Propecia cheapest price

AbstractBrazil is propecia cheapest price currently home visit their website to the largest Japanese population outside of Japan. In Brazil today, Japanese-Brazilians are considered to be successful members of Brazilian society. This was not always the case, however, and Japanese immigrants to Brazil endured much hardship to attain propecia cheapest price their current level of prestige. This essay explores this community’s trajectory towards the formation of the Japanese-Brazilian identity and the issues of mental health that arise in this immigrant community.

Through the analysis of Japanese-Brazilian novels, TV shows, film and public health studies, I seek to disentangle the themes of gender and modernisation, and how these themes concurrently grapple with Japanese-Brazilian mental health issues. These fictional narratives provide a lens into the experience of the Japanese-Brazilian community that is unavailable in traditional medical studies about their mental health.filmliterature and medicinemental health caregender studiesmedical humanitiesData availability statementData are available in a public, open access repository.Introduction and philosophical backgroundWork in the medical humanities has noted the importance of the ‘medical gaze’ and how it may ‘see’ the patient in ways which are specific, while possessing broad significance, in relation to developing medical knowledge propecia cheapest price. To diagnosis. And to the social position of the medical profession.1 Some authors have emphasised that vision is propecia cheapest price a distinctive modality of perception which merits its own consideration, and which may have a particular role to play in medical education and understanding.2 3 The clothing we wear has a strong impact on how we are perceived.

For example, commentary in this journal on the ‘white coat’ observes that while it may rob the medical doctor of individuality, it nonetheless grants an elevated status4. In contrast, the patient hospital gown may rob patients of individuality in a way that stigmatises them,5 reducing their status in the ward, and ultimately dehumanises them, in conflict with the humanistic approaches seen as central to the best practice in the care of older patients, and particularly those living with dementia.6The broad context of our concern is the visibility of patients and their needs. We draw on observations made during an ethnographic study of propecia cheapest price the everyday care of people living with dementia within acute hospital wards, to consider how patients’ clothing may impact on the way they were perceived by themselves and by others. Hence, we draw on this ethnography to contribute to discussion of the ‘medical gaze’ in a specific and informative context.The acute setting illustrates a situation in which there are great many biomedical, technical, recording, and timetabled routine task-oriented demands, organised and delivered by different staff members, together with demands for care and attention to particular individuals and an awareness of their needs.

Within this ward setting, we focus on patients who are living with dementia, since this group may be particularly vulnerable to a dehumanising gaze.6 We frame our discussion within the broader context of the general philosophical question of how we acquire knowledge of different types, and the moral consequences of this, particularly knowledge through visual perception.Debates throughout the history of philosophy raise questions about the nature and sources of our knowledge. Contrasts are often drawn between more reliable or propecia cheapest price less reliable knowledge. And between knowledge that is more technical or ‘objective’, and knowledge that is more emotionally based or more ‘subjective’. A frequent point of discussion is the reliability and characteristics of perception propecia cheapest price as a source of knowledge.

This epistemological discussion is mostly focused on vision, indicating its particular importance as a mode of perception to humans.7Likewise, in ethics, there is discussion of the origin of our moral knowledge and the particular role of perception.8 There is frequent recognition that the observer has some significant role in acquiring moral knowledge. Attention to qualities of the moral observer is not in itself a denial of moral reality. Indeed, it is the very essence of an ethical response to the world to recognise the deep reality of others as separate persons propecia cheapest price. The nature of ethical attention to the world and to those around us is debated and has been articulated in various ways.

The quality of ethical attention may vary and achieving a high level of ethical attention may require certain conditions, certain virtues, and the time and mental space to attend to the situation and claims of the other.9Consideration has already been given to how different modes of attention to the world might be of relevance to the practice of medicine. Work that examines different ways of processing information, and of interacting with and propecia cheapest price being in the world, can be found in Iain McGilchrist’s The Master and His Emissary,10 where he draws on neurological discoveries and applies his ideas to the development of human culture. McGilchrist has recently expanded on the relevance of understanding two different approaches to knowledge for the practice of medicine.11 He argues that task-oriented perception, and a wider, more emotionally attuned awareness of the environment are necessary partners, but may in some circumstances compete, with the competitive edge often being given to the narrower, task-based attention.There has been critique of McGilchrist’s arguments as well as much support. We find his work a useful framework for understanding important debates in the ethics of medicine and of nursing about relationships of staff to propecia cheapest price patients.

In particular, it helps to illuminate the consequences of patients’ dress and personal appearance for how they are seen and treated.Dementia and personal appearanceOur work focuses on patients living with dementia admitted to acute hospital wards. Here, they are a large group, present alongside older patients unaffected by dementia, as well as younger patients. This mixed population provides a useful setting to consider the impact of personal appearance on different patient groups.The role of appearance in the presentation of the self has been explored extensively by Tseëlon,12 13 drawing on Goffman’s work on stigma5 and the presentation of propecia cheapest price the self14 using interactionist approaches. Drawing on the experiences on women in the UK, Tseëlon argues Goffman’s interactionist approach best supports how we understand the relationship appearance plays in self presentation, and its relationships with other signs and interactions surrounding it.

Tseëlon suggests that understandings in this area, in the role appearance and clothing have in the presentation of the self, have been restricted by the perceived trivialities of the topic and limited to the field of fashion studies.15The personal appearance of older patients, and patients living with dementia in particular, has, more recently, been shown to be worthy of attention and of particular significance. Older people are often assumed to be left out of fashion, yet a concern with appearance propecia cheapest price remains.16 17 Lack of attention to clothing and to personal care may be one sign of the varied symptoms associated with cognitive impairment or dementia, and so conversely, attention to appearance is one way of combatting the stigma associated with dementia. Families and carers may also feel the importance of personal appearance. The significant body of work by Twigg and Buse in this field in particular draws attention to the role clothing has on preserving the identity and dignity or people living with dementia, while also constraining and enabling elements of care within long-term community settings.16–19 Within this paper, we examine the ways in which these phenomena can be even more acutely felt propecia cheapest price within the impersonal setting of the acute hospital.Work has also shown how people living with dementia strongly retain a felt, bodily appreciation for the importance of personal appearance.

The comfort and sensuous feel of familiar clothing may remain, even after cognitive capacities such as the ability to recognise oneself in a mirror, or verbal fluency, are lost.18 More strongly still, Kontos,20–22 drawing on the work of Merleau-Ponty and of Bourdieu, has convincingly argued that this attention to clothing and personal appearance is an important aspect of the maintenance of a bodily sense of self, which is also socially mediated, in part via such attention to appearance. Our observations lend support to Kontos’ hypothesis.Much of this previous work has considered clothing in the everyday life of people living with dementia in the context of community or long-term residential care.18 Here, we look at the visual impact of clothing and appearance in the different setting of the hospital ward and consider the consequent implications for patient care. This setting enables us to consider how the short-term and unfamiliar environments of the acute ward, together with the contrast between personal and institutional attire, impact on the perception of the patient by self and by others.There is a body of literature that examines the work of restoring the appearance of residents within long-term community care settings, for instance Ward et al’s work that demonstrates the importance of hair and grooming as a key component of care.23 24 The work of Iltanen-Tähkävuori25 examines the usage of garments designed for long-term care settings, exploring the conflict between clothing used to prevent undressing or facilitate the delivery of care, propecia cheapest price and the distress such clothing can cause, being powerfully symbolic of lower social status and associated with reduced autonomy.26 27Within this literature, there has also been a significant focus on the role of clothing, appearance and the tasks of personal care surrounding it, on the older female body. A corpus of feminist literature has examined the ageing process and the use of clothing to conceal ageing, the presentation of a younger self, or a ‘certain’ age28 It argues that once the ability to conceal the ageing process through clothing and grooming has been lost, the aged person must instead conceal themselves, dressing to hide themselves and becoming invisible in the process.29 This paper will explore how institutional clothing within hospital wards affects both the male and female body, the presentation of the ageing body and its role in reinforcing the invisibility of older people, at a time when they are paradoxically most visible, unclothed and undressed, or wearing institutional clothing within the hospital ward.Institutional clothing is designed and used to fulfil a practical function.

Its use may therefore perhaps incline us towards a ‘task-based’ mode of attention, which as McGilchrist argues,10 while having a vital place in our understanding of the world, may on occasion interfere with the forms of attention that may be needed to deliver good person-oriented care responsive to individual needs.MethodsEthnography involves the in-depth study of people’s actions and accounts within their natural everyday setting, collecting relatively unstructured data from a range of sources.30 Importantly, it can take into account the perspectives of patients, carers and hospital staff.31 Our approach to ethnography is informed by the symbolic interactionist research tradition, which aims to provide an interpretive understanding of the social world, with an emphasis on interaction, focusing on understanding how action and meaning are constructed within a setting.32 The value of this approach is the depth of understanding and theory generation it can provide.33The goal of ethnography is to identify social processes within the data. There are multiple complex and nuanced interactions within these clinical settings that are capable of ‘communicating many messages at once, propecia cheapest price even of subverting on one level what it appears to be “saying” on another’.34 Thus, it is important to observe interaction and performance. How everyday care work is organised and delivered. By obtaining observational data from within each institution on the everyday work of hospital wards, propecia cheapest price their family carers and the nursing and healthcare assistants (HCAs) who carry out this work, we can explore the ways in which hospital organisation, procedures and everyday care impact on care during a hospital admission.

It remedies a common weakness in many qualitative studies, that what people say in interviews may differ from what they do or their private justifications to others.35Data collection (observations and interviews) and analysis were informed by the analytic tradition of grounded theory.36 There was no prior hypothesis testing and we used the constant comparative method and theoretical sampling whereby data collection (observation and interview data) and analysis are inter-related,36 37 and are carried out concurrently.38 39 The flexible nature of this approach is important, because it can allow us to increase the ‘analytic incisiveness’35 of the study. Preliminary analysis of data collected from individual sites informed the focus of later stages of sampling, data collection and analysis in other sites.Thus, sampling requires a flexible, pragmatic approach and purposive and maximum variation sampling (theoretical sampling) was used. This included five hospitals selected to represent a range of propecia cheapest price hospitals types, geographies and socioeconomic catchments. Five hospitals were purposefully selected to represent a range of hospitals types.

Two large university teaching hospitals, two medium-sized general hospitals and one smaller general hospital. This included one urban, two inner city and two hospitals covering a mix of rural and suburban catchment areas, all situated within England and Wales.These sites represented a range of expertise and interventions in caring for people with dementia, from no formal propecia cheapest price expertise to the deployment of specialist dementia workers. Fractures, nutritional disorders, urinary tract and pneumonia40 41 are among the principal causes of admission to acute hospital settings among people with dementia. Thus, we focused observation within trauma and orthopaedic wards (80 days) and propecia cheapest price medical assessment units (MAU.

75 days).Across these sites, 155 days of observational fieldwork were carried out. At each of the five sites, a minimum of 30 days observation took place, split between the two ward types. Observations were carried out by two researchers, each propecia cheapest price working in clusters of 2–4 days over a 6-week period at each site. A single day of observation could last a minimum of 2 hours and a maximum of 12 hours.

A total of 684 hours of observation were conducted for this study. This produced approximately 600 000 words propecia cheapest price of observational fieldnotes that were transcribed, cleaned and anonymised (by KF and AN). We also carried out ethnographic (during observation) interviews with trauma and orthopaedic ward (192 ethnographic interviews and 22 group interviews) and MAU (222 ethnographic interviews) staff (including nurses, HCAs, auxiliary and support staff and medical teams) as they cared for this patient group. This allowed us to question what they are doing and why, and what are the caring practices of ward staff when interacting with people living with dementia.Patients within these settings with a diagnosis of dementia were identified through ward nursing handover notes, patient records and propecia cheapest price board data with the assistance of ward staff.

Following the provision of written and verbal information about the study, and the expression of willingness to take part, written consent was taken from patients, staff and visitors directly observed or spoken to as part of the study.To optimise the generalisability of our findings,42 our approach emphasises the importance of comparisons across sites,43 with theoretical saturation achieved following the search for negative cases, and on exploring a diverse and wide range of data. When no additional empirical data were found, we concluded that the analytical categories were saturated.36 44Grounded theory and ethnography are complementary traditions, with grounded theory strengthening the ethnographic aims of achieving a theoretical interpretation of the data, while the ethnographic approach prevents a rigid application of grounded theory.35 Using an ethnographic approach can mean that everything within a setting is treated as data, which can lead to large volumes of unconnected data and a descriptive analysis.45 This approach provides a middle ground in which the ethnographer, often seen as a passive observer of the social world, uses grounded theory to provide a systematic approach to data collection and analysis that can be used to develop theory to address the interpretive realities of participants within this setting.35Patient and public involvementThe data presented in this paper are drawn from a wider ethnographic study supported by an advisory group of people living with dementia and their family carers. It was this advisory group propecia cheapest price that informed us of the need of a better understanding of the impacts of the everyday care received by people living with dementia in acute hospital settings. The authors met with this group on a regular basis throughout the study, and received guidance on both the design of the study and the format of written materials used to recruit participants to the study.

The external oversight group for this study included, and was chaired, by carers of people living with dementia. Once data analysis was complete, the advisory group commented propecia cheapest price on our initial findings and recommendations. During and on completion of the analysis, a series of public consultation events were held with people living with dementia and family carers to ensure their involvement in discussing, informing and refining our analysis.FindingsWithin this paper, we focus on exploring the medical gaze through the embedded institutional cultures of patient clothing, and the implications this have for patients living with dementia within acute hospital wards. These findings emerged from our wider analysis of our ethnographic study examining ward cultures of propecia cheapest price care and the experiences of people living with dementia.

Here, we examine the ways in which the cultures of clothing within wards impact on the visibility of patients within it, what clothing and identity mean within the ward and the ways in which clothing can be a source of distress. We will look at how personal grooming and appearance can affect status within the ward, and finally explore the removal of clothing, and the impacts of its absence.Ward clothing culturesAcross our sites, there was variation in the cultures of patient clothing and dress. Within many wards, it was typical for all older patients to be dressed in hospital-issued institutional gowns and pyjamas (typically propecia cheapest price in pastel blue, pink, green or peach), paired with hospital supplied socks (usually bright red, although there was some small variation) with non-slip grip soles, while in other wards, it was standard practice for people to be supported to dress in their own clothes. Across all these wards, we observed that younger patients (middle aged/working age) were more likely to be able to wear their own clothes while admitted to a ward, than older patients and those with a dementia diagnosis.Among key signifiers of social status and individuality are the material things around the person, which in these hospital wards included the accoutrements around the bedside.

Significantly, it was observed that people living with dementia were more likely to be wearing an institutional hospital gown or institutional pyjamas, and to have little to individuate the person at the bedside, on either their cabinet or the mobile tray table at their bedside. The wearing of institutional clothing was typically connected to fewer personal items on display or within reach of the patient, with any items tidied away out of sight propecia cheapest price. In contrast, younger working age patients often had many personal belongings, cards, gadgets, books, media players, with young adults also often having a range of ‘get well soon’ gifts, balloons and so on from the hospital gift shop) on display. This both afforded some elements of familiarity, but also marked the person out as someone with individuality and a certain social standing and place.Visibility of patients on a wardThe significance of the obscurity or invisibility of the patient in artworks depicting doctors has been commented on.4 Likewise, propecia cheapest price we observed that some patients within these wards were much more ‘visible’ to staff than others.

It was often apparent how the wearing of personal clothing could make the patient and their needs more readily visible to others as a person. This may be especially so given the contrast in appearance clothing may produce in this particular setting. On occasion, propecia cheapest price this may be remarked on by staff, and the resulting attention received favourably by the patient.A member of the bay team returned to a patient and found her freshly dressed in a white tee shirt, navy slacks and black velvet slippers and exclaimed aloud and appreciatively, ‘Wow, look at you!. €™ The patient looked pleased as she sat and combed her hair [site 3 day 1].Such a simple act of recognition as someone with a socially approved appearance takes on a special significance in the context of an acute hospital ward, and for patients living with dementia whose personhood may be overlooked in various ways.46This question of visibility of patients may also be particularly important when people living with dementia may be less able to make their needs and presence known.

In this example, a whole bay of patients was seemingly ‘invisible’. Here, the ethnographer is observing a four-bed bay occupied by male patients living with dementia.The man propecia cheapest price in bed 17 is sitting in his bedside chair. He is dressed in green hospital issue pyjamas and yellow grip socks. At 10 a.m., the physiotherapy propecia cheapest price team come and see him.

The physiotherapist crouches down in front of him and asks him how he is. He says he is unhappy, and the physiotherapist explains that she’ll be back later to see him again. The nurse checks on him, asks him if he wants a pillow, and puts it behind his head explaining to him, ‘You need to sit in the chair for propecia cheapest price a bit’. She pulls his bedside trolley near to him.

With the help of a Healthcare Assistant they make the bed. The Healthcare Assistant chats to him, puts cake out for him, and puts a blanket over his propecia cheapest price legs. He is shaking slightly and I wonder if he is cold.The nurse explains to me, ‘The problem is this is a really unstimulating environment’, then says to the patient, ‘All done, let’s have a bit of a tidy up,’ before wheeling the equipment out.The neighbouring patient in bed 18, is now sitting in his bedside chair, wearing (his own) striped pyjamas. His eyes are open, propecia cheapest price and he is looking around.

After a while, he closes his eyes and dozes. The team chat to patient 19 behind the curtains. He says he propecia cheapest price doesn’t want to sit, and they say that is fine unless the doctors tell them otherwise.The nurse puts music on an old radio with a CD player which is at the doorway near the ward entrance. It sounds like music from a musical and the ward it is quite noisy suddenly.

She turns down the volume a bit, but it is very jaunty and upbeat. The man in bed 19 quietly sings along propecia cheapest price to the songs. €˜I am going to see my baby when I go home on victory day…’At ten thirty, the nurse goes off on her break. The rest of propecia cheapest price the team are spread around the other bays and side rooms.

There are long distances between bays within this ward. After all the earlier activity it is now very calm and peaceful in the bay. Patient 20 is sitting in the chair tapping propecia cheapest price his feet to the music. He has taken out a large hessian shopping bag out of his cabinet and is sorting through the contents.

There is a lot of paperwork in it which he is reading through closely propecia cheapest price and sorting.Opposite, patient 17 looks very uncomfortable. He is sitting with two pillows behind his back but has slipped down the chair. His head is in his hands and he suddenly looks in pain. He hasn’t touched his tea, and propecia cheapest price is talking to himself.

The junior medic was aware that 17 was not comfortable, and it had looked like she was going to get some advice, but she hasn’t come back. 18 drinks his tea and looks at a wool twiddle mitt sleeve, puts it down, and dozes. 19 has finished all his coffee and manages to put the cup propecia cheapest price down on the trolley.Everyone is tapping their feet or wiggling their toes to the music, or singing quietly to it, when a student nurse, who is working at the computer station in the corridor outside the room, comes in. She has a strong purposeful stride and looks irritated as she switches the music off.

It feels propecia cheapest price like a jolt to the room. She turns and looks at me and says, ‘Sorry were you listening to it?. €™ I tell her that I think these gentlemen were listening to it.She suddenly looks very startled and surprised and looks at the men in the room for the first time. They have all stopped tapping propecia cheapest price their toes and stopped singing along.

She turns it back on but asks me if she can turn it down. She leaves and goes back to her paperwork outside. Once it is turned back on everyone starts tapping their toes again propecia cheapest price. The music plays on.

€˜There’ll be bluebirds over the white cliffs of Dover, just you wait and see…’[Site 3 day propecia cheapest price 3]The music was played by staff to help combat the drab and unstimulating environment of this hospital ward for the patients, the very people the ward is meant to serve. Yet for this member of ward staff the music was perceived as a nuisance, the men for whom the music was playing seemingly did not register to her awareness. Only an individual of ‘higher’ status, the researcher, sitting at the end of this room was visible to her. This example illustrates the propecia cheapest price general question of the visibility or otherwise of patients.

Focusing on our immediate topic, there may be complex pathways through which clothing may impact on how patients living with dementia are perceived, and on their self-perception.Clothing and identityOn these wards, we also observed how important familiar aspects of appearance were to relatives. Family members may be distressed if they find the person they knew so well, looking markedly different. In the example below, a mother and two adult daughters propecia cheapest price visit the father of the family, who is not visible to them as the person they were so familiar with. His is not wearing his glasses, which are missing, and his daughters find this very difficult.

Even though he looks very different following his admission—he has lost a large amount of weight and has sunken cheekbones, and his skin propecia cheapest price has taken on a darker hue—it is his glasses which are a key concern for the family in their recognition of their father:As I enter the corridor to go back to the ward, I meet the wife and daughter of the patient in bed 2 in the hall and walk with them back to the ward. Their father looks very frail, his head is back, and his face is immobile, his eyes are closed, and his mouth is open. His skin looks darker than before, and his cheekbones and eye sockets are extremely prominent from weight loss. €˜I am like a bird I want to fly away…’ plays softly in the radio in the bay propecia cheapest price.

I sit with them for a bit and we chat—his wife holds his hand as we talk. His wife has to take two busses to get to the hospital and we talk about the potential care home they expect her husband will be discharged to. They hope it will be close because propecia cheapest price she does not drive. He isn’t wearing his glasses and his daughter tells me that they can’t find them.

We look propecia cheapest price in the bedside cabinet. She has never seen her dad without his glasses. €˜He doesn’t look like my dad without his glasses’ [Site 2 day 15].It was often these small aspects of personal clothing and grooming that prompted powerful responses from visiting family members. Missing glasses and missing teeth were notable in this regard (and with the follow-up visits from the relatives of discharged patients trying propecia cheapest price to retrieve these now lost objects).

The location of these possessions, which could have a medical purpose in the case of glasses, dental prosthetics, hearing aids or accessories which contained personal and important aspects of a patient’s identity, such as wallets or keys, and particularly, for female patients, handbags, could be a prominent source of distress for individuals. These accessories to personal clothing were notable on these wards by their everyday absence, hidden away in bedside cupboards or simply not brought in with the patient at admission, and by the frequency with which patients requested and called out for them or tried to look for them, often in repetitive cycles that indicated their underlying anxiety about these belongings, but which would become invisible to staff, becoming an everyday background intrusion to the work of the wards.When considering the visibility and recognition of individual persons, missing glasses, especially glasses for distance vision, have a particular significance, for without them, a person may be less able to recognise and interact visually with others. Their presence facilitates the subject of the gaze, in gazing back, and hence helps to ground meaningful propecia cheapest price and reciprocal relationships of recognition. This may be one factor behind the distress of relatives in finding their loved ones’ glasses to be absent.Clothing as a source of distressAcross all sites, we observed patients living with dementia who exhibited obvious distress at aspects of their institutional apparel and at the absence of their own personal clothing.

Some older patients were clearly able to verbalise their understandings of the impacts of wearing propecia cheapest price institutional clothing. One patient remarked to a nurse of her hospital blue tracksuit. €˜I look like an Olympian or Wentworth prison in this outfit!. The latter I expect…’ The staff laughed as they walked propecia cheapest price her out of the bay (site 3 day 1).Institutional clothing may be a source of distress to patients, although they may be unable to express this verbally.

Kontos has shown how people living with dementia may retain an awareness at a bodily level of the demands of etiquette.20 Likewise, in our study, a man living with dementia, wearing a very large institutional pyjama top, which had no collar and a very low V neck, continually tried to pull it up to cover his chest. The neckline was particularly low, because the pyjamas were far too large for him. He continued propecia cheapest price to fiddle with his very low-necked top even when his lunch tray was placed in front of him. He clearly felt very uncomfortable with such clothing.

