all people, many older adults lose their ability to live independently because of limited mobility, chronic pain, frailty or other mental or physical problems, and require long-term family care. In addition, as previously stated, older caregivers, being themselves elderly, are more likely to experience the drop in socioeconomic status that often accompanies retirement and also chronic illnesses, which may result in isolation, loss of independence, loneliness and psychological distress, all of which add to the caregiver burden.Studies have been conducted that examine attitudes to older caregivers of elderly patients, and while they tend to be based on surveys in developed countries, there are some that include relevant information from developing countries as well. Studies and anecdotal evidence relating to caregiving in specific national contexts shed some light on the way caregivers are perceived in different countries.In a meta-analysis of 116 empirical studies, Asian American caregivers were found to provide more caregiving hours than white, African American, and Hispanic caregivers; to use lower levels of formal support services; and to have fewer financial resources, lower levels of education and higher levels of depression than the other subgroups. These findings are relevant for the health-oncology team because caregivers who lack additional medical assistance tend to be more depressed than those who receive support from within the medical team. A study involving unmet needs and service barriers among Asian American caregivers found that caregivers refused outside help because they “felt too proud to accept it” or “didn’t want outsiders coming in.” Other reported barriers included “bureaucracy too complex” or “can’t find qualified providers” .Hispanic and African American patients and caregivers underutilize community health resources, including counseling and support groups, home care, residential care, and hospice services, one reason being that strong family ties may prevent minority caregivers from seeking help outside the family unit .A comparison among African American, white American, and Hispanic caregivers found that 75% of Hispanic patients and 60% of African American patients lived with the family of the primary caregiver. The minority families relied more on informal caregiving from friends and relatives and had larger social support networks than the white families. This increased sense of obligation to provide care for older family members was associated with more caregiving hours, greater resignation about caregiving, higher levels of caregiver strain, and a larger reduction in household income than that reported by white caregivers .Results showed that African American and Hispanic caregivers were more likely than white caregivers to reduce their work hours to care for sick relatives. In addition, minority caregivers were reluctant to use formal nursing home services for their loved ones or to choose hospice care. The decision to reduce work hours rather than place a relative in a nursing home was associated with increased psychological, social, and financial burden .Several personal resources that family caregivers draw on – such as their coping strategies, personality factors and social support – are often assumed to be conditioning variables in the caregiving stress process. Also among minority groups, caregivers for elderly cancer patients experienced high levels of depression and the presence of depressive symptoms is negatively associated with cancer screening .While traditionally caregiving has been mostly provided by women across cultures, the number of male caregivers is increasing, especially for older males. Most published studies thus far have investigated the effects of caregiving on spouses and women.Women caregivers have been found to exhibit moderate to severe sleep problems, fatigue and appetite disturbance, and to report higher levels of cancer-related distress than either cancer patients or survivors. Female caregivers described more unmet needs and a greater sense of burden than male caregivers, leading to the suggestion that male and female caregivers should be regarded as two distinct caregiver groups. This gender difference means women receive less support or acknowledgment for the caring role than do men in the same position .However, a 13 year follow-up of the Danish population revealed that the same is true for male spouses. Men whose partner was diagnosed with breast cancer were at an increased risk of being hospitalized with an affective disorder compared to men whose partner was not diagnosed with breast cancer .In a recent study by Increased ages of patients accentuated caregivers’ distress. Psychological distress of caregivers to cancer patients aged 71+ was four times higher than that of the control group, while they reported half of the coping behaviors reported by the control group. The higher distress levels found in caregivers for older patients could be due to a more realistic sense of inevitable separation and grief. Possibly, caregivers have to deal with feelings of hopelessness and helplessness about their own future as well. Caregivers to older patients (71+) reported lower levels of support from their spouse (the patient) in comparison to caregivers to younger patients (60–70 years). Caregivers for older patients with cancer may experience a continuous