He continued using his hands to try to pull it up to cover his exposed chest, during and after the meal was finished (site 3 day propecia cheapest price 5).For some patients, the communication of this distress in relation to clothing may be liable to misinterpretation and may have further impacts on how they are viewed within the ward. Here, a patient living with dementia recently admitted to this ward became tearful and upset after having a shower. She had no fresh clothes, and so the team had provided her with a pink hospital gown to wear.‘I want my trousers, where is my bra, I’ve got no bra on.’ It is clear she doesn’t feel right without her own clothes on. The one-to-one healthcare assistant assigned to propecia cheapest price this patient tells her, ‘Your bra is dirty, do you want to wear that?.

€™ She replies, ‘No I want a clean one. Where are my trousers?. I want them, I’ve lost them.’ The healthcare assistant repeats the explaination propecia cheapest price that her clothes are dirty, and asks her, ‘Do you want your dirty ones?. €™ She is very teary ‘No, I want my clean ones.’ The carer again explains that they are dirty.The cleaner who always works in the ward arrives to clean the floor and sweeps around the patient as she sits in her chair, and as he does this, he says ‘Hello’ to her.

She is very teary and explains that she has propecia cheapest price lost her clothes. The cleaner listens sympathetically as she continues ‘I am all confused. I have lost my clothes. I am propecia cheapest price all confused.

How am I going to go to the shops with no clothes on!. €™ (site 5 day 5).This person experienced significant distress because of her absent clothes, but this would often be simply attributed to confusion, seen as a feature of her dementia. This then may solidify propecia cheapest price staff perceptions of her condition. However, we need to consider that rather than her condition (her diagnosis of dementia) causing distress about clothing, the direction of causation may be the reverse.

The absence of her own familiar clothing contributes significantly to her distress and propecia cheapest price disorientation. Others have argued that people with limited verbal capacity and limited cognitive comprehension will have a direct appreciation of the grounding familiarity of wearing their own clothes, which give a bodily felt notion of comfort and familiarity.18 47 Familiar clothing may then be an essential prop to anchor the wearer within a recognisable social and meaningful space. To simply see clothing from a task-oriented point of view, as fulfilling a simply mechanical function, and that all clothing, whether personal or institutional have the same value and role, might be to interpret the desire to wear familiar clothing as an ‘optional extra’. However, for those patients most at risk of disorientation and distress within an unfamiliar environment, it could be a valuable necessity.Personal grooming and social statusIncluding in our consideration of clothing, we observed other propecia cheapest price aspects of the role of personal grooming.

Personal grooming was notable by its absence beyond the necessary cleaning required for reasons of immediate hygiene and clinical need (such as the prevention of pressure ulcers). Older patients, and particular those living with dementia who were unable to carry out ‘self-care’ independently and were not able to request support with personal grooming, could, over their admission, become visibly unkempt and scruffy, hair could be left unwashed, uncombed and unstyled, while men could become hirsute through a lack of shaving. The simple act of a visitor dressing and grooming a patient as they prepared for discharge could transform their appearance and leave that patient looking more alert, appear to having increased capacity, than when sitting ungroomed in their bed or bedside chair.It is important to consider the impact of appearance propecia cheapest price and of personal care in the context of an acute ward. Kontos’ work examining life in a care home, referred to earlier, noted that people living with dementia may be acutely aware of transgressions in grooming and appearance, and noted many acts of self-care with personal appearance, such as stopping to apply lipstick, and conformity with high standards of table manners.

Clothing, etiquette and personal grooming are important indicators of social class and hence an aspect of belonging and identity, and propecia cheapest price of how an individual relates to a wider group. In Kontos’ findings, these rituals and standards of appearance were also observed in negative reactions, such as expressions of disgust, towards those residents who breached these standards. Hence, even in cases where an individual may be assessed as having considerable cognitive impairment, the importance of personal appearance must not be overlooked.For some patients within these wards, routine practices of everyday care at the bedside can increase the potential to influence whether they feel and appear socially acceptable. The delivery of routine timetabled care at the bedside can impact on people’s appearance in ways that may mark them out as failing to achieve propecia cheapest price accepted standards of embodied personhood.

The task-oriented timetabling of mealtimes may have significance. It was a typical observed feature of this routine, when a mealtime has ended, that people living with dementia were left with visible signs and features of the mealtime through spillages on faces, clothes, bed sheets and bedsides, that leave them at risk of being assessed as less socially acceptable and marked as having reduced independence. For example, a volunteer attempts to propecia cheapest price ‘feed’ a person living with dementia, when she gives up and leave the bedside (this woman living with dementia has resisted her attempts and explicitly says ‘no’), remnants of the food is left spread around her mouth (site E). In a different ward, the mealtime has ended, yet a large white plastic bib to prevent food spillages remains attached around the neck of a person living with dementia who is unable to remove it (site X).Of note, an adult would not normally wear a white plastic bib at home or in a restaurant.

It signifies a task-based apparel that is propecia cheapest price demeaning to an individual’s social status. This example also contrasts poignantly with examples from Kontos’ work,20 such as that of a female who had little or no ability to verbalise, but who nonetheless would routinely take her pearl necklace out from under her bib at mealtimes, showing she retained an acute awareness of her own appearance and the ‘right’ way to display this symbol of individuality, femininity and status. Likewise, Kontos gives the example of a resident who at mealtimes ‘placed her hand on her chest, to prevent her blouse from touching the food as she leaned over her plate’.20Patients who are less robust, who have cognitive impairments, who may be liable to disorientation and whose agency and personhood are most vulnerable are thus those for whom appropriate and familiar clothing may be most advantageous. However, we found the ‘Matthew effect’ to be propecia cheapest price frequently in operation.

To those who have the least, even that which they have will be taken away.48 Although there may be institutional and organisational rationales for putting a plastic cover over a patient, leaving it on for an extended period following a meal may act as a marker of dehumanising loss of social status. By being able to maintain familiar clothing and adornment to visually display social standing and identity, a person living with dementia may maintain a continuity of selfhood.However, it is also possible that dressing and grooming an older person may itself be a task-oriented institutional activity in certain contexts, as discussed by Lee-Treweek49 in the context of a nursing home preparing residents for ‘lounge view’ where visitors would see them, using residents to ‘create a visual product for others’ sometimes to the detriment of residents’ needs. Our observations regarding the importance of patient appearance must therefore be considered as part of the care propecia cheapest price of the whole person and a significant feature of the institutional culture.Patient status and appearanceWithin these wards, a new grouping of class could become imposed on patients. We understand class not simply as socioeconomic class but as an indicator of the strata of local social organisation to which an individual belongs.

Those in the lowest classes may have limited opportunities to participate in society, and we observed the ways in which this applied to the people propecia cheapest price living with dementia within these acute wards. The differential impact of clothing as signifiers of social status has also been observed in a comparison of the white coat and the patient gown.4 It has been argued that while these both may help to mask individuality, they have quite different effects on social status on a ward. One might say that the white coat increases visibility as a person of standing and the attribution of agency, the patient gown diminishes both of these. (Within these wards, although propecia cheapest price white coats were not to be found, the dress code of medical staff did make them stand out.

For male doctors, for example, the uniform rarely strayed beyond chinos paired with a blue oxford button down shirt, sleeves rolled up, while women wore a wider range of smart casual office wear.) Likewise, we observed that the same arrangement of attire could be attributed to entirely different meanings for older patients with or without dementia.Removal of clothes and exposureWithin these wards, we observed high levels of behaviour perceived by ward staff as people living with dementia displaying ‘resistance’ to care.50 This included ‘resistance’ towards institutional clothing. This could include pulling up or removing hospital gowns, removing institutional pyjama trousers or pulling up gowns, and standing with gowns untied and exposed at the back (although this last example is an unavoidable design feature of the clothing itself). Importantly, the removal of clothing was limited to institutional gowns and pyjamas and we did not propecia cheapest price see any patients removing their own clothing. This also included the removal of institutional bedding, with instances of patients pulling or kicking sheets from their bed.

These acts propecia cheapest price could and was often interpreted by ward staff as a patient’s ‘resistance’ to care. There was some variation in this interpretation. However, when an individual patient response to their institutional clothing and bedding was repeated during a shift, it was more likely to be conceived by the ward team as a form of resistance to their care, and responded to by the replacement and reinforcement of the clothing and bedding to recover the person.The removal of gowns, pyjamas and bedsheets often resulted in a patient exposing their genitalia or continence products (continence pads could be visible as a large diaper or nappy or a pad visibly held in place by transparent net pants), and as such, was disruptive to the norms and highly visible to staff and other visitor to these wards. Notably, unlike other behaviours considered by staff to be disruptive or inappropriate within these wards such as shouting or crying out, the removal of bedsheets and the subsequent bodily exposure propecia cheapest price would always be immediately corrected, the sheet replaced and the patient covered by either the nurse or HCA.

The act of removal was typically interpreted by ward staff as representing a feature of the person’s dementia and staff responses were framed as an issue of patient dignity, or the dignity and embarrassment of other patients and visitors to the ward. However, such responses to removal could lead to further cycles of removal and replacement, leading propecia cheapest price to an escalation of distress in the person. This was important, because the recording of ‘refusal of care’, or presumed ‘confusion’ associated with this, could have significant impacts on the care and discharge pathways available and prescribed for the individual patient.Consider the case of a woman living with dementia who is 90 years old (patient 1), in the example below. Despite having no immediate medical needs, she has been admitted to the MAU from a care home (following her husband’s stroke, he could no longer care for her).

Across the previous evening and morning shift, she was shouting, refusing all food and care and has received assistance from the specialist dementia care worker propecia cheapest price. However, during this shift, she has become calmer following a visit from her husband earlier in the day, has since eaten and requested drinks. Her care home would not readmit her, which meant she was not able to be discharged from the unit (an overflow unit due to a high number of admissions to the emergency department during a patch of exceptionally hot weather) until alternative arrangements could be made by social services.During our observations, she remains calm for the first 2 hours. When she does talk, she is propecia cheapest price very loud and high pitched, but this is normal for her and not a sign of distress.

For staff working on this bay, their attention is elsewhere, because of the other six patients on the unit, one is ‘on suicide watch’ and another is ‘refusing their medication’ (but does not have a diagnosis of dementia). At 15:10 patient 1 begins to remove her propecia cheapest price sheets:15:10. The unit seems chaotic today. Patient 1 has begun to loudly drum her fingers on the tray table.

She still propecia cheapest price has not been brought more milk, which she requested from the HCA an hour earlier. The bay that patient 1 is admitted to is a temporary overflow unit and as a result staff do not know where things are. 1 has moved her sheets off her legs, her bare knees peeking out over the top of piled sheets.15:15. The nurse in charge says, ‘Hello,’ propecia cheapest price when she walks past 1’s bed.

1 looks across and smiles back at her. The nurse in charge explains to her that she propecia cheapest price needs to shuffle up the bed. 1 asks the nurse about her husband. The nurse reminds 1 that her husband was there this morning and that he is coming back tomorrow.

1 says that he hasn’t been and she does not believe the propecia cheapest price nurse.15:25. I overhear the nurse in charge question, under her breath to herself, ‘Why 1 has been left on the unit?. €™ 1 has started asking for somebody to come and see her. The nurse in charge tells 1 that she needs propecia cheapest price to do some jobs first and then will come and talk to her.15:30.

1 has once again kicked her sheets off of her legs. A social worker comes onto the unit propecia cheapest price. 1 shouts, ‘Excuse me’ to her. The social worker replies, ‘Sorry I’m not staff, I don’t work here’ and leaves the bay.15:40.

1 keeps kicking sheets off her bed, otherwise the unit is quiet propecia cheapest price. She now whimpers whenever anyone passes her bed, which is whenever anyone comes through the unit’s door. 1 is the only elderly patient on the unit. Again, the nurse in charge is heard sympathizing that this is not the right propecia cheapest price place for her.16:30.

A doctor approaches 1, tells her that she is on her list of people to say hello to, she is quite friendly. 1 tells her propecia cheapest price that she has been here for 3 days, (the rest is inaudible because of pitch). The doctor tries to cover 1 up, raising her bed sheet back over the bed, but 1 loudly refuses this. The doctor responds by ending the interaction, ‘See you later’, and leaves the unit.16:40.

1 attempts to talk to propecia cheapest price the new nurse assigned to the unit. She goes over to 1 and says, ‘What’s up my darling?. €™ It’s hard to follow 1 now as she sounds very upset. The RN’s first instinct, like with the doctor and the nurse in propecia cheapest price charge, is to cover up 1 s legs with her bed sheet.

When 1 reacts to this she talks to her and they agree to cover up her knees. 1 is talking about how her husband won’t come and visit propecia cheapest price her, and still sounds really upset about this. [Site 3, Day 13]Of note is that between days 6 and 15 at this site, observed over a particularly warm summer, this unit was uncomfortably hot and stuffy. The need to be uncovered could be viewed as a reasonable response, and in fact was considered acceptable for patients without a classification of dementia, provided they were otherwise clothed, such as the hospital gown patient 1 was wearing.

This is an example of an aspect of care where the choice and autonomy granted to patients assessed as having (or assumed to have) cognitive capacity is not available to people who are considered to have impaired cognitive capacity (a diagnosis of dementia) and carries the additional propecia cheapest price moral judgements of the appropriateness of behaviour and bodily exposure. In the example given above, the actions were linked to the patient’s resistance to their admission to the hospital, driven by her desire to return home and to be with her husband. Throughout observations over this 10-day period, patients perceived by staff as rational agents were allowed to strip down their bedding for comfort, whereas patients living with dementia who responded in this way were often viewed by staff as ‘undressing’, which would be interpreted as a feature of their condition, to be challenged and corrected by staff.Note how the same visual data triggered opposing interpretations of personal autonomy. Just as in the example above where distress over loss propecia cheapest price of familiar clothing may be interpreted as an aspect of confusion, yet lead to, or exacerbate, distress and disorientation.

So ‘deviant’ bedding may be interpreted, for some patients only, in ways that solidify notions of lack of agency and confusion, is another example of the Matthew effect48 at work through the organisational expectations of the clothed appearance of patients.Within wards, it is not unusual to see patients, especially those with a diagnosis of dementia or cognitive impairment, walking in the corridor inadvertently in some state of undress, typically exposed from behind by their hospital gowns. This exposure in itself is of course, an intrinsic functional propecia cheapest price feature of the design of the flimsy back-opening institutional clothing the patient has been placed in. This task-based clothing does not even fulfil this basic function very adequately. However, this inadvertent exposure could often be interpreted as an overt act of resistance to the ward and towards staff, especially when it led to exposed genitalia or continence products (pads or nappies).We speculate that the interpretation of resistance may be triggered by the visual prompt of disarrayed clothing and the meanings assumed to follow, where lack of decorum in attire is interpreted as indicating more general behavioural incompetence, cognitive impairment and/or standing outside the social order.DiscussionPrevious studies examining the significance of the visual, particularly Twigg and Buse’s work16–19 exploring the materialities of appearance, emphasise its key role in self-presentation, visibility, dignity and autonomy for older people and especially those living with dementia in care home settings.

Similarly, care home studies have demonstrated that institutional clothing, designed to facilitate task-based care, can be potentially dehumanising or and distressing.25 26 Our findings resonate with this work, but find that for people living with dementia within a key site of care, the acute ward, the impact of institutional clothing on the individual patient living with dementia, is poorly recognised, propecia cheapest price but is significant for the quality and humanity of their care.Our ethnographic approach enabled the researchers to observe the organisation and delivery of task-oriented fast-paced nature of the work of the ward and bedside care. Nonetheless, it should also be emphasised the instances in which staff such as HCAs and specialist dementia staff within these wards took time to take note of personal appearance and physical caring for patients and how important this can be for overall well-being. None of our observations should be read as critical of any individual staff, but reflects longstanding institutional cultures.Our previous work has examined how readily a person living with dementia within a hospital wards is vulnerable to dehumanisation,51 and to their behaviour within these wards being interpreted as a feature of their condition, rather than a response to the ways in which timetabled care is delivered at their bedside.50 We have also examined the ways in which visual stimuli within these wards in the form of signs and symbols indicating a diagnosis of dementia may inadvertently focus attention away from the individual patient and may incline towards simplified and inaccurate categorisation of both needs and the diagnostic category of dementia.52Our work supports the analysis of the two forms of attention arising from McGilchrist’s work.10 The institutional culture of the wards produces an organisational task-based technical attention, which we found appeared to compete with and reduce the opportunity for ward staff to seek a finer emotional attunement to the person they are caring for and their needs. Focus on propecia cheapest price efficiency, pace and record keeping that measures individual task completion within a timetable of care may worsen all these effects.

Indeed, other work has shown that in some contexts, attention to visual appearance may itself be little more than a ‘task’ to achieve.49 McGilchrist makes clear, and we agree, that both forms of attention are vital, but more needs to be done to enable staff to find a balance.Previous work has shown how important appearance is to older people, and to people living with dementia in particular, both in terms of how they are perceived by others, but also how for this group, people living with dementia, clothing and personal grooming may act as a particularly important anchor into a familiar social world. These twin aspects of clothing and appearance—self-perception and perception by others—may be especially propecia cheapest price important in the fast-paced context of an acute ward environment, where patients living with dementia may be struggling with the impacts of an additional acute medical condition within in a highly timetabled and regimented and unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways. We have seen above, for instance, how behaviour in relation to appearance may be seen as ‘resisting care’ in one group of patients, but as the natural expression of personal preference in patients viewed as being without cognitive impairments. Likewise, personal grooming might impact favourably on a patient’s alertness, visibility and status within the ward.Prior work has demonstrated the importance of the medical gaze for the perceptions of the patient.

Other work has also shown how older people, and in particular people living with dementia, may be thought to be beyond concern for appearance, yet this does not accurately reflect the propecia cheapest price importance of appearance we found for this patient group. Indeed, we argue that our work, along with the work of others such as Kontos,20 21 shows that if anything, visual appearance is especially important for people living with dementia particularly within clinical settings. In considering the task of washing the patient, Pols53 considered ‘dignitas’ in terms of aesthetic values, in comparison to humanitas conceived as citizen values of equality between persons. Attention to dignitas in the form of appearance may be a way of facilitating the treatment by others of a propecia cheapest price person with humanitas, and helping to realise dignity of patients.Data availability statementNo data are available.

Data are unavailable to protect anonymity.Ethics statementsPatient consent for publicationNot required.Ethics approvalEthics committee approval for the study was granted by the NHS Research Ethics Service (15/WA/0191).AcknowledgmentsThe authors acknowledge funding support from the NIHR.Notes1. Devan Stahl (2013) propecia cheapest price. €œLiving into the imagined body. How the diagnostic image confronts the lived body.” Medical Humanities.

Medhum-2012–010286.2. Joyce Zazulak et al. (2017). "The art of medicine.

Arts-based training in observation and mindfulness for fostering the empathic response in medical residents.” Medical Humanities. Medhum-2016-011180.3. E Forde (2018). "Using photography to enhance GP trainees’ reflective practice and professional development." Medical Humanities.

Medhum-2017-011203.4. Caroline Wellbery and Melissa Chan (2014) “White coat, patient gown.” Medical Humanities. Medhum-2013–0 10 463.5. E Goffman (1990a).

Stigma. Notes on the management of spoiled identity, Penguin.6. J Bridges and C Wilkinson (2011). €œAchieving dignity for older people with dementia in hospital.” Nursing Standard 5 (29).7.

J Dancy (1985). Contemporary Epistemology, John Wiley and Sons.8. D McNaughton (1988). Moral Vision.

Blackwell.9. S Weil (1953). Gravity and Grace. U of Nebraska Press.10.

I McGilchrist (2009). The Master and his Emissary. The divided brain and the making of the western world. New Haven and London, Yale University Press.11.

Iain McGilchrist (2011). €œPaying attention to the bipartite brain.” The Lancet 377 (9771). 1068–1069.12. Efrat Tseëlon (1992).

€œSelf presentation through appearance. A manipulative vs a dramaturgical approach”. Symbolic Interaction, 15(4). 501–514.13.

E Tseëlon (1995). The masque of femininity. The presentation of woman in everyday life. London.

Sage.14. E Goffman (1990b). The Presentation of Self in Everyday Life Penguin15. Efrat Tseëlon (2001).

€œFashion research and its discontents”. Fashion Theory, 5 (4). 435–451.16. Julia Twigg (2010a).

€œClothing and dementia. A neglected dimension?. € Journal of Ageing Studies 24(4). 223–230.17.

Julia Twigg and Christina E Buse (2013). €œDress, dementia and the embodiment of identity.” Dementia 12(3). 326–336.18. C.

E Buse and J. Twigg (2015). €œClothing, embodied identity and dementia. Maintaining the self through dress.” Age, Culture, Humanities (2).19.

Christina Buse and Julia Twigg (2018). €œDressing disrupted. Negotiating care through the materiality of dress in the context of dementia.” Sociology of Health &. Illness, 40(2).

340-352.20. PIA C Kontos (2004). Ethnographic reflections on selfhood, embodiment and Alzheimer's disease. Ageing &.

Society, 24(6). 829–849.21. P. C Kontos (2005).

€œEmbodied selfhood in Alzheimer's disease. Rethinking person-centred care.” Dementia 4 (4). 553–570.22. P.

C Kontos and G. Naglie (2007). €œBridging theory and practice. Imagination, the body, and person-centred dementia care.” Dementia 6 (4).

549–569.23. Richard Ward et al. (2016a). €œâ€˜Gonna make yer gorgeous’.

Everyday transformation, resistance and belonging in the care-based hair salon.” Dementia, 15(3). 395–413.24. Richard Ward, Sarah Campbell, and John Keady (2016b). €œAssembling the salon.

Learning from alternative forms of body work in dementia care.” Sociology of Health &. Illness, 38(8). 1287–1302.25. Sonja Iltanen-Tähkävuori, Minttu Wikberg, and Päivi Topo (2012).

Design and dementia. A case of garments designed to prevent undressing. Dementia, 11(1). 49–59.26.

Päivi Topo and Sonja Iltanen-Tähkävuori (2010). €œScripting patienthood with patient clothing.” Social Science &. Medicine, 70(11). 1682–1689.27.

Julia Twigg (2010b). €œWelfare embodied. The materiality of hospital dress. A commentary on Topo and Iltanen-Tähkävuori”.

Social Science and Medicine, 70(11), 1690–1692.28. Kathleen Woodward (2006). €œPerforming age, performing gender” National Women’s Studies Association (NWSA) Journal 18(1). 162–89.29.

K.M Woodward (1999). Introduction. In K.M. Woodward (ed.), Figuring Age.

Women, Bodies and Generations (pp. Ix-xxix). Bloomington. Indiana University Press.30.

M Hammersley and P Atkinson (1989). Ethnography. Principles in practice. London.

Routledge.31. V. J Caracelli (2006). Enhancing the policy process through the use of ethnography and other study frameworks.

A mixed-method strategy. Research in the Schools, 13(1). 84–92.32. W Housley and P Atkinson (2003).

Interactionism, Sage33. M Hammersley (1987) What's Wrong with Ethnography?. Methodological Explorations. London.

Routledge34. V Turner and E Bruner (1986). The Anthropology of Experience New York. PAJ Publications.

2435. K Charmaz and RG Mitchell (2001). €˜Grounded theory in ethnography’ in Atkinson P. (Ed) Handbook of Ethnography, 2001.

160-174. Sage. London36. B Glaser and A Strauss (1967).

The Discovery of Grounded Theory. London. Weidenfeld and Nicholson, 24(25). 288–30437.

Juliet M. Corbin and Anselm Strauss (1990). Grounded theoryrResearch. Procedures, canons, and evaluative criteria.

J Green (1998). Commentary. Grounded theory and the constant comparative method. BMJ (Clinical research ed.), 316 (7137),:1064.39.