process of disengagement resulting in a reduction in social involvement. The emotional support the patient could supply is either diminished or absent, leaving the caregiver with an unfulfilled expectation of support and emotional care.Why, then, do most family caregivers continue to care for relatives, in spite of all the stress and strain? Research that addresses this question reports that mutual caring can bestow both meaning, through a functional role, and pleasure, on the caregiver and the recipient of care. Similar factors emerged as the main satisfaction variables in the study by Nolan and Lundh among family caregivers in the UK and Sweden .Comparable findings came to light in earlier studies concerned with the experiences of stroke, cancer, and dementia patients. Those who care for their relatives at home, often do so of their own volition and a genuine love for the person. In such caring relationships based on love and integrity, the caregiver derives great satisfaction from being able to relieve, bring solace and provide the care recipient with a passionate sense of trust and joy .It is crucial to have evidence-based knowledge of the multifaceted aspects of caregiving to suggest possible psychological interventions for caregivers. A recent meta-analysis of different psychological interventions for family caregivers for cancer patients concluded that “clinicians need to deliver evidence-based interventions” to help caregivers and patients to cope effectively, maintain their quality of life, and increase resilience and meaning .The single salient perspective that can be drawn from this overview is that caregiving is not an episodic or closely bound feature of people’s lives. Caregiving involves a long-term commitment over the course of which the conditions that caregivers face, and the transitions through which they must pass are in a state of kaleidoscopic change.Characteristics of caregiver stressors, cultural norms concerning caregiving, and informal and formal support in different cultures may have a huge impact on caregiver vulnerability and/or resilience. To better understand and ameliorate caregiving stress and focus on evidence-based policies, there is a great need for studies describing appraisals provided by caregivers’ from different cultures about caring for a partner diagnosed with cancer. Specifically, there is a need for studies comparing cultures where most of the care is provided at home by close family members, to cultures where most of the care is provided by professional caregivers outside the patient’s home .Caring for an elderly relative who is a cancer patient is extremely complex and demanding. It is described as a blurry mixture of the complex and the simple, of mature and regressive behavior. It is a patchwork of moments of vivid intensity and compassion that at times lapse into blandness and despair.The caregiver’s life is an oscillation between hope and grief. The close relationship between the family caregiver and the care recipient may require being “on call” 24 h a day, and comprises shared emotions, experiences, and memories that place the caregiver at higher risk for psychological and physical exhaustion .Studies consistently report higher levels of depressive symptoms and severe fatigue among caregivers than among their non-caregiving peers .Most family caregivers of older people are themselves elderly. The average age of those caring for someone aged 65+ is sixty-three, with one third of these caregivers in fair to poor health. There is cumulative consistent evidence that informal caregivers for elderly cancer patients experience high rates of anxiety and depression, with 20–30% of all caregivers believed to be at high risk for psychiatric morbidity.Estimates show that between 40 and 70% of caregivers have clinically significant symptoms of depression, with approximately one quarter to one half of these caregivers meeting the diagnostic criteria for major depression . In addiFamily caregivers describe feeling frustrated, angry, drained, guilty, or helpless as a result of providing intense care. Some 16% feel emotionally strained and 26% say that caring for the patient is hard on them emotionally. An additional 13% of caregivers feel frustrated when there is little or no improvement in the condition of the care recipient .Caregiving may also result in loss of self-identity, lower levels of self-esteem, constant anxiety, or feelings of uncertainty, less self-acceptance, and a sense of being ineffective or lacking control .Furthermore, evidence shows that most caregivers are ill prepared for their role and provide care with little or no support, yet despite this, and the fact that they suffer from poor health themselves, more than one-third continues to provide intense care. It also emerges that an influential factor in a family caregiver’s decision to place a terminally ill relative in a long-term care facility is the state of his or her own physical health .Informal family caregivers for cancer patients are required to meet multidimensional needs, including treatment monitoring; treatment-related symptom management; emotional, financial and spiritual support; and the need for assistance with personal and instrumental care. Families are increasingly replacing skilled healthcare workers in the delivery of unfamiliar complex care to their ill relatives, despite the other obligations