Roy Suddaby (2006). €œFrom the editors. What grounded theory is not.” Academy of management journal, 49(4). 633–642.40.

Elizabeth L Sampson et al. (2009). €œDementia in the acute hospital. Prospective cohort study of prevalence and mortality”.

British Journal of Psychiatry,195(1). 61–66. Doi:10.1192/bjp.bp.108.05533541. C Pinkert and B Holle (2012).

€œPeople with dementia in acute hospitals. Literature review of prevalence and reasons for hospital admission”. Z. Gerontol.

Geriatr. 45. 728–734.42. Robert E Herriott and William A.

Firestone (1983) “Multisite qualitative policy research. Optimising description and generalizability”. Education Research 12:14–1943. F Vogt (2002).

€œNo ethnography without comparison. The methodological significance of comparison in ethnographic research” Studies in Education Ethnography 6:23–4244. Benjamin Saunders et al. (2018).

€œSaturation in qualitative research. Exploring its conceptualization and operationalization.” Quality and Quantity 52 (4). 1893–1907.45. A Coffey and P Atkinson (1996).

Making sense of qualitative data. Complementary research strategies. Sage Publications, Inc.46. Paula Boddington and Katie Featherstone (2018).

€œThe canary in the coal mine. Continence care for people with dementia in acute hospital wards as a crisis of dehumanisation”. Bioethics, 32(4). 251–260.47.

Christina Buse et al. (2014). €œLooking “out of place”. Analysing the spatial and symbolic meanings of dementia care settings through dress.” International Journal of Ageing and Later Life 9 (1).

€œThe Matthew effect in science. The reward and communication systems of science are considered.” Science 159 (3810). 56–63.49. Geraldine Lee-Treweek (1997) “Women, resistance and care.

An ethnographic study of nursing auxiliary work” Work, Employment and Society, 11(1). 47–6350. Katie Featherstone et al. (2019b).

€œRefusal and resistance to care by people living with dementia being cared for within acute hospital wards. An ethnographic study” Health Service and Delivery Research51. Katie Featherstone, Andy Northcott, and Jackie Bridges (2019a). €œRoutines of resistance.

An ethnography of the care of people living with dementia in acute hospital wards and its consequences.” International Journal of Nursing Studies.52. K Featherstone, A Northcott, and P Boddington (2020). €œUsing signs and symbols to identify hospital patients with a dementia diagnosis. Help or hindrance to recognition and care?.

€ Narrative Inquiry in Bioethics53. Jeannette Pols (2013). €œWashing the patient. Dignity and aesthetic values in nursing care” Nursing Philosophy, 14(3).

Propecia problems

	Propecia	Proscar
Female dosage	RX pharmacy	On the market
Best way to get	11h	13h
Best place to buy	Not always	Not always
How often can you take	1mg 60 tablet $53.95	5mg 90 tablet $103.95
Can cause heart attack	Online	Online

Farmers and people in rural areas are more comfortable talking about Symbicort turbuhaler price in canada stress and mental health challenges with others, and stigma around seeking help or treatment has decreased in propecia problems rural and farm communities but is still a factor, according to a new research poll from the American Farm Bureau Federation. AFBF conducted the survey of rural adults and farmers/farmworkers to measure changes and trends in stigma, personal experiences with mental health, awareness of information about mental health resources and comfort in talking about mental health with others. The poll results were compared with previous surveys AFBF conducted in 2019 and 2020 focusing on farmer mental health, and the propecia problems impacts of the hair loss treatment propecia on farmer mental health, respectively. €œFarm Bureau has been encouraging conversations to help reduce stigma around farmer stress and mental health through our Farm State of Mind campaign,” said AFBF President Zippy Duvall.

€œThis poll shows that we are making a difference, but we all still have work to do. It’s up to each of us to keep looking out for our family, friends and neighbors and let them know they’re not alone when they feel the increasing stress that comes with the daily business of farming and ranching.” Morning Consult conducted the poll on behalf of AFBF in December 2021 among a national propecia problems sample of 2,000 rural adults. Key findings include. Stigma around seeking help or treatment for mental health has decreased but is still a factor, particularly in agriculture.

Over the past year, there has been a decrease in rural adults saying their friends/acquaintances (-4%) and people in their local community (-9%) attach propecia problems stigma to seeking help or treatment for mental health. But a majority of rural adults (59%) say there is at least some stigma around stress and mental health in the agriculture community, including 63% of farmers/farm workers. Farmers/farm workers are more comfortable talking propecia problems to friends, family and their doctors about stress and mental health than they were in 2019. Four in five rural adults (83%) and 92% of farmers/farm workers say they would be comfortable talking about solutions with a friend or family member dealing with stress or a mental health condition, and the percentage of farmers/farm workers who say they would be comfortable talking to friends and family members has increased 22% since April 2019.

A majority of rural adults (52%) and farmers/farm workers (61%) are experiencing more stress and mental health challenges compared to a year ago, and they are seeking care because of increased stress. Younger rural adults are more likely than older rural adults to say they are experiencing more stress and mental health challenges compared to a year ago, and they are more likely than propecia problems older rural adults to say they have personally sought care from a mental health professional. A slide deck with additional detail on the full survey results is available here. AFBF will be featuring two events focused on farmer mental health at the 103rd AFBF Convention in Atlanta, Georgia.

A panel discussion with Farm Bureau representatives on propecia problems Sunday, Jan. 9, at 10:45 a.m. EST, and a QPR mental health training workshop conducted by AgriSafe that offers farmers and farm families skills to recognize and respond to mental health crises propecia problems using the Question, Persuade and Refer approach, on Monday, Jan. 10, at 2:00 p.m.

EST. If you or someone you propecia problems know is struggling emotionally or has concerns about their mental health, visit the Farm State of Mind website at farmstateofmind.org for information on crisis hotlines, treatment locators, tips for helping someone in emotional pain, ways to start a conversation and resources for managing stress, anxiety or depression. Contact. Mike TomkoDirector, Communications(202) 406-3642miket@fb.org Ray AtkinsonDirector, Communications(202) 406-3717raya@fb.org Return to NewsroomStart Preamble Federal Communications Commission.

Final rule propecia problems. In this document, the Federal Communications Commission (Commission or FCC) requires all covered text providers to support text messaging to 988, the 3-digit dialing code to reach the National Suicide Prevention Lifeline, by July 16, 2022. Given the popularity of propecia problems text messaging, particularly among at-risk populations, it is essential for Americans to be able to text the Lifeline with the same short, easy-to-remember code by which they will be able to call the Lifeline. This rule is effective February 4, 2022.

Start Further Info Start Printed Page 399 Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388, Michelle.Sclater@fcc.gov. End Further Info End Preamble Start Supplemental Information This is a summary propecia problems of the Commission's Second Report and Order (SRO) in WC Docket No. 18-336, adopted on November 18, 2021and released on November 19, 2021. The document is available for download at https://docs.fcc.gov/​public/​attachments/​FCC-21-119A1.pdf.

To request materials in accessible formats for people with propecia problems disabilities (Braille, large print, electronic files, audio format), send an email to FCC504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at 202-418-0530 (voice), 202-418-0432 (TTY). Synopsis I. Second Report and Order A propecia problems.

Text-to-988 Will Save Lives 1. We conclude propecia problems that requiring covered text providers to support text-to-988 will save lives. No commenter in the record opposes adoption of a text-to-988 requirement. As Americans become more reliant on texting to communicate, the need to access mental health assistance and resources by text is essential.

Text messaging to the propecia problems Lifeline will facilitate access to critical mental health resources for all, and particularly for at-risk populations who tend to prefer communicating through text rather than phone calls. 2. The record reflects overwhelming support for the conclusion that text-to-988 functionality will greatly improve consumer access to the Lifeline. Over 14 National Alliance on Mental Illness (NAMI) offices across the United States filed in support propecia problems of text messaging to 988.

Substance Abuse and Mental Health Services Administration (SAMHSA), the Government agency responsible for overseeing the Lifeline, states that texting capability would improve equitable access to the Lifeline, especially for at-risk communities. And Vibrant, the administrator of the Lifeline, also notes that “text-to-988 capability would improve consumer accessibility to the Lifeline and save lives.” Mental Health America suggests that “[i]f 988 is implemented without support propecia problems for text messaging, individuals in need of mental health crisis services, particularly youth and adolescents, will remain unanswered.” A bipartisan group of U.S. Representatives from Colorado express their support, stating that “[b]y allowing a text-to-988 option in addition to voice call, the Commission can lower the bar to entry and improve access to crisis counseling and mental health services.” Text-to-988 will provide greater access to anyone who is not comfortable calling the Lifeline or cannot make a phone call. For instance, individuals who are in abusive or controlling situations may feel safer texting than making a verbal call when in a crisis.

Similarly, for individuals who are helping someone who is experiencing symptoms such as paranoia or delusions and appears threatening, texting offers greater propecia problems safety when reaching out for crisis assistance. 3. The record also demonstrates that requiring covered text providers to support text-to-988 functionality will provide significant benefits to at-risk populations, particularly to young Americans who are disproportionately at risk for mental health crises. Research shows that serious psychological distress, major depression, and suicidal thoughts and propecia problems attempts among adolescents and young adults have increased significantly in recent years.

SAMHSA explains that individuals who send texts or online chats to the Lifeline both skew younger and are more likely to experience current suicidal ideation relative to the categories of individuals who typically access the Lifeline via phone. Nearly 95% of teens have access to smart phones and report that texting is the primary way by which propecia problems they connect. According to Mental Health America, “[m]ultiple sources of data demonstrate youth prefer communicating by text rather than calls,” including a study finding that young people “were more likely to forgo psychological support than talk in person or over the phone.” Nevada, which conducted one of the country's first text messaging for crisis response pilot programs, TextToday, found an increase in help-seeking behaviors by youth as a result of the program and a preference for texting among the youth age cohort. Some members of at-risk populations may prefer or find it easier to access the Lifeline via text as compared to the online chat portal, which requires people to have internet access, find the website, and locate the chat portal.

A survey addressing how teens are propecia problems coping and connecting during hair loss treatment reported that 65% of teens used texting to communicate with friends and family more than usual in response to the propecia. 4. In addition to young Americans, text-to-988 will help other American communities that are disproportionately impacted by suicide, including Veterans, LGBTQ+ individuals, racial and ethnic minorities, and rural Americans. Death by suicide amongst Veterans has steadily increased over the past several propecia problems years.

Furthermore, the suicide rate has risen faster among Veterans than it has for non-Veteran adults. LGBTQ+ youth are nearly five times as likely to have attempted suicide compared to heterosexual youth, and the suicide rate for Black children ages 5-12 is about two times higher compared to white children. The record indicates that these at-risk communities may use text services at higher rates than other communities propecia problems. For example, NAMI reports that people of color text at a higher rate than white individuals, and lower-income households send twice as many texts than households with higher incomes.

Mental Health America notes that data they collected demonstrate that individuals “who identify as Black or African American are more likely to propecia problems report that they would like to receive a phone number they can immediately call or text for help” than members of any other race or ethnicity. Individuals from communities, religious groups, or ethnic backgrounds that have been found to have lower professional help-seeking behaviors or whose communities are less typically accepting of mental health treatment will also benefit from the added privacy of seeking crisis support via text. 5. Text messaging has also propecia problems become a crucial form of communication for people who are deaf, hard of hearing, or have other disabilities that impact communication.

Studies find an increased risk of suicide among deaf and hard of hearing people when compared to those without hearing loss. These individuals have increasingly adopted widely available text messaging platforms in lieu of specialized legacy devices, such as text telephones (TTY), because of the ease of access, wide availability, and practicability of modern text-capable devices. Some individuals with propecia problems disabilities find it more effective to access mental health support through text messaging over other means of communications. Vibrant notes that for individuals in the disability community, the ability to text crisis services directly, without need for an intermediary interpreter or service, provides “substantial benefit.” SAMHSA highlights the convenience texting would provide to people with autism spectrum disorder (ASD), who are at an increased risk for suicide, yet may have “difficulties with back and forth conversations, and may therefore prefer to text rather than call the Lifeline.” Access to communications capabilities for individuals with disabilities is a longstanding Commission priority and statutory obligation.

Our requirement to support propecia problems Start Printed Page 400 text-to-988 broadens access to 988 and helps ensure individuals with disabilities that impact communication can more easily reach lifesaving resources. 6. The Commission's designation of 988 as the 3-digit telephone number for the Lifeline reflected its expectation that a simple, easy-to-remember, 3-digit dialing code for suicide prevention and mental health crisis counseling would “help increase the effectiveness of suicide prevention efforts, ease access to crisis services, reduce the stigma surrounding suicide and mental health conditions, and ultimately save lives.” We conclude that providing text access at the same short code number will generate synergies that enhance the value of efforts to promote 988. We are also mindful that the promotion and availability of the 988 short code for telephone calls to the Lifeline crisis hotline, propecia problems and by extension the Veterans Crisis Line, could create confusion as to whether that number is available for, and capable of, receiving text messages.

We find that requiring providers to implement text-to-988 will also help to avoid confusion or putting lives at risk. B. Designating a propecia problems Wholly Unique 3-Digit Dialing Code vs. An Existing N11 7.

We adopt our propecia problems proposed two-step process to establish the scope of text messages that fall within our text-to-988 requirement (86 FR 31404, June 11, 2021). While we acknowledge the importance of testing and coordination between covered text providers and the Lifeline, we decline at this time to adopt the Department of Veterans Affairs' (VA's) proposed “third-step” to our scope of text messages because the proposed testing and validation process is not germane to ex ante defining the scope of covered text providers. First, we establish an outer bound definition of “988 text message” that sets the maximum possible scope of text formats which covered text providers may be obligated to support for delivery to 988, based on the definition of “text message” that Congress enacted in 2018 in the Truth in Caller ID context. Second, we establish a process to ensure that covered text providers only must enable transmission of text messages in formats that the propecia problems Lifeline can actually receive.

We also define the scope of entities subject to our text-to-988 requirements— i.e., “covered text providers”—to be consistent with our text-to-911 rules, which include Commercial Mobile Radio Services (CMRS) providers and providers of interconnected text messaging services. We find that this approach, in combination, provides a forward-looking, flexible scope that will expand with the capabilities of the Lifeline without unnecessarily obligating covered text providers to support formats that the Lifeline cannot yet receive. 1 propecia problems. Scope of Covered Text Formats 8.

Outer Bound Definition propecia problems. Consistent with our proposal in the further notice of proposed rulemaking (FNPRM) (86 FR 31404, June 11, 2021), we adopt the Truth in Caller ID definition of “text message”—including the definitions for “short message service” (SMS) and, as a requirement when Lifeline is able to support it, “multimedia message service” (MMS)—as the outer bound scope of text messages that covered text providers may be obligated to transmit to 988, which provides that the term (1) means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number or N11 service code. (2) includes a SMS message and a multimedia message service (commonly referred to as `MMS') message. And (3) propecia problems does not include—(i) a real-time, two-way voice or video communication.

Or (ii) a message sent over an internet protocol (IP)-enabled messaging service to another user of the same messaging service, except a message described in clause (2). 9. We find that there are several propecia problems advantages to adopting the Truth in Caller ID definition in the text-to-988 context. The definition encompasses, but is not exclusive to, SMS and MMS messages without limiting the outer bounds of supported text formats to specific technologies, thus providing flexibility for inclusion of future text message formats under the rules.

It also represents a recent definition provided by Congress, albeit in a different policy context. We slightly modify the Truth in Caller ID definition to account for the 988 context by adopting our proposal to add “or 988” to the phrase from the Truth in Caller ID definition “10-digit telephone number or N11 service code.” This modification will ensure that covered text propecia problems providers' obligations encompass those text messages sent to the Lifeline via the 3-digit code 988. We also add language clarifying that the definition we adopt “includes and is not limited to” SMS and MMS messages. This addition clarifies that the word “includes,” within the definition we adopt, does not limit propecia problems the scope of messages meeting the first prong of the definition and instead merely eliminates doubt as to whether SMS and MMS meet that definition.

This clarification advances our policy goal of promoting availability of a broad range of communications methodologies for individuals reaching the Lifeline. Further, we think this clarification follows the canon of avoiding rendering language a nullity—if the definition included only SMS and MMS, the first provision would be unnecessary. 10. We decline to adopt the text-to-911 text message definition, as recommended by CTIA and T-Mobile.

The Truth in Caller ID definition is more recent than the text-to-911 text message definition, and it derives from Congress. The Truth in Caller ID definition expressly identifies that it includes images and sound. Allowing the parties that operate the Lifeline to incorporate graphics or other rich media in addition to textual communications, if they choose to do so, offers members of at-risk communities the means to communicate flexibly and fully with the Lifeline. Furthermore, the limitation of the initial implementation requirement to SMS messages, as discussed below, addresses CTIA and T-Mobile's concerns about meeting the implementation deadline if the Commission were to immediately require implementation of other text formats.

The annual review process we establish below, through which the Wireline Competition Bureau (Bureau) will require covered text providers to implement only those texting formats within the outer bound definition that the Lifeline can actually receive, will ensure that covered text providers are not burdened with unnecessary work, and will avoid any consumer confusion that would arise from implementing formats that cannot go through. 11. We clarify that the exclusions we adopt from the “988 text message” definition match those exclusions contained in the Truth in Caller ID “text message” definition. We therefore exclude “real-time, two-way voice or video communication[s],” as well as messages sent over “IP-enabled messaging service[s] to another user of the same messaging service” that are not SMS or MMS messages.

Similar to the Commission's interpretation in the Truth in Caller ID Second Report and Order (84 FR 45669, August 30, 20219), we conclude that “real-time, two-way voice or video communication” includes voice calling service. We find that the plain language of the Truth in Caller ID exclusion indicates that Congress explicitly intended to exclude real-time, two-way video communication from the definition of “text message. We further “interpret the latter exclusion to include non-MMS or SMS messages sent using IP-enable Start Printed Page 401 messaging services” between users of the same service. For example, a message transmitted via an application delivered over IP-based networks, such as Twitter or LinkedIn, to another user of the same messaging service would be excluded from the outer bound definition.

12. We decline the Consumer Electronics Association's (CEA's) request to affirmatively determine at this time what particular text messaging formats fit within the outer bound definition. We direct the Bureau to resolve questions concerning the scope of the outer bound during the annual review process by applying the statutory Truth in Caller ID definition and Commission precedent regarding that definition. We clarify that should the Bureau find in the future based on the record before it that rich communications service (RCS), real-time text (RTT), or other formats do not fall within the exclusions from the 988 text message definition, then they may be acceptable formats within the outer bound scope.

We anticipate that addressing scope issues as they arise, in the context of specific technologies, will lead to better decisions based on more detailed information than trying to decide well ahead of any specific issue arising. 13. Limitation to Currently-Employed Technology. As proposed in the FNPRM, we initially require that covered text providers only support transmission of SMS messages to 988.

We adopt the proposed procedure delegating to the Bureau future determinations to require covered text providers to support additional text formats within the outer bound definition, in consultation with our Federal partners and in consideration of what text formats the Lifeline is capable of receiving. We therefore define “covered 988 text message” as a 988 text message in SMS format and any other format that the Wireline Competition Bureau has determined must be supported by covered text providers. 14. The record supports requiring transmission of texts to 988 in SMS format.

Vibrant indicates that the Lifeline can currently receive and respond to SMS messages sent to the 10-digit number. Furthermore, representatives of covered text providers and public interest groups express support for requiring transmission of SMS messages to 988. In their support for adoption of requirements based on the Commission's text-to-911 rules, CTIA and T-Mobile note the technical feasibility of supporting SMS messages to 988, given that that format is currently supported in texting to 911. CEA also argues that the Commission should, at a minimum, require transmission of text messages in SMS within its broader outer bound definition.

Because there is no technical or operational impediment to transmitting SMS messages to 988 expressed by covered text providers, and the Lifeline is currently able to receive and respond to SMS messages, we require covered text providers to support SMS messages to 988. 15. We decline at this time to require covered text providers to support other text message formats, such as MMS, RCS, and RTT, because the Lifeline cannot currently receive texts in these formats. The Bureau will consider requiring covered text providers to support these or other additional formats through the Public Notice process we discuss below, should the Lifeline indicate it can receive such formats.

While commenters note that rich media communications and next-generation text formats may offer benefits to individuals attempting to access the Lifeline, requiring covered text providers to transmit messages in these formats is premature because we do not know if or when the Lifeline will accept these formats. In addition, as CTIA states, including additional text formats such as RTT and RCS in the scope of our text-to-988 requirements “would cause consumer confusion when the Lifeline is only capable of receiving SMS messages today” and, due to technical and engineering obstacles, would likely delay implementation of text-to-988 service. Finally, with respect to multimedia messages, both the Alliance for Telecommunications Industry Solutions (ATIS) and CTIA note that including media in text messages, a feature not currently supported in text-to-911 service, would present technical obstacles that could impede implementation by the July 16, 2022, deadline that we adopt. Although Vibrant indicates that the Lifeline is technically capable of receiving MMS formats, it clarifies that Lifeline policy and clinical standards “currently block[ ] images and video from being seen by the counselor.” Because of the impediments to transmitting media such as images and video with text to 988, we decline to require covered text providers to support MMS messages to 988.

16. Just as our Federal partners recently added a texting capability to the Lifeline, they may choose to expand the functionality of their texting service over time. It is important for the requirements we establish to keep pace flexibly and readily rather than resorting to a Commission-level proceeding every time the Lifeline can accept a new text format. We therefore direct the Bureau to routinely consult with our Federal partners at SAMHSA and the VA to determine when the Lifeline has implemented a new text message format to 988.

We further direct the Bureau, on or before June 30, 2023, and no less frequently than annually thereafter, to propose and seek comment on implementation parameters for covered text providers to transmit any additional text message formats to 988 that the Lifeline is capable of receiving and that are within the scope of the outer bound message definition adopted herein. The Bureau shall identify the additional text messaging format(s) that the Lifeline is capable of receiving, if any. Propose and seek comment on an interpretive determination as to whether the additional text message format(s) fall within the outer bound definition. And propose and seek comment on implementation deadline(s) for those additional text message formats.

If the Bureau finds after this process that the Lifeline is capable of receiving an additional text format that is within the scope of the outer bound definition that we have established, it shall release a second Public Notice requiring covered text providers to implement text-to-988 using that new format and setting an implementation date that is as prompt as reasonably practical. If the Bureau instead finds that, notwithstanding its initial proposal, the Lifeline is not capable of receiving an additional text format that is within the scope of the outer bound that we have established, it shall issue a Public Notice declining to adopt its initial proposal. The Bureau may set one implementation deadline or staggered implementation deadlines for different classes of providers, and it shall identify all implementation deadlines with certainty ( i.e., by a specified calendar date). In setting a deadline or deadlines for compliance, the Bureau shall assess factors such as technical and financial challenges with respect to implementation, the status of the Lifeline, and the public interest.

We find our two-step approach allows us to ensure rapid support for additional texting formats as technology evolves, while providing certainty to the industry and the public. Further, we find this approach facilitates further updates when the Lifeline implements a new texting format without requiring a Commission rulemaking, which often requires more time than Bureau-level action. Accordingly, we direct the Bureau to implement the approach we describe above, including through prescribing implementation deadlines. Start Printed Page 402 17.

CEA supports the Commission's proposal but asks for the Bureau to conduct annual public hearings rather than develop a written record. We find the proposed Public Notice procedure achieves the same purpose as a public hearing—providing a forum to establish a record regarding expansion of the covered 988 text message definition—while imposing fewer administrative burdens and costs on the public and the Commission. We expect the Bureau to meet with interested parties, as permitted by the Commission's ex parte rules. 18.

We decline to adopt CEA's proposals to bypass our Public Notice procedure and automatically include MMS, RCS, or RTT within the scope of covered 988 text messages if and when the Lifeline is ready to accept those new texting formats. We think the Public Notice process is valuable because it will allow the Bureau to gather information to set appropriate technology-specific implementation deadlines and to evaluate whether a given technology fits within the outer scope of the definition of 988 text message we adopt herein. It also provides the Bureau time to facilitate dialogue between parties should any complications arise. We are concerned that automatic inclusion of certain formats in the future could lead to avoidable problems, and we therefore decline CEA's suggestion.

19. We also decline CEA's proposal that, should the Bureau or Commission require inclusion of RCS, RTT, or any other format, covered text providers would be required to support the new format “by the later of (i) three months after the Lifeline states that it is ready to receive such format. Or (ii) the date upon which the affected covered text provider begins providing such texting format to its customers generally.” We find it best to grant the Bureau flexibility to determine an implementation timeframe appropriate to each technology the Lifeline may implement. We prefer this approach because the Bureau will be able to make a decision based on a thorough record focused on the Lifeline's actual implementation of the technology.

We anticipate that some technologies such as RTT that are already generally in use may be easier for covered text providers, especially larger providers, to support if implemented by the Lifeline, and we encourage the Bureau to take ease of implementation and availability of the technology into account when reaching a determination. 20. We decline requests from CEA and ZP Better Together (ZP) to require direct video communication (DVC) and direct dialing from video relay service (VRS) to 988. With respect to VRS, ZP believes that by dialing 988 directly, both a Lifeline counselor and a VRS communications assistant would show up simultaneously.

We are not addressing ZP's VRS request at this time because direct 988 dialing for VRS is beyond the scope of this item, which is focused on text-to-988. With respect to DVC, we strongly encourage the development and implementation of direct communications solutions for individuals with disabilities. However, the Lifeline does not receive direct communications via video. Requiring providers to support communications that the Lifeline is not currently capable of receiving would cause consumer confusion, as individuals in crisis may attempt to access the Lifeline via direct video communications without realizing that the Lifeline cannot answer.

We are pleased that the Lifeline is available to users of telecommunications relay services, including via 988, and the Lifeline maintains a separate TTY number, and we encourage our Federal partners to continue to consider additional alternative means by which individuals with disabilities may contact the Lifeline. Users of speech-to-speech services and TTY-based TRS dial 711 first to connect to a communications assistant who will complete the call to the Lifeline. 2. Definition of “Covered Text Provider” 21.

We adopt our proposed definition of “covered text providers” as that term is defined in the Commission's text-to-911 rules, to include “all CMRS providers, as well as providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones.” We find that the straightforward and well-established definition from the 911 context best delineates the scope of covered text providers obligated to support text-to-988 service. 22. The record supports our proposal to adopt the text-to-911 definition of “covered text provider” here.

CTIA encourages us to keep the text-to-988 scope consistent with the scope of covered text providers in the text-to-911 context in order to “identify a well-known and experienced scope of providers who will need to work collaboratively with the Lifeline to achieve the aggressive deadline that CTIA and others have suggested.” T-Mobile similarly agrees with CTIA that the Commission should look to its text-to-911 rules when establishing the scope of covered text providers in the text-to-988 context. And, as CTIA notes, no commenter suggests an alternative definition to our proposal. 23. We require interconnected text messaging service providers, which enable customers to “send text messages to all or substantially all text-capable U.S.

Telephone numbers and receive text messages from the same,” to support text-to-988 service. We decline to apply our requirements to non-interconnected text providers, as CEA suggests. By definition, non-interconnected text providers cannot send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, meaning they are unlikely to be able to transmit texts to and receive texts from 988.

Even non-interconnected text providers that use telephone numbers—for instance where an application uses telephone numbers to identify users relative to each other rather than for routing—may nonetheless be unable to send text messages to users of other services or to all or substantially all telephone numbers. Obligating non-interconnected text providers to attempt to route texts to 988 via telephone numbers when physical routing is beyond such providers' control could increase customer confusion or diminish public trust in texting as a means to reach the Lifeline. 24. Voice on the Net (VON) and Mitel request that we exempt covered text providers in Wi-Fi only locations because “there remain challenges to the reliability of routing text messages to interconnected networks without the benefit of a CMRS provider.” We decline at this time to adopt a blanket exemption for covered text providers in Wi-Fi only locations.

While we anticipate interconnected text messaging service providers will typically use CMRS-based solutions to support text-to-988, CMRS networks are not the only means of interconnection, and covered text providers may use any reliable method or methods to support text routing and transmission to 988. Furthermore, neither VON nor Mitel elaborate on or provide evidence to support their claims of technical challenges associated with routing without access to a CMRS network, or that such challenges cannot be bypassed by adopting a non-CMRS solution. While we agree with Mitel that “[r]outing messages to the interconnected network often requires access to an underlying wireless network or provider,” commenters have not provided sufficient support for us to Start Printed Page 403 conclude that covered text providers in Wi-Fi only locations are never able to use a CMRS-based or alternative method to reliably support text routing and transmission to 988. We reiterate that our requirements exclude providers that are unable to allow consumers to send text messages to and receive text messages from all or substantially all text-capable U.S.

Telephone numbers. C. Routing Texts to 988 25. We adopt our proposal to require covered text providers to route covered 988 text messages to the Lifeline's current 10-digit number, 1-800-273-8255 (TALK).

Our decision is consistent with the Commission's approach in the 988 Report and Order (85 FR 57767, September 16, 2020) to require service providers to “transmit all calls initiated by an end user dialing 988 to the current toll free access number for the Lifeline.” Most commenters support centralized routing for text-to-988. 26. We find our centralized routing rule will allow for swift implementation of text-to-988 to the Lifeline's 10-digit number by lowering technical requirements and costs for covered text providers to route texts to the Lifeline. As Vibrant states, our centralized routing solution for text-to-988 will “allow[] for a seamless delivery of crisis intervention services that is consistent with clinical standards, best practices, and national guidelines overseen by the administrator and SAMHSA.” CTIA notes that by requiring centralized routing, “the Commission can significantly lower technical hurdles to enable wireless providers to deploy text-to-988 as soon as possible.” ATIS “has not identified any technical challenges associated with” routing covered 988 texts to the Lifeline 10-digit number.

We note that several wireless providers were able to implement routing calls to 988 within six months of adoption, and we anticipate that similarly swift implementation may be possible here. 27. We also find that adopting our proposal will provide our Federal partners with the flexibility to develop and expand routing solutions to meet the Lifeline's needs. Once text messages are routed to the Lifeline's 10-digit number, the Lifeline can then “forward those messages to the appropriate local crisis center,” similar to the current mechanism for voice call routing to 988.

Currently, the Lifeline's network consists of over 180 crisis centers, with 33 centers providing text service. SAMHSA has identified resource strain and capacity issues experienced during its rollout of text service to the Lifeline's 10-digit number and, as a result, indicates its intention to explore working with existing crisis text and chat services outside the Lifeline as well as expanding text capacity within the network. We encourage SAMHSA and the VA to work with outside entities as needed to meet increased demand, and we believe our centralized routing rule will better allow for the Lifeline's network to adapt, evolve, and expand as necessary to meet capacity and technological needs. 28.

We decline to require covered text providers to route covered 988 text messages directly to a Lifeline local crisis center or Veterans Crisis Line crisis center. While text-to-911 uses such direct routing, we believe that approach would be counterproductive for text-to-988. We disagree with Intrado's proposal to leverage the existing text-to-911 infrastructure by using Intrado's Text Control Center (TCC) services to transmit texts to 988 directly to an individual local crisis center, once the crisis center has made a valid request for text-to-988 service. This proposal mirrors the text-to-911 rules, where a covered text provider must enable text-to-911 service within six months of a local Public Safety Answering Point's (PSAP's) valid request for service.

We are concerned that implementation of a localized routing model would be time-consuming, contrary to our goal of making text-to-988 rapidly available to all Americans. CTIA and T-Mobile point to specific technical and administrative challenges should the Commission require covered text providers to route texts to 988 to local crisis centers, which would compromise swift implementation by the July 16, 2022, date. ATIS, T-Mobile, and VON also note routing to the local crisis centers would require the adoption of new technical standards and specifications, including the development of intermediate gateway providers at regional centers, which could increase costs and delay launch of text-to-988. Requiring delivery of texts to 988 to individual crisis centers could impede the Lifeline network's future expansion, as covered text providers would need to implement text routing to each new center to ensure that the community served by that center can communicate via text if desired, as opposed to immediate nationwide access through centralized routing.

Furthermore, as CTIA points out, “Intrado fails to explain why texts to 9-8-8 should be routed differently from voice calls to 9-8-8.” We see no difference between voice and text service to the Lifeline presented in the record that would justify adopting alternate routing infrastructures for either service. In contrast, there are significant differences between 988 and 911, chief among them the nationwide Lifeline voice and text service routed through a centralized, toll free 10-digit number as opposed to the localized PSAP network. 29. We find that it is premature to require covered text providers to enable covered 988 text messages to include location information.

As instructed by Congress in the National Suicide Hotline Designation Act of 2020, in April 2021 the Bureau released a report on the costs and feasibility of providing location information with calls to 988. In the report, the Bureau recommended the establishment of a multi-stakeholder advisory committee to develop detailed recommendations on how to address several challenges presented in the record, including privacy considerations, technical implementation, and cost recovery. NAMI and Vibrant reiterate arguments raised in the 988 Geolocation Report that requiring geolocation information with calls and texts to local crisis centers will improve accuracy in connecting individuals in crisis with counselors who are in the best position to provide localized care. Yet, as the Bureau identified in the 988 Geolocation Report, requiring providers to transmit location information to 988 “raises important privacy and legal issues, is technically complex, and could impose significant costs.” Several commenters, including ATIS and CTIA, highlight the challenges identified in the 988 Geolocation Report and oppose a location information requirement for text-to-988, indicating it would be premature for the Commission to adopt such a mandate without further study and standards development.

Given the similar complexity and interrelation between call and text routing to 988, we decline, at this time, NAMI and Vibrant's requests to require location information with texts transmitted to 988. Commenters also raise privacy concerns should the Commission require the transmission of location information without the texter's consent. Given the Bureau's recommendation and the similar concerns raised in the record regarding technical limitations of providing location information, we decline, at the present time, to require covered text providers to include location information with texts to 988. 30.

We also decline to require covered text providers to take action to route texts to 988 to the Veterans Crisis Line, and we instead defer to our Federal partners to determine whether and how to make it possible to text 988 for the Start Printed Page 404 Veterans Crisis Line's text service. Telephone callers to the Lifeline's 10-digit number can press “1” to connect directly with a crisis counselor at the Veterans Crisis Line. Texting, on the other hand, is not presently integrated—texters who wish to reach the Veterans Crisis Line contact a text short code (838255) rather than the Lifeline's toll free 10-digit number. We recognize that there would be significant benefits to enabling texters to reach the Veterans Crisis Line by texting 988.

At the same time, we recognize the critical need for carefully developing a pilot program and extensively testing the transfer of texts between 988 and the Veterans Crisis Line to ensure that no Service Member, Veteran, or family member is left without access to lifesaving resources. Any rush to enable texting 988 for the Veterans Crisis Line's text service before sufficient implementation work and testing would raise safety concerns, should any text conversations be dropped or lost in transfer. We believe our Federal partners at the VA and SAMHSA are best positioned to evaluate the benefits, challenges, and costs of transferring texts and to pursue a solution, if desirable. We agree with ATIS that use of 988 “makes it infeasible to automatically route calls to one service or the other” without additional information, such as through a secondary input exchange, to enable providers to correctly route the text to the proper recipient.

There is no record support for Commission action to require providers to selectively route texts to 988 to the Veterans Crisis Lifeline's text service. Nor does the record reveal any solutions for requiring providers to implement texting to 988 for the Veterans Crisis Line's text service that we could effectuate in conjunction with requiring providers to implement texting to 988 for the Lifeline. After evaluation and testing, our Federal partners may be able to pursue a workable, reliable approach to enabling texts to 988 to reach the Veterans Crisis Line. At the present time, Service Members, Veterans, and their families may reach the Veterans Crisis Line by calling 1-800-273-8255 and pressing 1, by texting 838255, or by chat through the Veterans Crisis Line's website, https://www.veteranscrisisline.net.

We recognize that during the rollout and launch of 988, our Federal partners at the VA will face challenges in promoting widespread public awareness that the Veterans Crisis Line is reachable by text through a short code that is separate from 988. We direct Commission staff to work cooperatively with our Federal partners to promote awareness of how Service Members, Veterans, and their families can reach the Veterans Crisis Line. D. Implementation Timeframe 31.

We adopt our proposal to set a uniform nationwide implementation deadline for text-to-988 of July 16, 2022—concurrent with 988's voice implementation deadline—for all covered text providers to support transmission of all covered 988 text messages. As stated above, this deadline applies only to texts the user sends to 988. It does not apply to texts to the Veterans Crisis Line using its existing short code. Guiding our decision is the need to minimize the time needed to implement text-to-988 so as to help address the growing epidemic of suicide as quickly as possible.

By setting a uniform deadline, rollout of text-to-988 will be most effective, enabling stakeholders to clearly and consistently communicate when the public can access texting services universally, while avoiding any confusion stemming from a different deadline than voice implementation. Although a phased-in approach may enable us to set a shorter deadline for some providers, this approach risks confusion not just among those “unaware of the details of staggered regulatory deadlines,” but also among those who may seek to call rather than text. Such a scenario “could be disastrous for individuals and, in the aggregate, could erode trust in the Lifeline.” Further, we find that a July 16, 2022, deadline provides the Lifeline adequate time to prepare for additional texting volume, with Vibrant expressing confidence following its successful 2021 pilot program that “the Lifeline has the capability to receive text-to-988 messages on the first day of 988 operation.” And as ATIS highlights, because we only require that covered text providers send text messages to the Lifeline's 10-digit number, the need for a phased approach is eliminated. 32.

We specifically set a deadline of July 16, 2022, which nearly all commenters who address timing support. Just as we concluded previously with respect to 988 implementation for voice calls, we set as early of a deadline as possible because of the numerous benefits of swift implementation in preventing suicide. As explained above, providers need not route calls to individual call centers, eliminating the need for lengthy development of new technical standards and specifications. Some providers themselves also support a July 16, 2022, deadline as providing sufficient time for implementation.

Setting a deadline for text-to-988 that matches the existing deadline for implementing calls to 988 also avoids public confusion and enhances the efficacy of marketing campaigns promoting 988. As the Mental Health Associations state, “[d]elaying an implementation deadline [beyond July 2022] will not prevent people in crisis from reaching out to 988 through text,” and such individuals will find their “[r]equest for help will go unanswered” without action in this proceeding. 33. We reject VON's arguments that we should set a deadline of 12 months following the effective date of the order due to “[t]he need to develop and implement new routing and technical standards” that may pose challenges to meeting the voice deadline of July 16, 2022.

Specifically, VON compares the Lifeline's call centers to PSAPs, explaining how in the context of text-to-911, a new joint standard needed to be created in order to direct texts to the latter. However, as explained above, we do not require that providers route texts to individual call centers, but instead to the Lifeline's toll free 10-digit number. Additionally, VON cites these potential challenges only in vague terms, and claims only that they “might” serve as obstacles to “meeting the voice deadline of July 16, 2022.” Moreover, as explained below, the flexible text-to-988 rules we adopt in this document do not generate significant technical obstacles, and the record's support for a July 16, 2022, deadline suggests that the issues pertinent to a texting solution specifically can be overcome in the given timeframe. For example, ATIS supports a July 16, 2022, deadline as “reasonable” given that “it is already possible to text the existing Lifeline toll-free number,” highlighting that “texting to the new three-digit short code (988) would create no new technical challenges.” E.

Technical Considerations 34. We adopt our proposal to allow covered text providers to use any reliable method or methods to support text routing and transmission to 988. We reiterate that covered text providers may use any reliable method or methods to support text routing and transmission to 988, and emphasize our neutrality on the technologies that covered text providers use to support text messaging to 988. We find that this approach accounts for currently-available text messaging formats and technologies and also provides the flexibility to adapt to future availability.

No commenter opposed our proposal. As ATIS explains, texting to 988 “can and should be implemented in a timely manner[,]” Start Printed Page 405 and should “create no technical challenges.” 35. Network Upgrades. Based on the record, we do not expect that covered text providers will need to install significant network upgrades to implement the texting to 988 requirements adopted herein.

Though covered text providers must determine how to support texting to 988 as adopted, the rules we adopt in this document provide the flexibility to choose the most effective method for doing so. For example, covered text providers may choose to route text messages to 988 over their mobile-switched networks or use an IP-based method to deliver text messages to the Lifeline. We are encouraged that many providers have implemented voice calling to 988 a year or more before the implementation deadline, and we envision that covered text providers can also easily implement texting to 988. 36.

Equipment Upgrades. We find, based on the record, that no significant software or equipment upgrades will be necessary to implement texting to 988. We agree with ATIS, one of the organizations that set the standards for texting to 911, that “[a] focus on functionality rather than technical standards is required to meet the needs of those who communicate primarily via texting.” We are not persuaded by VON's argument that, like implementing text-to-911, industry needs to develop new routing and technical standards that may delay text-to-988's implementation. VON generically states that 911 networks and the Lifeline are “two distinct infrastructures” that will require new standards, but does not explain why these infrastructural differences merit developing new standards.

We find more convincing ATIS's assertion that changes to industry standards will “be minimal if, as expected, no changes are required to consumer devices to support text-to-988 requirements” because the bulk of the record indicates that texting to 988's centralized routing solution, limited scope of text messaging service technologies, and other adopted requirements are straightforward to implement by our adoption deadline. 37. We exempt legacy devices that are incapable of sending text messages via 3-digit codes from the text-to-988 requirements, provided the software for these devices cannot be upgraded over the air to allow text-to-988. In the Text-to-911 proceeding, the Commission did not require certain legacy devices to comply with the text-to-911 requirements because “the messaging application or interface on the mobile device will likely provide an error message indicating an invalid destination number, reducing user confusion somewhat” that the legacy device could not support texting to 911.

No commenter discussed legacy devices nor indicated that circumstances have changed since the Commission adopted this exemption in the Text-to-911 proceeding. Accordingly, we find that the same exemption is appropriate here. 38. Network Access.

We require CMRS providers to allow access to their SMS networks by any other covered text provider for the capabilities necessary to transmit 988 text messages originating on such other covered text providers' networks, similar to the text-to-911 rules. We find this rule is necessary to implement our text to 988 requirement as we anticipate that many interconnected text providers will choose CMRS network-based solutions to implement texting to 988. No commenter opposed providing this network access. Mitel explains that, like in the texting to 911 context, routing messages to interconnected networks often requires access to an underlying wireless network and provider.

Similar to the text-to-911 rules, we adopt this requirement to “respond to consumers' reasonable expectations and reduce consumer confusion” regarding text-to-988's availability. 39. Similar to the Commission's position in the Text-to-911 Second Report and Order (79 FR 55367, September 14, 2014), we conclude that it is the responsibility of the covered text provider using the CMRS-based solution to ensure that its text messaging service is technically compatible with the CMRS providers' SMS-based network and devices and in conformance with any applicable technical standards. As in the text-to-911 context, we further require CMRS providers to make any necessary specifications for accessing their SMS networks available to other covered text providers upon request, and to inform such covered text providers in advance of any changes to these specifications.

We clarify, however, that we do not intend to use these requirements to establish an open-ended obligation for CMRS providers to maintain underlying SMS network support merely for the use of other providers, nor do we require CMRS providers to reconfigure any SMS text-to-988 platforms in order to facilitate the ability of other covered text providers to access the CMRS providers' networks. Further, as with the text-to-911 rules, CMRS providers' obligation to allow access to CMRS networks “is limited to the extent that the CMRS providers offers SMS.” While we expect that adopting these rules will similarly encourage “interconnected text providers to actively develop solutions to support [text-to-988] without reliance on CMRS providers' underlying networks,” we nonetheless encourage providers to enact solutions to carry other covered text providers' text messages to 988 over their networks. F. Other Issues 40.

Cost Recovery. We adopt our proposal to require all covered text providers to bear their own costs to implement text-to-988. We find that this approach promotes efficiency in implementation and avoids unnecessary administrative costs. In the 988 Report and Order, we observed that “[u]nlike previous numbering proceedings in which the Commission established a cost recovery mechanism,” implementation of 988 itself does not involve “shared industry costs such as central or regional numbering databases or third-party administrators.” Similarly, we conclude that implementation of a text-to-988 solution requires no shared industry costs, with costs being provider-specific and solutions unique to each.

As such, as proposed in the FNPRM we find that the requirements in section 251(e)(2) of the Act that “[t]he cost of establishing telecommunications numbering administration arrangements and number portability shall be borne by all telecommunications carriers on a competitively neutral basis” does not apply. 41. Bounce-back Messages. We decline to require covered text providers to send an automatic bounce-back message specifically designed to address where text-to-988 service is unavailable for several reasons.

First, the record indicates that failed messages are likely to be rare. CTIA explains that network failures are “rare due to redundancies in the SMS network” and Vibrant indicates that to date the Lifeline's text messaging service has not experienced any downtime. Second, in the rare instance that covered text providers fail to deliver a text message to the Lifeline, current notice practices are sufficient. Individuals texting the Lifeline currently receive a bounce-back message under a variety of circumstances.

CTIA explains that covered text providers usually send customers a notification from a device or network when a CMRS provider cannot deliver a text message due to a network failure. Vibrant also indicates that the Lifeline currently sends individuals scheduled text messages approximately every 10 minutes if there is a wait to reach a crisis counselor that informs them they are in the queue, offers access to other Start Printed Page 406 resources while they wait, and provides the option to call the Lifeline. Consequently, we further agree with commenters that to the extent operational concerns, network congestion, or outsized demand prevent texters from reaching a crisis counselor, the parties that operate the Lifeline are in the best position to send a message to texters because covered text providers do not have visibility into the Lifeline's operations. Third, we decline to require 988-specific bounce-back messages because such a mandate risks delay of text-to-988 implementation.

We recognize comments from CTIA which state that developing a bounce-back messaging capability “would require substantial additional time and complexity, as well as the development of standards and requirements for implementation, and would significantly delay the July 16, 2022 implementation target.” T-Mobile further asserts that when a CMRS provider has not delivered a text message to the Lifeline due to network congestion, sending a Lifeline-specific automatic bounce-back message could be technically infeasible because “[c]arriers cannot determine if a text sent to the 10-digit Lifeline number has not been delivered due to network congestion or other factors related to nature of SMS generally.” 42. Finally, a key circumstance that prompted the Commission to require automatic bounce-back messaging for text-to-911 are not present for text-to-988. In the Text-to-911 proceeding, the Commission adopted an automatic bounce-back messaging requirement because texting was and is only available to some PSAPs, and Americans in many parts of the country could not text 911 at all. In contrast, our centralized routing approach ensures that texting to 988 will be uniformly available nationwide.

The unique geographic gaps that the bounce-back requirement addresses in the 911 context are not present here. It is possible that, as in the text-to-911 context, requiring a bounce-back message for text-to-988 could help “persons in emergency situations being able to know immediately if a text message has been delivered to the proper authorities” in the limited situations when consumers cannot send text messages to the Lifeline. However, given the urgency of improving access to lifesaving suicide prevention resources, and in light of existing protections against and in the event of a delivery failure, we decline to a bounce-back messaging requirement for text-to-988 at this time. We will monitor the operation of texting to 988 post-implementation and will not hesitate to revisit the issue of requiring a bounce-back if warranted.