and responsibilities that characterize their lives .The above data clearly reveals that providing care for a chronically sick person can have harmful physical, mental, and emotional consequences for the caregiver. As family members struggle to care for others, they endanger their own health. Caregiver health is becoming a public health issue that requires more focused attention from health professionals, policy makers and caregivers themselves, to ensure the health and safety of those individuals dedicating their lives to the care of others .Increasing appropriate psychological health services and integrative care for family caregivers are appropriate steps toward addressing caregiver health. Although caregiving could have a negative impact on caregivers’ health and well-being, research also demonstrates its effects can be alleviated at least partially by providing adequate skills and professional guidance and organizing community support. Keeping family caregivers healthy and able to provide care is central to maintaining a long-term care system and, with the aging of the population, the issue will only become more significant in the coming decades .Literature on family caregivers of elderly cancer patients highlights: (1) The increasing number of patients with ongoing chronically complex care needs; (2) The increasing number of complex tasks assumed by family caregivers; (3) The high proportion of unmet caregiver needs; (4) The subjective nature of the caregiving experience that encompasses both positive and negative elements, and (5) The conceptualization of caregiver burden as positively linked to negative reactions to caregiving .Learn from yesterday, live for today, hope for tomorrow. The important thing is to not stop questioning.Albert EinsteinAny study of caregivers of elderly people requires an integrative evaluation of aging according to cultural, social, and psychological variables. Social norms and traditions regulate the rituals and actions through which people are recognized, and the processes of these dimensions are identifiable within the caregivers’ social and cultural space. Culture also shapes the need for and the behavior of caring, giving it meaning and style in accordance with patients’ values, needs, and priorities.Age is one of the determinants of the complex notion of culture and, conversely, culture shapes the way we look at the elderly in different societies. The tendency to see older persons through the biased prism of ageism in Western cultures, predominantly based on productivity, is an example of this interrelation .Ageism, by isolating the elderly as no longer productive members of society, determines the individual approach of healthcare providers to older patients and their caregivers, as well as institutional decisions and policymaking in most industrialized countries. By contrast, in other cultures the elderly are considered important members of society, and are respected and valued for their wisdom, so that caregiving is not perceived as only a burden.Alongside major demographic shifts and globalization there is an increasing multi-ethnicity and multi-culturality in most societies. This calls for the need to learn how to understand, respect and address cultural difference in the practice of medicine and also in sustaining caregivers. Cultural pluralism in individual life, as in medical care, enriches us while also representing a moral and ethical quandary, and misunderstandings, up to real ethical dilemmas, may arise in cross-cultural medical encounters or in communication and interaction with caregivers from different cultures .For this reason, all health workers should acquire “cultural competence” – a set of knowledge, attitudes and skills that facilitates communication and negotiation in cross-cultural clinical encounters with patients and their caregivers. Cultural competence and sensitivity are particularly needed in dealing with elderly patients and their families and caregivers.Moreover, there is a growing need for more adequately trained healthcare professionals who possess the knowledge and skills to become leaders of the emerging field of geriatrics and the related formal and informal family care .In the context of this cultural complexity, caring for a family member is not just a private experience, but rather a mutual and interrelated one between caregiver and care recipient within their social and cultural space. When family caregivers hold their ill relatives in their arms they not only fulfill the need for physical contact, but also offer hope and spiritual bonding in a mutual experience of emotional linkage within the boundaries of their traditional behavioral norms.Caregiving is not always supplied by relatives or significant others. We may find caregivers among friends and strangers, in encounters with other families in the hospital or in community settings, as a mutuality of love and concern within a “space” of trust and communion .Individuals and systems of care must respond compassionately and effectively to people of all cultures, languages, races, ethnic backgrounds, and religions. Their approach should recognize, affirm, and value individuals, families, and caregivers within their own space, so as to protect and preserve the dignity of each person and family while supporting them through illness and care.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.