43. Federal Coordination. We direct the Bureau to continue to coordinate implementation of 988 with SAMHSA, including any issues pertaining to the delivery of text messages to 988. We direct the Bureau and Commission staff to support the VA in promoting awareness of texting options for Service Members, Veterans, and their families, and to support the VA and SAMHSA in piloting, testing, and implementing any solution our Federal partners may choose to pursue to allow texting to 988 for the Veterans Crisis Line's text service.

We also encourage SAMHSA to continue to work to expand the Lifeline's texting infrastructure. We will continue to work with and support our Federal partners in their efforts to assist Americans in crisis. 44. Future Technical Corrections to Lifeline 10-Digit Number.

In our rules, we identify the current 10-digit telephone number of the Lifeline, 1-800-273-8255 (TALK). We direct the Bureau, after notice and comment, to update this reference to the correct number if the Lifeline ever changes telephone numbers. This direction applies to the text-to-988 rules we adopt in this document and to our previously-adopted 988 telephone rules. G.

Legal Authority 45. We conclude that Title III of the Act and the Twenty-First Century Communications and Video Accessibility Act (CVAA) provide us with authority for the rules we adopt in this document. No commenter opposes these conclusions. With respect to CMRS providers, we find that Title III provides us the authority to require wireless carriers to enable and support text-to-988 service.

Consistent with the U.S. Supreme Court's recognition that Title III provides the Commission a “broad mandate” to manage spectrum usage in the public interest, we find that significant public interest benefits will likely inure from broadly enabling access to lifesaving services through texting. Further, the rules adopted here are analogous to those the Commission adopted to facilitate text-to-911, which relied in part on the Commission's Title III authority. Therefore, with respect to CMRS providers, we conclude that Title III provides sufficient authority for the rules we adopt in this document.

46. As to interconnected text messaging service providers, the CVAA granted us authority to adopt “other regulations. . .

As are necessary to achieve reliable, interoperable communication that ensures access by individuals with disabilities to an internet protocol-enabled emergency network.” We conclude that the Lifeline constitutes an “emergency network” within the meaning of the CVAA. The CVAA does not define what an “emergency network” is, nor does it elaborate on what qualifies as “emergency services.” However, Congress, through the National Suicide Hotline Designation Act, deemed “life-saving resources” such as the Lifeline and the Veterans Crisis Line “essential” and recognized the need for an “easy-to-remember, 3-digit phone number”—that is, one readily available in an emergency situation. As CTIA argues, it is therefore reasonable to conclude that such services should be considered “emergency services” and that the Lifeline and Veterans Crisis Line act as an “emergency network” within the meaning of the CVAA. Moreover, texting capabilities provide “easy access to emergency services for people with disabilities,” including those with hearing and speech disabilities.

Such individuals may not be able to take advantage of 988's voice service, necessitating that an alternative means of communicating be provided. We therefore conclude that the CVAA provides authority for the rules we adopt in this document, and the record reflects agreement with our analysis. Because we find that Title III and the CVAA provide sufficient authority for the rules we adopt in this document, we find it unnecessary to address other possible sources of authority to adopt these rules. H.

Benefits and Costs of Text-to-988 47. Consistent with our proposal in the FNPRM, we find that benefits of requiring service providers to support text-to-988 far exceed the costs of implementation. The loss of victims' lives to suicide cannot be adequately captured by any pecuniary measure. The principal benefit of text-to-988 is that it will reduce suicide risk by providing an additional means of reaching help for the most vulnerable.

Text-to-988 will reduce the risk of suicide mortality, primarily among those who would either send a text to 988 or forgo a lifesaving intervention altogether. Three vulnerable communities, in particular, face this stark choice. Youth, who rely heavily on text messages for their general communications needs. The deaf, deafblind, hard of hearing, and speech disabled.

And those who are reluctant to dial 988 because they feel unsafe, ashamed or embarrassed, including many LGBTQ+ youth and victims of domestic abuse. As outlined Start Printed Page 407 above, the ability to text to the short and easy-to-remember 988 code will make the lifesaving interventions of the Lifeline crisis centers even more accessible than dialing alone. As no commenter in the record disputes, we find that the benefits of implementing text-to-988 will quickly exceed costs, and dwarf them over time. 48.

In the FNPRM, we estimated the cost of implementing text to 988 would be nearly $27 million over five years. We based our estimate on Intrado's existing estimates of the costs of upgrading 911 call centers to receive text messages. Although one commenter asserts that the costs of implementation are likely to be “substantially lower” than our estimate, no commenters provided any individual estimates or disputed our underlying approach or our estimate of the combined total cost of nearly $27 million with an alternate figure. We agree that implementation costs may be lower than we projected.

However, since no commenter provided an estimate of the impact of these potential reductions, we find it prudent to rely on our original estimate. 49. Commenters suggest quantifiable benefits that would greatly exceed these costs. For example, the Mental Health Associations emphasize that improved access to “mental health response to mental health crises” will result in cost savings for communities and individuals.

These “[e]mergency department visits for mental health and substance use disorders cost an average of $520 across 10.7 million visits in 2017, for a total cost nationwide of nearly $5.6 billion.” Any reduction in these visits and resulting cost savings are benefits of implementing text-to-988. In addition, the Center for Law and Social Policy (CLASP) points to an evaluation of Nevada's TextToday pilot program, one of the country's first crisis response lines that accepted text messages. The evaluation found an increase in help-seeking by youth and a preference for texting. Groups that would be especially likely to benefit from text-to-988 are members of the LGBTQ+ community, and deaf, deafblind, hard of hearing, and speech-disabled adults.

Between 2015 and 2019, we estimate there were more than 39,000 suicides among youth 10-19, LGBTQ+ adults, and deaf, deafblind, hard of hearing, and speech-disabled adults. If text-to-988 reduces the annual risk of suicide mortality among these groups and others by even a very small amount, the benefits would easily outweigh the costs of implementing text-to-988. II. Final Regulatory Flexibility Analysis 1.

As required by the Regulatory Flexibility Act of 1980, as amended (RFA), an Initial Regulatory Flexibility Analysis (IRFA) was incorporated into the FNPRM, released April 2021. The Commission sought written public comments on the proposals in the FNPRM, including comment on the IRFA. No comments were filed addressing the IRFA. Because the Commission amends its rules in the Second Report and Order, the Commission has included this Final Regulatory Flexibility Analysis (FRFA).

This present FRFA conforms to the RFA. A. Need for, and Objectives of, the Rules 2. In the Second Report and Order, the Commission adopts rules requiring CMRS providers and providers of interconnected text messaging services that enable consumers to send text messages to, and receive text messages from, all or substantially all text-capable U.S.

Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones (covered text providers) to enable delivery of text messages to 988. The Commission further requires that covered text providers route 988 text messages to the National Suicide Prevention Lifeline's (Lifeline) 10-digit number, currently 1-800-273-8255 (TALK). The Commission believes these rules will expand the availability of mental health and crisis counseling resources to Americans who suffer from depressive or suicidal thoughts, by allowing individuals in crisis to reach the Lifeline by texting 988. B.

Summary of Significant Issues Raised by Public Comments in Response to the IRFA 3. There were no comments filed that specifically addressed the proposed rules and policies presented in the IRFA. C. Response to Comments by the Chief Counsel for Advocacy of the Small Business Administration 4.

Pursuant to the Small Business Jobs Act of 2010, which amended the RFA, the Commission is required to respond to any comments filed by the Chief Counsel for Advocacy of the Small Business Administration (SBA), and to provide a detailed statement of any change made to the proposed rules as a result of those comments. 5. The Chief Counsel did not file any comments in response to the proposed rules in this proceeding. D.

Description and Estimate of the Number of Small Entities to Which the Rules Will Apply 6. The RFA directs agencies to provide a description of, and where feasible, an estimate of the number of small entities that may be affected by the final rules adopted pursuant to the Second Report and Order. The RFA generally defines the term “small entity” as having the same meaning as the terms “small business,” “small organization,” and “small governmental jurisdiction.” In addition, the term “small business” has the same meaning as the term “small-business concern” under the Small Business Act. A “small-business concern” is one which.

(1) Is independently owned and operated. (2) is not dominant in its field of operation. And (3) satisfies any additional criteria established by the SBA. 7.

Small Businesses, Small Organizations, Small Governmental Jurisdictions. Our actions, over time, may affect small entities that are not easily categorized at present. We therefore describe here, at the outset, three broad groups of small entities that could be directly affected herein. First, while there are industry specific size standards for small businesses that are used in the regulatory flexibility analysis, according to data from the SBA's Office of Advocacy, in general a small business is an independent business having fewer than 500 employees.

These types of small businesses represent 99.9% of all businesses in the United States, which translates to 30.7 million businesses. 8. Next, the type of small entity described as a “small organization” is generally “any not-for-profit enterprise which is independently owned and operated and is not dominant in its field.” The Internal Revenue Service (IRS) uses a revenue benchmark of $50,000 or less to delineate its annual electronic filing requirements for small exempt organizations. Nationwide, for tax year 2018, there were approximately 571,709 small exempt organizations in the U.S.

Reporting revenues of $50,000 or less according to the registration and tax data for exempt organizations available from the IRS. 9. Finally, the small entity described as a “small governmental jurisdiction” is defined generally as “governments of cities, counties, towns, townships, villages, school districts, or special districts, with a population of less than fifty thousand.” U.S. Census Bureau data from the 2017 Census of Governments indicate that there were 90,075 local governmental jurisdictions consisting of general purpose Start Printed Page 408 governments and special purpose governments in the United States.

Of this number there were 36,931 general purpose governments (county, municipal and town or township) with populations of less than 50,000 and 12,040 special purpose governments—independent school districts with enrollment populations of less than 5ll governmental jurisdictions. 10. Wired Telecommunications Carriers. The U.S.

Census Bureau defines this industry as “establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired communications networks. Transmission facilities may be based on a single technology or a combination of technologies. Establishments in this industry use the wired telecommunications network facilities that they operate to provide a variety of services, such as wired telephony services, including [voice over internet protocol] VoIP services, wired (cable) audio and video programming distribution, and wired broadband internet services. By exception, establishments providing satellite television distribution services using facilities and infrastructure that they operate are included in this industry.” The SBA has developed a small business size standard for Wired Telecommunications Carriers, which consists of all such companies having 1,500 or fewer employees.

U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated that year. Of this total, 3,083 operated with fewer than 1,000 employees. Thus, under this size standard, the majority of firms in this industry can be considered small.

11. Local Exchange Carriers (LECs). Neither the Commission nor the SBA has developed a size standard for small businesses specifically applicable to local exchange services. The closest applicable North American Industry Classification System (NAICS) Code category is Wired Telecommunications Carriers.

Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated for the entire year. Of that total, 3,083 operated with fewer than 1,000 employees.

Thus under this category and the associated size standard, the Commission estimates that the majority of local exchange carriers are small entities. 12. Incumbent Local Exchange Carriers (Incumbent LECs). Neither the Commission nor the SBA has developed a small business size standard specifically for incumbent local exchange services.

The closest applicable NAICS Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated the entire year.

Of this total, 3,083 operated with fewer than 1,000 employees. Consequently, the Commission estimates that most providers of incumbent local exchange service are small businesses that may be affected by our actions. According to Commission data, one thousand three hundred and seven (1,307) Incumbent Local Exchange Carriers reported that they were incumbent local exchange service providers. Of this total, an estimated 1,006 have 1,500 or fewer employees.

Thus, using the SBA's size standard the majority of incumbent LECs can be considered small entities. 13. Competitive Local Exchange Carriers (Competitive LECs). Competitive Access Providers (CAPs), Shared-Tenant Service Providers, and Other Local Service Providers.

Neither the Commission nor the SBA has developed a small business size standard specifically for these service providers. The appropriate NAICS Code category is Wired Telecommunications Carriers and under that size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated during that year.

Of that number, 3,083 operated with fewer than 1,000 employees. Based on these data, the Commission concludes that the majority of Competitive LECS, CAPs, Shared-Tenant Service Providers, and Other Local Service Providers, are small entities. According to Commission data, 1,442 carriers reported that they were engaged in the provision of either competitive local exchange services or competitive access provider services. Of these 1,442 carriers, an estimated 1,256 have 1,500 or fewer employees.

In addition, 17 carriers have reported that they are Shared-Tenant Service Providers, and all 17 are estimated to have 1,500 or fewer employees. Also, 72 carriers have reported that they are Other Local Service Providers. Of this total, 70 have 1,500 or fewer employees. Consequently, based on internally researched FCC data, the Commission estimates that most providers of competitive local exchange service, competitive access providers, Shared-Tenant Service Providers, and Other Local Service Providers are small entities.

14. Interexchange Carriers (IXCs). Neither the Commission nor the SBA has developed a small business size standard specifically for Interexchange Carriers. The closest applicable NAICS Code category is Wired Telecommunications Carriers.

The applicable size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated for the entire year. Of that number, 3,083 operated with fewer than 1,000 employees.

According to internally developed Commission data, 359 companies reported that their primary telecommunications service activity was the provision of interexchange services. Of this total, an estimated 317 have 1,500 or fewer employees. Consequently, the Commission estimates that the majority of interexchange service providers are small entities. 15.

Local Resellers. The SBA has not developed a small business size standard specifically for Local Resellers. The SBA category of Telecommunications Resellers is the closest NAICS code category for local resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households.

Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. Mobile virtual network operators (MVNOs) are included in this industry. Under the SBA's size standard, such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data from 2012 show that 1,341 firms provided resale services during that year. Of that number, all operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities.

According to Commission data, 213 carriers have reported that they are engaged in the provision of local resale services. Of these, an estimated 211 have 1,500 or fewer employees and two have more than 1,500 employees. Consequently, the Commission estimates that the majority of local resellers are small entities. 16.

Toll Resellers. The Commission has not developed a definition for Toll Resellers. The closest NAICS Code Category is Telecommunications Start Printed Page 409 Resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households.

Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. MVNOs are included in this industry. The SBA has developed a small business size standard for the category of Telecommunications Resellers.

Under that size standard, such a business is small if it has 1,500 or fewer employees. 2012 U.S. Census Bureau data show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees.

Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities. According to Commission data, 881 carriers have reported that they are engaged in the provision of toll resale services. Of this total, an estimated 857 have 1,500 or fewer employees. Consequently, the Commission estimates that the majority of toll resellers are small entities.

17. Other Toll Carriers. Neither the Commission nor the SBA has developed a definition for small businesses specifically applicable to Other Toll Carriers. This category includes toll carriers that do not fall within the categories of interexchange carriers, operator service providers, prepaid calling card providers, satellite service carriers, or toll resellers.

The closest applicable size standard under SBA rules is for Wired Telecommunications Carriers. The applicable SBA size standard consists of all such companies having 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicates that 3,117 firms operated during that year.

Of that number, 3,083 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of Other Toll Carriers can be considered small. According to internally developed Commission data, 284 companies reported that their primary telecommunications service activity was the provision of other toll carriage. Of these, an estimated 279 have 1,500 or fewer employees.

Consequently, the Commission estimates that most Other Toll Carriers are small entities. 18. Prepaid Calling Card Providers. Neither the Commission nor the SBA has developed a small business definition specifically for prepaid calling card providers.

The most appropriate NAICS code-based category for defining prepaid calling card providers is Telecommunications Resellers. This industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure.

MVNOs are included in this industry. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that 1,341 firms provided resale services during that year.

Of that number, 1,341 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these prepaid calling card providers can be considered small entities. According to the Commission's Form 499 Filer Database, 86 active companies reported that they were engaged in the provision of prepaid calling cards. The Commission does not have data regarding how many of these companies have 1,500 or fewer employees, however, the Commission estimates that the majority of the 86 active prepaid calling card providers that may be affected by these rules are likely small entities.

19. Wireless Telecommunications Carriers (except Satellite). This industry comprises establishments engaged in operating and maintaining switching and transmission facilities to provide communications via the airwaves. Establishments in this industry have spectrum licenses and provide services using that spectrum, such as cellular services, paging services, wireless internet access, and wireless video services.

The appropriate size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees. For this industry, U.S. Census Bureau data for 2012 show that there were 967 firms that operated for the entire year. Of this total, 955 firms employed fewer than 1,000 employees and 12 firms employed of 1000 employees or more.

Thus under this category and the associated size standard, the Commission estimates that the majority of Wireless Telecommunications Carriers (except Satellite) are small entities. 20. The Commission's own data—available in its Universal Licensing System—indicate that, as of August 31, 2018, there are 265 Cellular licensees that will be affected by our actions. The Commission does not know how many of these licensees are small, as the Commission does not collect that information for these types of entities.

Similarly, according to internally developed Commission data, 413 carriers reported that they were engaged in the provision of wireless telephony, including cellular service, Personal Communications Service (PCS), and Specialized Mobile Radio (SMR) Telephony services. Of this total, an estimated 261 have 1,500 or fewer employees, and 152 have more than 1,500 employees. Thus, using available data, we estimate that the majority of wireless firms can be considered small. 21.

Cable and Other Subscription Programming. The U.S. Census Bureau defines this industry as establishments primarily engaged in operating studios and facilities for the broadcasting of programs on a subscription or fee basis. The broadcast programming is typically narrowcast in nature ( e.g., limited format, such as news, sports, education, or youth-oriented).

These establishments produce programming in their own facilities or acquire programming from external sources. The programming material is usually delivered to a third party, such as cable systems or direct-to-home satellite systems, for transmission to viewers. The SBA size standard for this industry establishes as small any company in this category with annual receipts less than $41.5 million. Based on U.S.

Census Bureau data for 2012, 367 firms operated for the entire year. Of that number, 319 firms operated with annual receipts of less than $25 million a year and 48 firms operated with annual receipts of $25 million or more. Based on this data, the Commission estimates that a majority of firms in this industry are small. 22.

Cable Companies and Systems (Rate Regulation). The Commission has also developed its own small business size standards, for the purpose of cable rate regulation. Under the Commission's rules, a “small cable company” is one serving 400,000 or fewer subscribers nationwide. Industry data indicate that there are 4,600 active cable systems in the United States.

Of this total, all but five cable operators nationwide are small under the 400,000-subscriber size standard. In addition, under the Commission's rate regulation rules, a “small system” is a cable system serving 15,000 or fewer subscribers. Commission records show 4,600 cable systems nationwide. Of this total, 3,900 cable systems have fewer than 15,000 subscribers, and 700 systems have Start Printed Page 410 15,000 or more subscribers, based on the same records.

Thus, under this standard as well, we estimate that most cable systems are small entities. 23. Cable System Operators (Telecom Act Standard). The Communications Act of 1934, as amended, also contains a size standard for small cable system operators, which is “a cable operator that, directly or through an affiliate, serves in the aggregate fewer than one percent of all subscribers in the United States and is not affiliated with any entity or entities whose gross annual revenues in the aggregate exceed $250,000,000.” As of 2019, there were approximately 48,646,056 basic cable video subscribers in the United States.

Accordingly, an operator serving fewer than 486,460 subscribers shall be deemed a small operator if its annual revenues, when combined with the total annual revenues of all its affiliates, do not exceed $250 million in the aggregate. Based on available data, we find that all but five cable operators are small entities under this size standard. We note that the Commission neither requests nor collects information on whether cable system operators are affiliated with entities whose gross annual revenues exceed $250 million. Therefore, we are unable at this time to estimate with greater precision the number of cable system operators that would qualify as small cable operators under the definition in the Communications Act.

24. All Other Telecommunications. The “All Other Telecommunications” category is comprised of establishments primarily engaged in providing specialized telecommunications services, such as satellite tracking, communications telemetry, and radar station operation. This industry also includes establishments primarily engaged in providing satellite terminal stations and associated facilities connected with one or more terrestrial systems and capable of transmitting telecommunications to, and receiving telecommunications from, satellite systems.

Establishments providing internet services or VoIP services via client-supplied telecommunications connections are also included in this industry. The SBA has developed a small business size standard for “All Other Telecommunications”, which consists of all such firms with annual receipts of $35 million or less. For this category, U.S. Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year.

Of those firms, a total of 1,400 had annual receipts less than $25 million and 15 firms had annual receipts of $25 million to $49,999,999. Thus, the Commission estimates that the majority of “All Other Telecommunications” firms potentially affected by our action can be considered small. 25. Radio and Television Broadcasting and Wireless Communications Equipment Manufacturing.

This industry comprises establishments primarily engaged in manufacturing radio and television broadcast and wireless communications equipment. Examples of products made by these establishments are. Transmitting and receiving antennas, cable television equipment, Global Positioning System (GPS) equipment, pagers, cellular phones, mobile communications equipment, and radio and television studio and broadcasting equipment. The SBA has established a small business size standard for this industry of 1,250 employees or less.

U.S. Census Bureau data for 2012 show that 841 establishments operated in this industry in that year. Of that number, 828 establishments operated with fewer than 1,000 employees, 7 establishments operated with between 1,000 and 2,499 employees and 6 establishments operated with 2,500 or more employees. Based on this data, we conclude that a majority of manufacturers in this industry are small.

26. Semiconductor and Related Device Manufacturing. This industry comprises establishments primarily engaged in manufacturing semiconductors and related solid state devices. Examples of products made by these establishments are integrated circuits, memory chips, microprocessors, diodes, transistors, solar cells and other optoelectronic devices.

The SBA has developed a small business size standard for Semiconductor and Related Device Manufacturing, which consists of all such companies having 1,250 or fewer employees. U.S. Census Bureau data for 2012 show that there were 862 establishments that operated that year. Of this total, 843 operated with fewer than 1,000 employees.

Thus, under this size standard, the majority of firms in this industry can be considered small. 27. Software Publishers. This industry comprises establishments primarily engaged in computer software publishing or publishing and reproduction.

Establishments in this industry carry out operations necessary for producing and distributing computer software, such as designing, providing documentation, assisting in installation, and providing support services to software purchasers. These establishments may design, develop, and publish, or publish only. The SBA has established a size standard for this industry of annual receipts of $41.5 million or less per year. U.S.

Census data for 2012 indicates that 5,079 firms operated for the entire year. Of that number 4,691 firms had annual receipts of less than $25 million and 166 firms had annual receipts of $25,000,000 to $49,999,999. Based on this data, we conclude that a majority of firms in this industry are small. 28.

Internet Service Providers (Broadband). Broadband internet service providers include wired ( e.g., cable, digital subscriber line (DSL)) and VoIP service providers using their own operated wired telecommunications infrastructure fall in the category of Wired Telecommunication Carriers. Wired Telecommunications Carriers are comprised of establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired telecommunications networks. Transmission facilities may be based on a single technology or a combination of technologies.

The SBA size standard for this category classifies a business as small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated that year. Of this total, 3,083 operated with fewer than 1,000 employees.

Consequently, under this size standard the majority of firms in this industry can be considered small. 29. Internet Service Providers (Non-Broadband). Internet access service providers such as dial-up internet service providers (ISPs), VoIP service providers using client-supplied telecommunications connections and internet service providers using client-supplied telecommunications connections ( e.g., dial-up ISPs) fall in the category of All Other Telecommunications.

The SBA has developed a small business size standard for All Other Telecommunications which consists of all such firms with gross annual receipts of $35 million or less. For this category, U.S. Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year. Of these firms, a total of 1,400 had gross annual receipts of less than $25 million.

Consequently, under this size standard a majority of firms in this industry can be considered small. 30. All Other Information Services. The U.S.

Census Bureau has determined that this category “comprises establishments primarily engaged in providing other information services (except news syndicates, libraries, archives, internet publishing and Start Printed Page 411 broadcasting, and Web search portals).” The SBA has developed a small business size standard for this category, which consists of all such firms with annual receipts of $30 million or less. U.S. Census Bureau data for 2012 show that there were 512 firms that operated for the entire year. Of those firms, a total of 498 had annual receipts less than $25 million and 7 firms had annual receipts of $25 million to $49,999,999.

Consequently, we estimate that the majority of these firms are small entities that may be affected by our action. E. Description of Projected Reporting, Recordkeeping, and Other Compliance Requirements for Small Entities 31. The Second Report and Order modifies the Commission's rules to require covered text providers to support text messaging to 988.

It concludes that text-to-988 functionality will greatly improve consumer access to the Lifeline, particularly for at-risk populations and thereby save lives. The final rules adopted in the Second Report and Order require CMRS providers and interconnected text messaging service providers to route texts sent to 988 to the 10-digit Lifeline number, presently 1-800-273-8255 (TALK). The Second Report and Order (1) establishes a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. (2) directs the Wireline Competition Bureau (Bureau) to identify text formats within the scope of that definition that the Lifeline can receive and thus covered text providers must support by routing to the 10-digit Lifeline number.

And (3) requires CMRS providers that offer SMS to allow access by any other covered text provider to the capabilities necessary for transmission of 988 text messages originating on such other covered text providers' application services. F. Steps Taken To Minimize the Significant Economic Impact on Small Entities, and Significant Alternatives Considered 32. The RFA requires an agency to describe any significant, specifically small business, alternatives that it has considered in reaching its approach, which may include the following four alternatives (among others).

€œ(1) the establishment of differing compliance or reporting requirements or timetables that take into account the resources available to small entities. (2) the clarification, consolidation, or simplification of compliance and reporting requirements under the rules for such small entities. (3) the use of performance rather than design standards. And (4) an exemption from coverage of the rule, or any part thereof, for such small entities.” 33.

In the Second Report and Order, the Commission adopts a uniform implementation deadline for all covered text providers to route covered 988 text messages to 988 to the Lifeline's 10-digit number by July 16, 2022. The Commission believes that applying the same rules equally to all entities in this context is necessary to alleviate potential consumer confusion from adopting different rules, at different times, for different covered text providers. However, the Commission does not believe that the actions in the Second Report and Order will overly burden small carriers or providers. Further, the Commission believes that by its actions, all entities, including small carriers or providers, will benefit from reduced costs.

For example, the Commission believes that adopting our proposal to require all covered text providers to bear their own costs to implement text-to-988 will avoid any unnecessary administrative costs. Further, the Commission provides covered text provider flexibility in how they support texting to 988, allowing them to choose the most effective method for doing so. G. Report to Congress 34.

The Commission will send a copy of the Second Report and Order, including this FRFA, in a report to be sent to Congress pursuant to the Congressional Review Act. In addition, the Commission will send a copy of the Second Report and Order, including this FRFA, to the Chief Counsel for Advocacy of the SBA. A copy of the Second Report and Order and FRFA (or summaries thereof) will also be published in the Federal Register. III.

Procedural Matters 35. Paperwork Reduction Act of 1995 Analysis. This document does not contain proposed information collection(s) subject to the Paperwork Reduction Act of 1995 (PRA), Public Law 104-13. In addition, therefore, it does not contain any new or modified information collection burden for small business concerns with fewer than 25 employees, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, see 44 U.S.C.

3506(c)(4). 36. Final Regulatory Flexibility Analysis. As required by the Regulatory Flexibility Act of 1980,103 the Commission has prepared a Final Regulatory Flexibility Analysis (FRFA) of the possible significant economic impact on small entities of the policies and rules, as proposed, addressed in the Second Report and Order.

The FRFA is set forth in Appendix B of the Second Report and Order. The Commission will send a copy of the Second Report and Order, including the FRFA, to the Chief Counsel for Advocacy of the Small Business Administration (SBA). 37. Congressional Review Act.

The Commission has determined, and the Administrator of the Office of Information and Regulatory Affairs, Office of Management and Budget, concurs that this rule is non-major under the Congressional Review Act, 5 U.S.C. 804(2). The Commission will send a copy of the Second Report and Order to Congress and the Government Accountability Office pursuant to 5 U.S.C. 801(a)(1)(A).

38. People With Disabilities. To request materials in accessible formats for people with disabilities (braille, large print, electronic files, audio format), send an email to fcc504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at (202) 418-0530 (voice), 202-418-0432 (tty).

39. Contact Person. For further information about this rulemaking proceeding, please contact Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388 or michelle.sclater@fcc.gov. IV.

Ordering Clauses 40. Accordingly, it is ordered , pursuant to sections 201, 251(e)(4), 301, 303, 307, 309, 316, and 615c of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251(e)(4), 301, 303, 307, 309, 316, 615c, that the Second Report and Order in WC Docket No. 18-336 is adopted.

41. It is further ordered that, pursuant to §§ 1.4(b)(1) and 1.103(a) of the Commission's rules, 47 CFR 1.4(b)(1), 1.103(a), the Report and Order shall be effective 30 days after publication in the Federal Register. 42. It is further ordered that part 52 of the Commission's rules is amended as set forth in Appendix A of the Second Report and Order.

43. It is further ordered that the Commission shall send a copy of the Second Report and Order to Congress and to the Government Accountability Office pursuant to the Congressional Review Act, see 5 U.S.C. 801(a)(1)(A). 44.

It is further ordered that the Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, shall send a copy of the Second Report and Order, including the Final Regulatory Flexibility Analysis (FRFA), to the Chief Counsel for Advocacy of the Small Business Administration. Start List of Subjects Start Printed Page 412 Communications common carriersTelecommunicationsTelephone End List of Subjects (47 U.S.C. 201, 251, 301, 303, 307, 309, 316) Start Signature Federal Communications Commission. Katura Jackson, Federal Register Liaison Officer.

End Signature Final Rules For the reasons stated in the preamble, the Federal Communications Commission amends 47 CFR part 52 as follows. Start Part End Part Start Amendment Part1. The authority citation for part 52 continues to read as follows. End Amendment Part Start Authority 47 U.S.C.

151, 152, 153, 154, 155, 201-205, 207-209, 218, 225-227, 251-252, 271, 303, 332, unless otherwise noted. End Authority Start Amendment Part2. Add § 52.201 to read as follows. End Amendment Part Texting to the National Suicide Prevention and Mental Health Crisis Hotline.

(a) Support for 988 text message service. Beginning July 16, 2022, all covered text providers must route a covered 988 text message to the current toll free access number for the National Suicide Prevention Lifeline, presently 1-800-273-8255 (TALK). (b) Access to SMS networks for 988 text messages. To the extent that Commercial Mobile Radio Services (CMRS) providers offer Short Message Service (SMS), they shall allow access by any other covered text provider to the capabilities necessary for transmission of 988 text messages originating on such other covered text providers' application services.

(c) Definitions. For purposes of this section. 988 text message. (i) Means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number, N11 service code, or 988.

(ii) Includes and is not limited to a SMS message and a multimedia message service (MMS) message. And (iii) Does not include— (A) A real-time, two-way voice or video communication. Or (B) A message sent over an IP-enabled messaging service to another user of the same messaging service, except a message described in paragraph (b) of this section. Covered 988 text message means a 988 text message in SMS format and any other format that the Wireline Competition Bureau has determined must be supported by covered text providers.

Covered text provider includes all CMRS providers as well as all providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones. Multimedia message service ( MMS ) shall have the same definition as the term in § 64.1600(k) of this chapter. Short message service ( SMS ) shall have the same definition as the term in § 64.1600(m) of this chapter.

End Supplemental Information [FR Doc. 2021-27878 Filed 1-4-22. 8:45 am]BILLING CODE 6712-01-P.

Farmers and people in rural areas are more comfortable talking about stress and mental health challenges with others, and stigma around seeking help or treatment has decreased in rural and farm communities but is still a factor, according to a new research poll from the American Farm propecia cheapest price Bureau Federation. AFBF conducted the survey of rural adults and farmers/farmworkers to measure changes and trends in stigma, personal experiences with mental health, awareness of information about mental health resources and comfort in talking about mental health with others. The poll results were compared with previous surveys AFBF conducted in 2019 and 2020 focusing on farmer mental health, and the impacts of the propecia cheapest price hair loss treatment propecia on farmer mental health, respectively. €œFarm Bureau has been encouraging conversations to help reduce stigma around farmer stress and mental health through our Farm State of Mind campaign,” said AFBF President Zippy Duvall. €œThis poll shows that we are making a difference, but we all still have work to do.

It’s up propecia cheapest price to each of us to keep looking out for our family, friends and neighbors and let them know they’re not alone when they feel the increasing stress that comes with the daily business of farming and ranching.” Morning Consult conducted the poll on behalf of AFBF in December 2021 among a national sample of 2,000 rural adults. Key findings include. Stigma around seeking help or treatment for mental health has decreased but is still a factor, particularly in agriculture. Over the past year, there has been a decrease in rural adults saying their friends/acquaintances (-4%) and people in their local community (-9%) attach stigma to seeking help or treatment for mental health propecia cheapest price. But a majority of rural adults (59%) say there is at least some stigma around stress and mental health in the agriculture community, including 63% of farmers/farm workers.

Farmers/farm workers are more comfortable propecia cheapest price talking to friends, family and their doctors about stress and mental health than they were in 2019. Four in five rural adults (83%) and 92% of farmers/farm workers say they would be comfortable talking about solutions with a friend or family member dealing with stress or a mental health condition, and the percentage of farmers/farm workers who say they would be comfortable talking to friends and family members has increased 22% since April 2019. A majority of rural adults (52%) and farmers/farm workers (61%) are experiencing more stress and mental health challenges compared to a year ago, and they are seeking care because of increased stress. Younger rural adults are more likely than older rural adults to say they are experiencing more stress and mental health challenges compared to a year ago, and they are more likely than propecia cheapest price older rural adults to say they have personally sought care from a mental health professional. A slide deck with additional detail on the full survey results is available here.

AFBF will be featuring two events focused on farmer mental health at the 103rd AFBF Convention in Atlanta, Georgia. A panel discussion with Farm Bureau representatives on Sunday, Jan propecia cheapest price. 9, at 10:45 a.m. EST, and a QPR mental health training workshop conducted by AgriSafe that offers farmers and farm families skills to recognize and respond to propecia cheapest price mental health crises using the Question, Persuade and Refer approach, on Monday, Jan. 10, at 2:00 p.m.

EST. If you or someone you know is struggling emotionally or has concerns about their mental health, visit the Farm State of Mind website propecia cheapest price at farmstateofmind.org for information on crisis hotlines, treatment locators, tips for helping someone in emotional pain, ways to start a conversation and resources for managing stress, anxiety or depression. Contact. Mike TomkoDirector, Communications(202) 406-3642miket@fb.org Ray AtkinsonDirector, Communications(202) 406-3717raya@fb.org Return to NewsroomStart Preamble Federal Communications Commission. Final rule propecia cheapest price.

In this document, the Federal Communications Commission (Commission or FCC) requires all covered text providers to support text messaging to 988, the 3-digit dialing code to reach the National Suicide Prevention Lifeline, by July 16, 2022. Given the popularity of text messaging, particularly propecia cheapest price among at-risk populations, it is essential for Americans to be able to text the Lifeline with the same short, easy-to-remember code by which they will be able to call the Lifeline. This rule is effective February 4, 2022. Start Further Info Start Printed Page 399 Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388, Michelle.Sclater@fcc.gov. End Further Info End Preamble Start Supplemental Information This propecia cheapest price is a summary of the Commission's Second Report and Order (SRO) in WC Docket No.

18-336, adopted on November 18, 2021and released on November 19, 2021. The document is available for download at https://docs.fcc.gov/​public/​attachments/​FCC-21-119A1.pdf. To request materials in accessible propecia cheapest price formats for people with disabilities (Braille, large print, electronic files, audio format), send an email to FCC504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at 202-418-0530 (voice), 202-418-0432 (TTY). Synopsis I.

Second Report propecia cheapest price and Order A. Text-to-988 Will Save Lives 1. We conclude that requiring covered text providers to support text-to-988 will save propecia cheapest price lives. No commenter in the record opposes adoption of a text-to-988 requirement. As Americans become more reliant on texting to communicate, the need to access mental health assistance and resources by text is essential.

Text messaging propecia cheapest price to the Lifeline will facilitate access to critical mental health resources for all, and particularly for at-risk populations who tend to prefer communicating through text rather than phone calls. 2. The record reflects overwhelming support for the conclusion that text-to-988 functionality will greatly improve consumer access to the Lifeline. Over 14 National Alliance on Mental Illness (NAMI) offices across the United States filed in support of text messaging to 988 propecia cheapest price. Substance Abuse and Mental Health Services Administration (SAMHSA), the Government agency responsible for overseeing the Lifeline, states that texting capability would improve equitable access to the Lifeline, especially for at-risk communities.

And Vibrant, the administrator of the Lifeline, also notes that “text-to-988 capability propecia cheapest price would improve consumer accessibility to the Lifeline and save lives.” Mental Health America suggests that “[i]f 988 is implemented without support for text messaging, individuals in need of mental health crisis services, particularly youth and adolescents, will remain unanswered.” A bipartisan group of U.S. Representatives from Colorado express their support, stating that “[b]y allowing a text-to-988 option in addition to voice call, the Commission can lower the bar to entry and improve access to crisis counseling and mental health services.” Text-to-988 will provide greater access to anyone who is not comfortable calling the Lifeline or cannot make a phone call. For instance, individuals who are in abusive or controlling situations may feel safer texting than making a verbal call when in a crisis. Similarly, for individuals who are helping someone who is experiencing symptoms such as paranoia or delusions and appears threatening, texting propecia cheapest price offers greater safety when reaching out for crisis assistance. 3.

The record also demonstrates that requiring covered text providers to support text-to-988 functionality will provide significant benefits to at-risk populations, particularly to young Americans who are disproportionately at risk for mental health crises. Research shows that serious psychological distress, major depression, and suicidal thoughts and attempts among adolescents propecia cheapest price and young adults have increased significantly in recent years. SAMHSA explains that individuals who send texts or online chats to the Lifeline both skew younger and are more likely to experience current suicidal ideation relative to the categories of individuals who typically access the Lifeline via phone. Nearly 95% of teens have access propecia cheapest price to smart phones and report that texting is the primary way by which they connect. According to Mental Health America, “[m]ultiple sources of data demonstrate youth prefer communicating by text rather than calls,” including a study finding that young people “were more likely to forgo psychological support than talk in person or over the phone.” Nevada, which conducted one of the country's first text messaging for crisis response pilot programs, TextToday, found an increase in help-seeking behaviors by youth as a result of the program and a preference for texting among the youth age cohort.

Some members of at-risk populations may prefer or find it easier to access the Lifeline via text as compared to the online chat portal, which requires people to have internet access, find the website, and locate the chat portal. A survey addressing how teens are coping and connecting during hair loss treatment reported that 65% of teens used texting propecia cheapest price to communicate with friends and family more than usual in response to the propecia. 4. In addition to young Americans, text-to-988 will help other American communities that are disproportionately impacted by suicide, including Veterans, LGBTQ+ individuals, racial and ethnic minorities, and rural Americans. Death by suicide amongst Veterans has steadily increased over the propecia cheapest price past several years.

Furthermore, the suicide rate has risen faster among Veterans than it has for non-Veteran adults. LGBTQ+ youth are nearly five times as likely to have attempted suicide compared to heterosexual youth, and the suicide rate for Black children ages 5-12 is about two times higher compared to white children. The record indicates that these at-risk communities may use text services at higher rates than propecia cheapest price other communities. For example, NAMI reports that people of color text at a higher rate than white individuals, and lower-income households send twice as many texts than households with higher incomes. Mental Health America notes that data they collected demonstrate that individuals “who identify as Black or African American are more likely propecia cheapest price to report that they would like to receive a phone number they can immediately call or text for help” than members of any other race or ethnicity.

Individuals from communities, religious groups, or ethnic backgrounds that have been found to have lower professional help-seeking behaviors or whose communities are less typically accepting of mental health treatment will also benefit from the added privacy of seeking crisis support via text. 5. Text messaging has also become a crucial form of communication for people who are deaf, propecia cheapest price hard of hearing, or have other disabilities that impact communication. Studies find an increased risk of suicide among deaf and hard of hearing people when compared to those without hearing loss. These individuals have increasingly adopted widely available text messaging platforms in lieu of specialized legacy devices, such as text telephones (TTY), because of the ease of access, wide availability, and practicability of modern text-capable devices.

Some individuals with propecia cheapest price disabilities find it more effective to access mental health support through text messaging over other means of communications. Vibrant notes that for individuals in the disability community, the ability to text crisis services directly, without need for an intermediary interpreter or service, provides “substantial benefit.” SAMHSA highlights the convenience texting would provide to people with autism spectrum disorder (ASD), who are at an increased risk for suicide, yet may have “difficulties with back and forth conversations, and may therefore prefer to text rather than call the Lifeline.” Access to communications capabilities for individuals with disabilities is a longstanding Commission priority and statutory obligation. Our requirement to support propecia cheapest price Start Printed Page 400 text-to-988 broadens access to 988 and helps ensure individuals with disabilities that impact communication can more easily reach lifesaving resources. 6. The Commission's designation of 988 as the 3-digit telephone number for the Lifeline reflected its expectation that a simple, easy-to-remember, 3-digit dialing code for suicide prevention and mental health crisis counseling would “help increase the effectiveness of suicide prevention efforts, ease access to crisis services, reduce the stigma surrounding suicide and mental health conditions, and ultimately save lives.” We conclude that providing text access at the same short code number will generate synergies that enhance the value of efforts to promote 988.

We are also mindful that the promotion propecia cheapest price and availability of the 988 short code for telephone calls to the Lifeline crisis hotline, and by extension the Veterans Crisis Line, could create confusion as to whether that number is available for, and capable of, receiving text messages. We find that requiring providers to implement text-to-988 will also help to avoid confusion or putting lives at risk. B. Designating a Wholly Unique 3-Digit Dialing Code vs propecia cheapest price. An Existing N11 7.

We adopt our proposed two-step process to establish the scope of text messages that fall within our text-to-988 requirement (86 FR 31404, June 11, propecia cheapest price 2021). While we acknowledge the importance of testing and coordination between covered text providers and the Lifeline, we decline at this time to adopt the Department of Veterans Affairs' (VA's) proposed “third-step” to our scope of text messages because the proposed testing and validation process is not germane to ex ante defining the scope of covered text providers. First, we establish an outer bound definition of “988 text message” that sets the maximum possible scope of text formats which covered text providers may be obligated to support for delivery to 988, based on the definition of “text message” that Congress enacted in 2018 in the Truth in Caller ID context. Second, we establish a process to ensure that covered text providers only must enable transmission of propecia cheapest price text messages in formats that the Lifeline can actually receive. We also define the scope of entities subject to our text-to-988 requirements— i.e., “covered text providers”—to be consistent with our text-to-911 rules, which include Commercial Mobile Radio Services (CMRS) providers and providers of interconnected text messaging services.

We find that this approach, in combination, provides a forward-looking, flexible scope that will expand with the capabilities of the Lifeline without unnecessarily obligating covered text providers to support formats that the Lifeline cannot yet receive. 1 propecia cheapest price. Scope of Covered Text Formats 8. Outer Bound propecia cheapest price Definition. Consistent with our proposal in the further notice of proposed rulemaking (FNPRM) (86 FR 31404, June 11, 2021), we adopt the Truth in Caller ID definition of “text message”—including the definitions for “short message service” (SMS) and, as a requirement when Lifeline is able to support it, “multimedia message service” (MMS)—as the outer bound scope of text messages that covered text providers may be obligated to transmit to 988, which provides that the term (1) means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number or N11 service code.

(2) includes a SMS message and a multimedia message service (commonly referred to as `MMS') message. And (3) does propecia cheapest price not include—(i) a real-time, two-way voice or video communication. Or (ii) a message sent over an internet protocol (IP)-enabled messaging service to another user of the same messaging service, except a message described in clause (2). 9. We find propecia cheapest price that there are several advantages to adopting the Truth in Caller ID definition in the text-to-988 context.

The definition encompasses, but is not exclusive to, SMS and MMS messages without limiting the outer bounds of supported text formats to specific technologies, thus providing flexibility for inclusion of future text message formats under the rules. It also represents a recent definition provided by Congress, albeit in a different policy context. We slightly propecia cheapest price modify the Truth in Caller ID definition to account for the 988 context by adopting our proposal to add “or 988” to the phrase from the Truth in Caller ID definition “10-digit telephone number or N11 service code.” This modification will ensure that covered text providers' obligations encompass those text messages sent to the Lifeline via the 3-digit code 988. We also add language clarifying that the definition we adopt “includes and is not limited to” SMS and MMS messages. This addition clarifies that the word “includes,” propecia cheapest price within the definition we adopt, does not limit the scope of messages meeting the first prong of the definition and instead merely eliminates doubt as to whether SMS and MMS meet that definition.

This clarification advances our policy goal of promoting availability of a broad range of communications methodologies for individuals reaching the Lifeline. Further, we think this clarification follows the canon of avoiding rendering language a nullity—if the definition included only SMS and MMS, the first provision would be unnecessary. 10. We decline to adopt the text-to-911 text message definition, as recommended by CTIA and T-Mobile. The Truth in Caller ID definition is more recent than the text-to-911 text message definition, and it derives from Congress.

The Truth in Caller ID definition expressly identifies that it includes images and sound. Allowing the parties that operate the Lifeline to incorporate graphics or other rich media in addition to textual communications, if they choose to do so, offers members of at-risk communities the means to communicate flexibly and fully with the Lifeline. Furthermore, the limitation of the initial implementation requirement to SMS messages, as discussed below, addresses CTIA and T-Mobile's concerns about meeting the implementation deadline if the Commission were to immediately require implementation of other text formats. The annual review process we establish below, through which the Wireline Competition Bureau (Bureau) will require covered text providers to implement only those texting formats within the outer bound definition that the Lifeline can actually receive, will ensure that covered text providers are not burdened with unnecessary work, and will avoid any consumer confusion that would arise from implementing formats that cannot go through. 11.

We clarify that the exclusions we adopt from the “988 text message” definition match those exclusions contained in the Truth in Caller ID “text message” definition. We therefore exclude “real-time, two-way voice or video communication[s],” as well as messages sent over “IP-enabled messaging service[s] to another user of the same messaging service” that are not SMS or MMS messages. Similar to the Commission's interpretation in the Truth in Caller ID Second Report and Order (84 FR 45669, August 30, 20219), we conclude that “real-time, two-way voice or video communication” includes voice calling service. We find that the plain language of the Truth in Caller ID exclusion indicates that Congress explicitly intended to exclude real-time, two-way video communication from the definition of “text message. We further “interpret the latter exclusion to include non-MMS or SMS messages sent using IP-enable Start Printed Page 401 messaging services” between users of the same service.

For example, a message transmitted via an application delivered over IP-based networks, such as Twitter or LinkedIn, to another user of the same messaging service would be excluded from the outer bound definition. 12. We decline the Consumer Electronics Association's (CEA's) request to affirmatively determine at this time what particular text messaging formats fit within the outer bound definition. We direct the Bureau to resolve questions concerning the scope of the outer bound during the annual review process by applying the statutory Truth in Caller ID definition and Commission precedent regarding that definition. We clarify that should the Bureau find in the future based on the record before it that rich communications service (RCS), real-time text (RTT), or other formats do not fall within the exclusions from the 988 text message definition, then they may be acceptable formats within the outer bound scope.

We anticipate that addressing scope issues as they arise, in the context of specific technologies, will lead to better decisions based on more detailed information than trying to decide well ahead of any specific issue arising. 13. Limitation to Currently-Employed Technology. As proposed in the FNPRM, we initially require that covered text providers only support transmission of SMS messages to 988. We adopt the proposed procedure delegating to the Bureau future determinations to require covered text providers to support additional text formats within the outer bound definition, in consultation with our Federal partners and in consideration of what text formats the Lifeline is capable of receiving.

We therefore define “covered 988 text message” as a 988 text message in SMS format and any other format that the Wireline Competition Bureau has determined must be supported by covered text providers. 14. The record supports requiring transmission of texts to 988 in SMS format. Vibrant indicates that the Lifeline can currently receive and respond to SMS messages sent to the 10-digit number. Furthermore, representatives of covered text providers and public interest groups express support for requiring transmission of SMS messages to 988.

In their support for adoption of requirements based on the Commission's text-to-911 rules, CTIA and T-Mobile note the technical feasibility of supporting SMS messages to 988, given that that format is currently supported in texting to 911. CEA also argues that the Commission should, at a minimum, require transmission of text messages in SMS within its broader outer bound definition. Because there is no technical or operational impediment to transmitting SMS messages to 988 expressed by covered text providers, and the Lifeline is currently able to receive and respond to SMS messages, we require covered text providers to support SMS messages to 988. 15. We decline at this time to require covered text providers to support other text message formats, such as MMS, RCS, and RTT, because the Lifeline cannot currently receive texts in these formats.

The Bureau will consider requiring covered text providers to support these or other additional formats through the Public Notice process we discuss below, should the Lifeline indicate it can receive such formats. While commenters note that rich media communications and next-generation text formats may offer benefits to individuals attempting to access the Lifeline, requiring covered text providers to transmit messages in these formats is premature because we do not know if or when the Lifeline will accept these formats. In addition, as CTIA states, including additional text formats such as RTT and RCS in the scope of our text-to-988 requirements “would cause consumer confusion when the Lifeline is only capable of receiving SMS messages today” and, due to technical and engineering obstacles, would likely delay implementation of text-to-988 service. Finally, with respect to multimedia messages, both the Alliance for Telecommunications Industry Solutions (ATIS) and CTIA note that including media in text messages, a feature not currently supported in text-to-911 service, would present technical obstacles that could impede implementation by the July 16, 2022, deadline that we adopt. Although Vibrant indicates that the Lifeline is technically capable of receiving MMS formats, it clarifies that Lifeline policy and clinical standards “currently block[ ] images and video from being seen by the counselor.” Because of the impediments to transmitting media such as images and video with text to 988, we decline to require covered text providers to support MMS messages to 988.

16. Just as our Federal partners recently added a texting capability to the Lifeline, they may choose to expand the functionality of their texting service over time. It is important for the requirements we establish to keep pace flexibly and readily rather than resorting to a Commission-level proceeding every time the Lifeline can accept a new text format. We therefore direct the Bureau to routinely consult with our Federal partners at SAMHSA and the VA to determine when the Lifeline has implemented a new text message format to 988. We further direct the Bureau, on or before June 30, 2023, and no less frequently than annually thereafter, to propose and seek comment on implementation parameters for covered text providers to transmit any additional text message formats to 988 that the Lifeline is capable of receiving and that are within the scope of the outer bound message definition adopted herein.

The Bureau shall identify the additional text messaging format(s) that the Lifeline is capable of receiving, if any. Propose and seek comment on an interpretive determination as to whether the additional text message format(s) fall within the outer bound definition. And propose and seek comment on implementation deadline(s) for those additional text message formats. If the Bureau finds after this process that the Lifeline is capable of receiving an additional text format that is within the scope of the outer bound definition that we have established, it shall release a second Public Notice requiring covered text providers to implement text-to-988 using that new format and setting an implementation date that is as prompt as reasonably practical. If the Bureau instead finds that, notwithstanding its initial proposal, the Lifeline is not capable of receiving an additional text format that is within the scope of the outer bound that we have established, it shall issue a Public Notice declining to adopt its initial proposal.

The Bureau may set one implementation deadline or staggered implementation deadlines for different classes of providers, and it shall identify all implementation deadlines with certainty ( i.e., by a specified calendar date). In setting a deadline or deadlines for compliance, the Bureau shall assess factors such as technical and financial challenges with respect to implementation, the status of the Lifeline, and the public interest. We find our two-step approach allows us to ensure rapid support for additional texting formats as technology evolves, while providing certainty to the industry and the public. Further, we find this approach facilitates further updates when the Lifeline implements a new texting format without requiring a Commission rulemaking, which often requires more time than Bureau-level action. Accordingly, we direct the Bureau to implement the approach we describe above, including through prescribing implementation deadlines.

Start Printed Page 402 17. CEA supports the Commission's proposal but asks for the Bureau to conduct annual public hearings rather than develop a written record. We find the proposed Public Notice procedure achieves the same purpose as a public hearing—providing a forum to establish a record regarding expansion of the covered 988 text message definition—while imposing fewer administrative burdens and costs on the public and the Commission. We expect the Bureau to meet with interested parties, as permitted by the Commission's ex parte rules. 18.

We decline to adopt CEA's proposals to bypass our Public Notice procedure and automatically include MMS, RCS, or RTT within the scope of covered 988 text messages if and when the Lifeline is ready to accept those new texting formats. We think the Public Notice process is valuable because it will allow the Bureau to gather information to set appropriate technology-specific implementation deadlines and to evaluate whether a given technology fits within the outer scope of the definition of 988 text message we adopt herein. It also provides the Bureau time to facilitate dialogue between parties should any complications arise. We are concerned that automatic inclusion of certain formats in the future could lead to avoidable problems, and we therefore decline CEA's suggestion. 19.

We also decline CEA's proposal that, should the Bureau or Commission require inclusion of RCS, RTT, or any other format, covered text providers would be required to support the new format “by the later of (i) three months after the Lifeline states that it is ready to receive such format. Or (ii) the date upon which the affected covered text provider begins providing such texting format to its customers generally.” We find it best to grant the Bureau flexibility to determine an implementation timeframe appropriate to each technology the Lifeline may implement. We prefer this approach because the Bureau will be able to make a decision based on a thorough record focused on the Lifeline's actual implementation of the technology. We anticipate that some technologies such as RTT that are already generally in use may be easier for covered text providers, especially larger providers, to support if implemented by the Lifeline, and we encourage the Bureau to take ease of implementation and availability of the technology into account when reaching a determination. 20.

We decline requests from CEA and ZP Better Together (ZP) to require direct video communication (DVC) and direct dialing from video relay service (VRS) to 988. With respect to VRS, ZP believes that by dialing 988 directly, both a Lifeline counselor and a VRS communications assistant would show up simultaneously. We are not addressing ZP's VRS request at this time because direct 988 dialing for VRS is beyond the scope of this item, which is focused on text-to-988. With respect to DVC, we strongly encourage the development and implementation of direct communications solutions for individuals with disabilities. However, the Lifeline does not receive direct communications via video.

Requiring providers to support communications that the Lifeline is not currently capable of receiving would cause consumer confusion, as individuals in crisis may attempt to access the Lifeline via direct video communications without realizing that the Lifeline cannot answer. We are pleased that the Lifeline is available to users of telecommunications relay services, including via 988, and the Lifeline maintains a separate TTY number, and we encourage our Federal partners to continue to consider additional alternative means by which individuals with disabilities may contact the Lifeline. Users of speech-to-speech services and TTY-based TRS dial 711 first to connect to a communications assistant who will complete the call to the Lifeline. 2. Definition of “Covered Text Provider” 21.

We adopt our proposed definition of “covered text providers” as that term is defined in the Commission's text-to-911 rules, to include “all CMRS providers, as well as providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones.” We find that the straightforward and well-established definition from the 911 context best delineates the scope of covered text providers obligated to support text-to-988 service. 22. The record supports our proposal to adopt the text-to-911 definition of “covered text provider” here. CTIA encourages us to keep the text-to-988 scope consistent with the scope of covered text providers in the text-to-911 context in order to “identify a well-known and experienced scope of providers who will need to work collaboratively with the Lifeline to achieve the aggressive deadline that CTIA and others have suggested.” T-Mobile similarly agrees with CTIA that the Commission should look to its text-to-911 rules when establishing the scope of covered text providers in the text-to-988 context.

And, as CTIA notes, no commenter suggests an alternative definition to our proposal. 23. We require interconnected text messaging service providers, which enable customers to “send text messages to all or substantially all text-capable U.S. Telephone numbers and receive text messages from the same,” to support text-to-988 service. We decline to apply our requirements to non-interconnected text providers, as CEA suggests.

By definition, non-interconnected text providers cannot send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, meaning they are unlikely to be able to transmit texts to and receive texts from 988. Even non-interconnected text providers that use telephone numbers—for instance where an application uses telephone numbers to identify users relative to each other rather than for routing—may nonetheless be unable to send text messages to users of other services or to all or substantially all telephone numbers. Obligating non-interconnected text providers to attempt to route texts to 988 via telephone numbers when physical routing is beyond such providers' control could increase customer confusion or diminish public trust in texting as a means to reach the Lifeline. 24.

Voice on the Net (VON) and Mitel request that we exempt covered text providers in Wi-Fi only locations because “there remain challenges to the reliability of routing text messages to interconnected networks without the benefit of a CMRS provider.” We decline at this time to adopt a blanket exemption for covered text providers in Wi-Fi only locations. While we anticipate interconnected text messaging service providers will typically use CMRS-based solutions to support text-to-988, CMRS networks are not the only means of interconnection, and covered text providers may use any reliable method or methods to support text routing and transmission to 988. Furthermore, neither VON nor Mitel elaborate on or provide evidence to support their claims of technical challenges associated with routing without access to a CMRS network, or that such challenges cannot be bypassed by adopting a non-CMRS solution. While we agree with Mitel that “[r]outing messages to the interconnected network often requires access to an underlying wireless network or provider,” commenters have not provided sufficient support for us to Start Printed Page 403 conclude that covered text providers in Wi-Fi only locations are never able to use a CMRS-based or alternative method to reliably support text routing and transmission to 988. We reiterate that our requirements exclude providers that are unable to allow consumers to send text messages to and receive text messages from all or substantially all text-capable U.S.

Telephone numbers. C. Routing Texts to 988 25. We adopt our proposal to require covered text providers to route covered 988 text messages to the Lifeline's current 10-digit number, 1-800-273-8255 (TALK). Our decision is consistent with the Commission's approach in the 988 Report and Order (85 FR 57767, September 16, 2020) to require service providers to “transmit all calls initiated by an end user dialing 988 to the current toll free access number for the Lifeline.” Most commenters support centralized routing for text-to-988.

26. We find our centralized routing rule will allow for swift implementation of text-to-988 to the Lifeline's 10-digit number by lowering technical requirements and costs for covered text providers to route texts to the Lifeline. As Vibrant states, our centralized routing solution for text-to-988 will “allow[] for a seamless delivery of crisis intervention services that is consistent with clinical standards, best practices, and national guidelines overseen by the administrator and SAMHSA.” CTIA notes that by requiring centralized routing, “the Commission can significantly lower technical hurdles to enable wireless providers to deploy text-to-988 as soon as possible.” ATIS “has not identified any technical challenges associated with” routing covered 988 texts to the Lifeline 10-digit number. We note that several wireless providers were able to implement routing calls to 988 within six months of adoption, and we anticipate that similarly swift implementation may be possible here. 27.

We also find that adopting our proposal will provide our Federal partners with the flexibility to develop and expand routing solutions to meet the Lifeline's needs. Once text messages are routed to the Lifeline's 10-digit number, the Lifeline can then “forward those messages to the appropriate local crisis center,” similar to the current mechanism for voice call routing to 988. Currently, the Lifeline's network consists of over 180 crisis centers, with 33 centers providing text service. SAMHSA has identified resource strain and capacity issues experienced during its rollout of text service to the Lifeline's 10-digit number and, as a result, indicates its intention to explore working with existing crisis text and chat services outside the Lifeline as well as expanding text capacity within the network. We encourage SAMHSA and the VA to work with outside entities as needed to meet increased demand, and we believe our centralized routing rule will better allow for the Lifeline's network to adapt, evolve, and expand as necessary to meet capacity and technological needs.

28. We decline to require covered text providers to route covered 988 text messages directly to a Lifeline local crisis center or Veterans Crisis Line crisis center. While text-to-911 uses such direct routing, we believe that approach would be counterproductive for text-to-988. We disagree with Intrado's proposal to leverage the existing text-to-911 infrastructure by using Intrado's Text Control Center (TCC) services to transmit texts to 988 directly to an individual local crisis center, once the crisis center has made a valid request for text-to-988 service. This proposal mirrors the text-to-911 rules, where a covered text provider must enable text-to-911 service within six months of a local Public Safety Answering Point's (PSAP's) valid request for service.

We are concerned that implementation of a localized routing model would be time-consuming, contrary to our goal of making text-to-988 rapidly available to all Americans. CTIA and T-Mobile point to specific technical and administrative challenges should the Commission require covered text providers to route texts to 988 to local crisis centers, which would compromise swift implementation by the July 16, 2022, date. ATIS, T-Mobile, and VON also note routing to the local crisis centers would require the adoption of new technical standards and specifications, including the development of intermediate gateway providers at regional centers, which could increase costs and delay launch of text-to-988. Requiring delivery of texts to 988 to individual crisis centers could impede the Lifeline network's future expansion, as covered text providers would need to implement text routing to each new center to ensure that the community served by that center can communicate via text if desired, as opposed to immediate nationwide access through centralized routing. Furthermore, as CTIA points out, “Intrado fails to explain why texts to 9-8-8 should be routed differently from voice calls to 9-8-8.” We see no difference between voice and text service to the Lifeline presented in the record that would justify adopting alternate routing infrastructures for either service.

In contrast, there are significant differences between 988 and 911, chief among them the nationwide Lifeline voice and text service routed through a centralized, toll free 10-digit number as opposed to the localized PSAP network. 29. We find that it is premature to require covered text providers to enable covered 988 text messages to include location information. As instructed by Congress in the National Suicide Hotline Designation Act of 2020, in April 2021 the Bureau released a report on the costs and feasibility of providing location information with calls to 988. In the report, the Bureau recommended the establishment of a multi-stakeholder advisory committee to develop detailed recommendations on how to address several challenges presented in the record, including privacy considerations, technical implementation, and cost recovery.

NAMI and Vibrant reiterate arguments raised in the 988 Geolocation Report that requiring geolocation information with calls and texts to local crisis centers will improve accuracy in connecting individuals in crisis with counselors who are in the best position to provide localized care. Yet, as the Bureau identified in the 988 Geolocation Report, requiring providers to transmit location information to 988 “raises important privacy and legal issues, is technically complex, and could impose significant costs.” Several commenters, including ATIS and CTIA, highlight the challenges identified in the 988 Geolocation Report and oppose a location information requirement for text-to-988, indicating it would be premature for the Commission to adopt such a mandate without further study and standards development. Given the similar complexity and interrelation between call and text routing to 988, we decline, at this time, NAMI and Vibrant's requests to require location information with texts transmitted to 988. Commenters also raise privacy concerns should the Commission require the transmission of location information without the texter's consent. Given the Bureau's recommendation and the similar concerns raised in the record regarding technical limitations of providing location information, we decline, at the present time, to require covered text providers to include location information with texts to 988.

30. We also decline to require covered text providers to take action to route texts to 988 to the Veterans Crisis Line, and we instead defer to our Federal partners to determine whether and how to make it possible to text 988 for the Start Printed Page 404 Veterans Crisis Line's text service. Telephone callers to the Lifeline's 10-digit number can press “1” to connect directly with a crisis counselor at the Veterans Crisis Line. Texting, on the other hand, is not presently integrated—texters who wish to reach the Veterans Crisis Line contact a text short code (838255) rather than the Lifeline's toll free 10-digit number. We recognize that there would be significant benefits to enabling texters to reach the Veterans Crisis Line by texting 988.

At the same time, we recognize the critical need for carefully developing a pilot program and extensively testing the transfer of texts between 988 and the Veterans Crisis Line to ensure that no Service Member, Veteran, or family member is left without access to lifesaving resources. Any rush to enable texting 988 for the Veterans Crisis Line's text service before sufficient implementation work and testing would raise safety concerns, should any text conversations be dropped or lost in transfer. We believe our Federal partners at the VA and SAMHSA are best positioned to evaluate the benefits, challenges, and costs of transferring texts and to pursue a solution, if desirable. We agree with ATIS that use of 988 “makes it infeasible to automatically route calls to one service or the other” without additional information, such as through a secondary input exchange, to enable providers to correctly route the text to the proper recipient. There is no record support for Commission action to require providers to selectively route texts to 988 to the Veterans Crisis Lifeline's text service.

Nor does the record reveal any solutions for requiring providers to implement texting to 988 for the Veterans Crisis Line's text service that we could effectuate in conjunction with requiring providers to implement texting to 988 for the Lifeline. After evaluation and testing, our Federal partners may be able to pursue a workable, reliable approach to enabling texts to 988 to reach the Veterans Crisis Line. At the present time, Service Members, Veterans, and their families may reach the Veterans Crisis Line by calling 1-800-273-8255 and pressing 1, by texting 838255, or by chat through the Veterans Crisis Line's website, https://www.veteranscrisisline.net. We recognize that during the rollout and launch of 988, our Federal partners at the VA will face challenges in promoting widespread public awareness that the Veterans Crisis Line is reachable by text through a short code that is separate from 988. We direct Commission staff to work cooperatively with our Federal partners to promote awareness of how Service Members, Veterans, and their families can reach the Veterans Crisis Line.

D. Implementation Timeframe 31. We adopt our proposal to set a uniform nationwide implementation deadline for text-to-988 of July 16, 2022—concurrent with 988's voice implementation deadline—for all covered text providers to support transmission of all covered 988 text messages. As stated above, this deadline applies only to texts the user sends to 988. It does not apply to texts to the Veterans Crisis Line using its existing short code.

Guiding our decision is the need to minimize the time needed to implement text-to-988 so as to help address the growing epidemic of suicide as quickly as possible. By setting a uniform deadline, rollout of text-to-988 will be most effective, enabling stakeholders to clearly and consistently communicate when the public can access texting services universally, while avoiding any confusion stemming from a different deadline than voice implementation. Although a phased-in approach may enable us to set a shorter deadline for some providers, this approach risks confusion not just among those “unaware of the details of staggered regulatory deadlines,” but also among those who may seek to call rather than text. Such a scenario “could be disastrous for individuals and, in the aggregate, could erode trust in the Lifeline.” Further, we find that a July 16, 2022, deadline provides the Lifeline adequate time to prepare for additional texting volume, with Vibrant expressing confidence following its successful 2021 pilot program that “the Lifeline has the capability to receive text-to-988 messages on the first day of 988 operation.” And as ATIS highlights, because we only require that covered text providers send text messages to the Lifeline's 10-digit number, the need for a phased approach is eliminated. 32.

We specifically set a deadline of July 16, 2022, which nearly all commenters who address timing support. Just as we concluded previously with respect to 988 implementation for voice calls, we set as early of a deadline as possible because of the numerous benefits of swift implementation in preventing suicide. As explained above, providers need not route calls to individual call centers, eliminating the need for lengthy development of new technical standards and specifications. Some providers themselves also support a July 16, 2022, deadline as providing sufficient time for implementation. Setting a deadline for text-to-988 that matches the existing deadline for implementing calls to 988 also avoids public confusion and enhances the efficacy of marketing campaigns promoting 988.

As the Mental Health Associations state, “[d]elaying an implementation deadline [beyond July 2022] will not prevent people in crisis from reaching out to 988 through text,” and such individuals will find their “[r]equest for help will go unanswered” without action in this proceeding. 33. We reject VON's arguments that we should set a deadline of 12 months following the effective date of the order due to “[t]he need to develop and implement new routing and technical standards” that may pose challenges to meeting the voice deadline of July 16, 2022. Specifically, VON compares the Lifeline's call centers to PSAPs, explaining how in the context of text-to-911, a new joint standard needed to be created in order to direct texts to the latter. However, as explained above, we do not require that providers route texts to individual call centers, but instead to the Lifeline's toll free 10-digit number.

Additionally, VON cites these potential challenges only in vague terms, and claims only that they “might” serve as obstacles to “meeting the voice deadline of July 16, 2022.” Moreover, as explained below, the flexible text-to-988 rules we adopt in this document do not generate significant technical obstacles, and the record's support for a July 16, 2022, deadline suggests that the issues pertinent to a texting solution specifically can be overcome in the given timeframe. For example, ATIS supports a July 16, 2022, deadline as “reasonable” given that “it is already possible to text the existing Lifeline toll-free number,” highlighting that “texting to the new three-digit short code (988) would create no new technical challenges.” E. Technical Considerations 34. We adopt our proposal to allow covered text providers to use any reliable method or methods to support text routing and transmission to 988. We reiterate that covered text providers may use any reliable method or methods to support text routing and transmission to 988, and emphasize our neutrality on the technologies that covered text providers use to support text messaging to 988.

We find that this approach accounts for currently-available text messaging formats and technologies and also provides the flexibility to adapt to future availability. No commenter opposed our proposal. As ATIS explains, texting to 988 “can and should be implemented in a timely manner[,]” Start Printed Page 405 and should “create no technical challenges.” 35. Network Upgrades. Based on the record, we do not expect that covered text providers will need to install significant network upgrades to implement the texting to 988 requirements adopted herein.

Though covered text providers must determine how to support texting to 988 as adopted, the rules we adopt in this document provide the flexibility to choose the most effective method for doing so. For example, covered text providers may choose to route text messages to 988 over their mobile-switched networks or use an IP-based method to deliver text messages to the Lifeline. We are encouraged that many providers have implemented voice calling to 988 a year or more before the implementation deadline, and we envision that covered text providers can also easily implement texting to 988. 36. Equipment Upgrades.

We find, based on the record, that no significant software or equipment upgrades will be necessary to implement texting to 988. We agree with ATIS, one of the organizations that set the standards for texting to 911, that “[a] focus on functionality rather than technical standards is required to meet the needs of those who communicate primarily via texting.” We are not persuaded by VON's argument that, like implementing text-to-911, industry needs to develop new routing and technical standards that may delay text-to-988's implementation. VON generically states that 911 networks and the Lifeline are “two distinct infrastructures” that will require new standards, but does not explain why these infrastructural differences merit developing new standards. We find more convincing ATIS's assertion that changes to industry standards will “be minimal if, as expected, no changes are required to consumer devices to support text-to-988 requirements” because the bulk of the record indicates that texting to 988's centralized routing solution, limited scope of text messaging service technologies, and other adopted requirements are straightforward to implement by our adoption deadline. 37.

We exempt legacy devices that are incapable of sending text messages via 3-digit codes from the text-to-988 requirements, provided the software for these devices cannot be upgraded over the air to allow text-to-988. In the Text-to-911 proceeding, the Commission did not require certain legacy devices to comply with the text-to-911 requirements because “the messaging application or interface on the mobile device will likely provide an error message indicating an invalid destination number, reducing user confusion somewhat” that the legacy device could not support texting to 911. No commenter discussed legacy devices nor indicated that circumstances have changed since the Commission adopted this exemption in the Text-to-911 proceeding. Accordingly, we find that the same exemption is appropriate here. 38.

Network Access. We require CMRS providers to allow access to their SMS networks by any other covered text provider for the capabilities necessary to transmit 988 text messages originating on such other covered text providers' networks, similar to the text-to-911 rules. We find this rule is necessary to implement our text to 988 requirement as we anticipate that many interconnected text providers will choose CMRS network-based solutions to implement texting to 988. No commenter opposed providing this network access. Mitel explains that, like in the texting to 911 context, routing messages to interconnected networks often requires access to an underlying wireless network and provider.

Similar to the text-to-911 rules, we adopt this requirement to “respond to consumers' reasonable expectations and reduce consumer confusion” regarding text-to-988's availability. 39. Similar to the Commission's position in the Text-to-911 Second Report and Order (79 FR 55367, September 14, 2014), we conclude that it is the responsibility of the covered text provider using the CMRS-based solution to ensure that its text messaging service is technically compatible with the CMRS providers' SMS-based network and devices and in conformance with any applicable technical standards. As in the text-to-911 context, we further require CMRS providers to make any necessary specifications for accessing their SMS networks available to other covered text providers upon request, and to inform such covered text providers in advance of any changes to these specifications. We clarify, however, that we do not intend to use these requirements to establish an open-ended obligation for CMRS providers to maintain underlying SMS network support merely for the use of other providers, nor do we require CMRS providers to reconfigure any SMS text-to-988 platforms in order to facilitate the ability of other covered text providers to access the CMRS providers' networks.

Further, as with the text-to-911 rules, CMRS providers' obligation to allow access to CMRS networks “is limited to the extent that the CMRS providers offers SMS.” While we expect that adopting these rules will similarly encourage “interconnected text providers to actively develop solutions to support [text-to-988] without reliance on CMRS providers' underlying networks,” we nonetheless encourage providers to enact solutions to carry other covered text providers' text messages to 988 over their networks. F. Other Issues 40. Cost Recovery. We adopt our proposal to require all covered text providers to bear their own costs to implement text-to-988.

We find that this approach promotes efficiency in implementation and avoids unnecessary administrative costs. In the 988 Report and Order, we observed that “[u]nlike previous numbering proceedings in which the Commission established a cost recovery mechanism,” implementation of 988 itself does not involve “shared industry costs such as central or regional numbering databases or third-party administrators.” Similarly, we conclude that implementation of a text-to-988 solution requires no shared industry costs, with costs being provider-specific and solutions unique to each. As such, as proposed in the FNPRM we find that the requirements in section 251(e)(2) of the Act that “[t]he cost of establishing telecommunications numbering administration arrangements and number portability shall be borne by all telecommunications carriers on a competitively neutral basis” does not apply. 41. Bounce-back Messages.

We decline to require covered text providers to send an automatic bounce-back message specifically designed to address where text-to-988 service is unavailable for several reasons. First, the record indicates that failed messages are likely to be rare. CTIA explains that network failures are “rare due to redundancies in the SMS network” and Vibrant indicates that to date the Lifeline's text messaging service has not experienced any downtime. Second, in the rare instance that covered text providers fail to deliver a text message to the Lifeline, current notice practices are sufficient. Individuals texting the Lifeline currently receive a bounce-back message under a variety of circumstances.

CTIA explains that covered text providers usually send customers a notification from a device or network when a CMRS provider cannot deliver a text message due to a network failure. Vibrant also indicates that the Lifeline currently sends individuals scheduled text messages approximately every 10 minutes if there is a wait to reach a crisis counselor that informs them they are in the queue, offers access to other Start Printed Page 406 resources while they wait, and provides the option to call the Lifeline. Consequently, we further agree with commenters that to the extent operational concerns, network congestion, or outsized demand prevent texters from reaching a crisis counselor, the parties that operate the Lifeline are in the best position to send a message to texters because covered text providers do not have visibility into the Lifeline's operations. Third, we decline to require 988-specific bounce-back messages because such a mandate risks delay of text-to-988 implementation. We recognize comments from CTIA which state that developing a bounce-back messaging capability “would require substantial additional time and complexity, as well as the development of standards and requirements for implementation, and would significantly delay the July 16, 2022 implementation target.” T-Mobile further asserts that when a CMRS provider has not delivered a text message to the Lifeline due to network congestion, sending a Lifeline-specific automatic bounce-back message could be technically infeasible because “[c]arriers cannot determine if a text sent to the 10-digit Lifeline number has not been delivered due to network congestion or other factors related to nature of SMS generally.” 42.

Finally, a key circumstance that prompted the Commission to require automatic bounce-back messaging for text-to-911 are not present for text-to-988. In the Text-to-911 proceeding, the Commission adopted an automatic bounce-back messaging requirement because texting was and is only available to some PSAPs, and Americans in many parts of the country could not text 911 at all. In contrast, our centralized routing approach ensures that texting to 988 will be uniformly available nationwide. The unique geographic gaps that the bounce-back requirement addresses in the 911 context are not present here. It is possible that, as in the text-to-911 context, requiring a bounce-back message for text-to-988 could help “persons in emergency situations being able to know immediately if a text message has been delivered to the proper authorities” in the limited situations when consumers cannot send text messages to the Lifeline.

However, given the urgency of improving access to lifesaving suicide prevention resources, and in light of existing protections against and in the event of a delivery failure, we decline to a bounce-back messaging requirement for text-to-988 at this time. We will monitor the operation of texting to 988 post-implementation and will not hesitate to revisit the issue of requiring a bounce-back if warranted. 43. Federal Coordination. We direct the Bureau to continue to coordinate implementation of 988 with SAMHSA, including any issues pertaining to the delivery of text messages to 988.

We direct the Bureau and Commission staff to support the VA in promoting awareness of texting options for Service Members, Veterans, and their families, and to support the VA and SAMHSA in piloting, testing, and implementing any solution our Federal partners may choose to pursue to allow texting to 988 for the Veterans Crisis Line's text service. We also encourage SAMHSA to continue to work to expand the Lifeline's texting infrastructure. We will continue to work with and support our Federal partners in their efforts to assist Americans in crisis. 44. Future Technical Corrections to Lifeline 10-Digit Number.

In our rules, we identify the current 10-digit telephone number of the Lifeline, 1-800-273-8255 (TALK). We direct the Bureau, after notice and comment, to update this reference to the correct number if the Lifeline ever changes telephone numbers. This direction applies to the text-to-988 rules we adopt in this document and to our previously-adopted 988 telephone rules. G. Legal Authority 45.

We conclude that Title III of the Act and the Twenty-First Century Communications and Video Accessibility Act (CVAA) provide us with authority for the rules we adopt in this document. No commenter opposes these conclusions. With respect to CMRS providers, we find that Title III provides us the authority to require wireless carriers to enable and support text-to-988 service. Consistent with the U.S. Supreme Court's recognition that Title III provides the Commission a “broad mandate” to manage spectrum usage in the public interest, we find that significant public interest benefits will likely inure from broadly enabling access to lifesaving services through texting.

Further, the rules adopted here are analogous to those the Commission adopted to facilitate text-to-911, which relied in part on the Commission's Title III authority. Therefore, with respect to CMRS providers, we conclude that Title III provides sufficient authority for the rules we adopt in this document. 46. As to interconnected text messaging service providers, the CVAA granted us authority to adopt “other regulations. .

. As are necessary to achieve reliable, interoperable communication that ensures access by individuals with disabilities to an internet protocol-enabled emergency network.” We conclude that the Lifeline constitutes an “emergency network” within the meaning of the CVAA. The CVAA does not define what an “emergency network” is, nor does it elaborate on what qualifies as “emergency services.” However, Congress, through the National Suicide Hotline Designation Act, deemed “life-saving resources” such as the Lifeline and the Veterans Crisis Line “essential” and recognized the need for an “easy-to-remember, 3-digit phone number”—that is, one readily available in an emergency situation. As CTIA argues, it is therefore reasonable to conclude that such services should be considered “emergency services” and that the Lifeline and Veterans Crisis Line act as an “emergency network” within the meaning of the CVAA. Moreover, texting capabilities provide “easy access to emergency services for people with disabilities,” including those with hearing and speech disabilities.

Such individuals may not be able to take advantage of 988's voice service, necessitating that an alternative means of communicating be provided. We therefore conclude that the CVAA provides authority for the rules we adopt in this document, and the record reflects agreement with our analysis. Because we find that Title III and the CVAA provide sufficient authority for the rules we adopt in this document, we find it unnecessary to address other possible sources of authority to adopt these rules. H. Benefits and Costs of Text-to-988 47.

Consistent with our proposal in the FNPRM, we find that benefits of requiring service providers to support text-to-988 far exceed the costs of implementation. The loss of victims' lives to suicide cannot be adequately captured by any pecuniary measure. The principal benefit of text-to-988 is that it will reduce suicide risk by providing an additional means of reaching help for the most vulnerable. Text-to-988 will reduce the risk of suicide mortality, primarily among those who would either send a text to 988 or forgo a lifesaving intervention altogether. Three vulnerable communities, in particular, face this stark choice.

Youth, who rely heavily on text messages for their general communications needs. The deaf, deafblind, hard of hearing, and speech disabled. And those who are reluctant to dial 988 because they feel unsafe, ashamed or embarrassed, including many LGBTQ+ youth and victims of domestic abuse. As outlined Start Printed Page 407 above, the ability to text to the short and easy-to-remember 988 code will make the lifesaving interventions of the Lifeline crisis centers even more accessible than dialing alone. As no commenter in the record disputes, we find that the benefits of implementing text-to-988 will quickly exceed costs, and dwarf them over time.

48. In the FNPRM, we estimated the cost of implementing text to 988 would be nearly $27 million over five years. We based our estimate on Intrado's existing estimates of the costs of upgrading 911 call centers to receive text messages. Although one commenter asserts that the costs of implementation are likely to be “substantially lower” than our estimate, no commenters provided any individual estimates or disputed our underlying approach or our estimate of the combined total cost of nearly $27 million with an alternate figure. We agree that implementation costs may be lower than we projected.

However, since no commenter provided an estimate of the impact of these potential reductions, we find it prudent to rely on our original estimate. 49. Commenters suggest quantifiable benefits that would greatly exceed these costs. For example, the Mental Health Associations emphasize that improved access to “mental health response to mental health crises” will result in cost savings for communities and individuals. These “[e]mergency department visits for mental health and substance use disorders cost an average of $520 across 10.7 million visits in 2017, for a total cost nationwide of nearly $5.6 billion.” Any reduction in these visits and resulting cost savings are benefits of implementing text-to-988.

In addition, the Center for Law and Social Policy (CLASP) points to an evaluation of Nevada's TextToday pilot program, one of the country's first crisis response lines that accepted text messages. The evaluation found an increase in help-seeking by youth and a preference for texting. Groups that would be especially likely to benefit from text-to-988 are members of the LGBTQ+ community, and deaf, deafblind, hard of hearing, and speech-disabled adults. Between 2015 and 2019, we estimate there were more than 39,000 suicides among youth 10-19, LGBTQ+ adults, and deaf, deafblind, hard of hearing, and speech-disabled adults. If text-to-988 reduces the annual risk of suicide mortality among these groups and others by even a very small amount, the benefits would easily outweigh the costs of implementing text-to-988.

II. Final Regulatory Flexibility Analysis 1. As required by the Regulatory Flexibility Act of 1980, as amended (RFA), an Initial Regulatory Flexibility Analysis (IRFA) was incorporated into the FNPRM, released April 2021. The Commission sought written public comments on the proposals in the FNPRM, including comment on the IRFA. No comments were filed addressing the IRFA.

Because the Commission amends its rules in the Second Report and Order, the Commission has included this Final Regulatory Flexibility Analysis (FRFA). This present FRFA conforms to the RFA. A. Need for, and Objectives of, the Rules 2. In the Second Report and Order, the Commission adopts rules requiring CMRS providers and providers of interconnected text messaging services that enable consumers to send text messages to, and receive text messages from, all or substantially all text-capable U.S.

Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones (covered text providers) to enable delivery of text messages to 988. The Commission further requires that covered text providers route 988 text messages to the National Suicide Prevention Lifeline's (Lifeline) 10-digit number, currently 1-800-273-8255 (TALK). The Commission believes these rules will expand the availability of mental health and crisis counseling resources to Americans who suffer from depressive or suicidal thoughts, by allowing individuals in crisis to reach the Lifeline by texting 988. B. Summary of Significant Issues Raised by Public Comments in Response to the IRFA 3.

There were no comments filed that specifically addressed the proposed rules and policies presented in the IRFA. C. Response to Comments by the Chief Counsel for Advocacy of the Small Business Administration 4. Pursuant to the Small Business Jobs Act of 2010, which amended the RFA, the Commission is required to respond to any comments filed by the Chief Counsel for Advocacy of the Small Business Administration (SBA), and to provide a detailed statement of any change made to the proposed rules as a result of those comments. 5.

The Chief Counsel did not file any comments in response to the proposed rules in this proceeding. D. Description and Estimate of the Number of Small Entities to Which the Rules Will Apply 6. The RFA directs agencies to provide a description of, and where feasible, an estimate of the number of small entities that may be affected by the final rules adopted pursuant to the Second Report and Order. The RFA generally defines the term “small entity” as having the same meaning as the terms “small business,” “small organization,” and “small governmental jurisdiction.” In addition, the term “small business” has the same meaning as the term “small-business concern” under the Small Business Act.

A “small-business concern” is one which. (1) Is independently owned and operated. (2) is not dominant in its field of operation. And (3) satisfies any additional criteria established by the SBA. 7.

Small Businesses, Small Organizations, Small Governmental Jurisdictions. Our actions, over time, may affect small entities that are not easily categorized at present. We therefore describe here, at the outset, three broad groups of small entities that could be directly affected herein. First, while there are industry specific size standards for small businesses that are used in the regulatory flexibility analysis, according to data from the SBA's Office of Advocacy, in general a small business is an independent business having fewer than 500 employees. These types of small businesses represent 99.9% of all businesses in the United States, which translates to 30.7 million businesses.

8. Next, the type of small entity described as a “small organization” is generally “any not-for-profit enterprise which is independently owned and operated and is not dominant in its field.” The Internal Revenue Service (IRS) uses a revenue benchmark of $50,000 or less to delineate its annual electronic filing requirements for small exempt organizations. Nationwide, for tax year 2018, there were approximately 571,709 small exempt organizations in the U.S. Reporting revenues of $50,000 or less according to the registration and tax data for exempt organizations available from the IRS. 9.

Finally, the small entity described as a “small governmental jurisdiction” is defined generally as “governments of cities, counties, towns, townships, villages, school districts, or special districts, with a population of less than fifty thousand.” U.S. Census Bureau data from the 2017 Census of Governments indicate that there were 90,075 local governmental jurisdictions consisting of general purpose Start Printed Page 408 governments and special purpose governments in the United States. Of this number there were 36,931 general purpose governments (county, municipal and town or township) with populations of less than 50,000 and 12,040 special purpose governments—independent school districts with enrollment populations of less than 5ll governmental jurisdictions. 10. Wired Telecommunications Carriers.

The U.S. Census Bureau defines this industry as “establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired communications networks. Transmission facilities may be based on a single technology or a combination of technologies. Establishments in this industry use the wired telecommunications network facilities that they operate to provide a variety of services, such as wired telephony services, including [voice over internet protocol] VoIP services, wired (cable) audio and video programming distribution, and wired broadband internet services. By exception, establishments providing satellite television distribution services using facilities and infrastructure that they operate are included in this industry.” The SBA has developed a small business size standard for Wired Telecommunications Carriers, which consists of all such companies having 1,500 or fewer employees.

U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated that year. Of this total, 3,083 operated with fewer than 1,000 employees. Thus, under this size standard, the majority of firms in this industry can be considered small. 11.

Local Exchange Carriers (LECs). Neither the Commission nor the SBA has developed a size standard for small businesses specifically applicable to local exchange services. The closest applicable North American Industry Classification System (NAICS) Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S.

Census Bureau data for 2012 show that there were 3,117 firms that operated for the entire year. Of that total, 3,083 operated with fewer than 1,000 employees. Thus under this category and the associated size standard, the Commission estimates that the majority of local exchange carriers are small entities. 12. Incumbent Local Exchange Carriers (Incumbent LECs).

Neither the Commission nor the SBA has developed a small business size standard specifically for incumbent local exchange services. The closest applicable NAICS Code category is Wired Telecommunications Carriers. Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 indicate that 3,117 firms operated the entire year.

Of this total, 3,083 operated with fewer than 1,000 employees. Consequently, the Commission estimates that most providers of incumbent local exchange service are small businesses that may be affected by our actions. According to Commission data, one thousand three hundred and seven (1,307) Incumbent Local Exchange Carriers reported that they were incumbent local exchange service providers. Of this total, an estimated 1,006 have 1,500 or fewer employees. Thus, using the SBA's size standard the majority of incumbent LECs can be considered small entities.

13. Competitive Local Exchange Carriers (Competitive LECs). Competitive Access Providers (CAPs), Shared-Tenant Service Providers, and Other Local Service Providers. Neither the Commission nor the SBA has developed a small business size standard specifically for these service providers. The appropriate NAICS Code category is Wired Telecommunications Carriers and under that size standard, such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data for 2012 indicate that 3,117 firms operated during that year. Of that number, 3,083 operated with fewer than 1,000 employees. Based on these data, the Commission concludes that the majority of Competitive LECS, CAPs, Shared-Tenant Service Providers, and Other Local Service Providers, are small entities. According to Commission data, 1,442 carriers reported that they were engaged in the provision of either competitive local exchange services or competitive access provider services.

Of these 1,442 carriers, an estimated 1,256 have 1,500 or fewer employees. In addition, 17 carriers have reported that they are Shared-Tenant Service Providers, and all 17 are estimated to have 1,500 or fewer employees. Also, 72 carriers have reported that they are Other Local Service Providers. Of this total, 70 have 1,500 or fewer employees. Consequently, based on internally researched FCC data, the Commission estimates that most providers of competitive local exchange service, competitive access providers, Shared-Tenant Service Providers, and Other Local Service Providers are small entities.

14. Interexchange Carriers (IXCs). Neither the Commission nor the SBA has developed a small business size standard specifically for Interexchange Carriers. The closest applicable NAICS Code category is Wired Telecommunications Carriers. The applicable size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data for 2012 indicate that 3,117 firms operated for the entire year. Of that number, 3,083 operated with fewer than 1,000 employees. According to internally developed Commission data, 359 companies reported that their primary telecommunications service activity was the provision of interexchange services. Of this total, an estimated 317 have 1,500 or fewer employees.

Consequently, the Commission estimates that the majority of interexchange service providers are small entities. 15. Local Resellers. The SBA has not developed a small business size standard specifically for Local Resellers. The SBA category of Telecommunications Resellers is the closest NAICS code category for local resellers.

The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. Mobile virtual network operators (MVNOs) are included in this industry. Under the SBA's size standard, such a business is small if it has 1,500 or fewer employees.

U.S. Census Bureau data from 2012 show that 1,341 firms provided resale services during that year. Of that number, all operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities. According to Commission data, 213 carriers have reported that they are engaged in the provision of local resale services.

Of these, an estimated 211 have 1,500 or fewer employees and two have more than 1,500 employees. Consequently, the Commission estimates that the majority of local resellers are small entities. 16. Toll Resellers. The Commission has not developed a definition for Toll Resellers.

The closest NAICS Code Category is Telecommunications Start Printed Page 409 Resellers. The Telecommunications Resellers industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. MVNOs are included in this industry.

The SBA has developed a small business size standard for the category of Telecommunications Resellers. Under that size standard, such a business is small if it has 1,500 or fewer employees. 2012 U.S. Census Bureau data show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees.

Thus, under this category and the associated small business size standard, the majority of these resellers can be considered small entities. According to Commission data, 881 carriers have reported that they are engaged in the provision of toll resale services. Of this total, an estimated 857 have 1,500 or fewer employees. Consequently, the Commission estimates that the majority of toll resellers are small entities. 17.

Other Toll Carriers. Neither the Commission nor the SBA has developed a definition for small businesses specifically applicable to Other Toll Carriers. This category includes toll carriers that do not fall within the categories of interexchange carriers, operator service providers, prepaid calling card providers, satellite service carriers, or toll resellers. The closest applicable size standard under SBA rules is for Wired Telecommunications Carriers. The applicable SBA size standard consists of all such companies having 1,500 or fewer employees.

U.S. Census Bureau data for 2012 indicates that 3,117 firms operated during that year. Of that number, 3,083 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of Other Toll Carriers can be considered small. According to internally developed Commission data, 284 companies reported that their primary telecommunications service activity was the provision of other toll carriage.

Of these, an estimated 279 have 1,500 or fewer employees. Consequently, the Commission estimates that most Other Toll Carriers are small entities. 18. Prepaid Calling Card Providers. Neither the Commission nor the SBA has developed a small business definition specifically for prepaid calling card providers.

The most appropriate NAICS code-based category for defining prepaid calling card providers is Telecommunications Resellers. This industry comprises establishments engaged in purchasing access and network capacity from owners and operators of telecommunications networks and reselling wired and wireless telecommunications services (except satellite) to businesses and households. Establishments in this industry resell telecommunications. They do not operate transmission facilities and infrastructure. MVNOs are included in this industry.

Under the applicable SBA size standard, such a business is small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that 1,341 firms provided resale services during that year. Of that number, 1,341 operated with fewer than 1,000 employees. Thus, under this category and the associated small business size standard, the majority of these prepaid calling card providers can be considered small entities.

According to the Commission's Form 499 Filer Database, 86 active companies reported that they were engaged in the provision of prepaid calling cards. The Commission does not have data regarding how many of these companies have 1,500 or fewer employees, however, the Commission estimates that the majority of the 86 active prepaid calling card providers that may be affected by these rules are likely small entities. 19. Wireless Telecommunications Carriers (except Satellite). This industry comprises establishments engaged in operating and maintaining switching and transmission facilities to provide communications via the airwaves.

Establishments in this industry have spectrum licenses and provide services using that spectrum, such as cellular services, paging services, wireless internet access, and wireless video services. The appropriate size standard under SBA rules is that such a business is small if it has 1,500 or fewer employees. For this industry, U.S. Census Bureau data for 2012 show that there were 967 firms that operated for the entire year. Of this total, 955 firms employed fewer than 1,000 employees and 12 firms employed of 1000 employees or more.

Thus under this category and the associated size standard, the Commission estimates that the majority of Wireless Telecommunications Carriers (except Satellite) are small entities. 20. The Commission's own data—available in its Universal Licensing System—indicate that, as of August 31, 2018, there are 265 Cellular licensees that will be affected by our actions. The Commission does not know how many of these licensees are small, as the Commission does not collect that information for these types of entities. Similarly, according to internally developed Commission data, 413 carriers reported that they were engaged in the provision of wireless telephony, including cellular service, Personal Communications Service (PCS), and Specialized Mobile Radio (SMR) Telephony services.

Of this total, an estimated 261 have 1,500 or fewer employees, and 152 have more than 1,500 employees. Thus, using available data, we estimate that the majority of wireless firms can be considered small. 21. Cable and Other Subscription Programming. The U.S.

Census Bureau defines this industry as establishments primarily engaged in operating studios and facilities for the broadcasting of programs on a subscription or fee basis. The broadcast programming is typically narrowcast in nature ( e.g., limited format, such as news, sports, education, or youth-oriented). These establishments produce programming in their own facilities or acquire programming from external sources. The programming material is usually delivered to a third party, such as cable systems or direct-to-home satellite systems, for transmission to viewers. The SBA size standard for this industry establishes as small any company in this category with annual receipts less than $41.5 million.

Based on U.S. Census Bureau data for 2012, 367 firms operated for the entire year. Of that number, 319 firms operated with annual receipts of less than $25 million a year and 48 firms operated with annual receipts of $25 million or more. Based on this data, the Commission estimates that a majority of firms in this industry are small. 22.

Cable Companies and Systems (Rate Regulation). The Commission has also developed its own small business size standards, for the purpose of cable rate regulation. Under the Commission's rules, a “small cable company” is one serving 400,000 or fewer subscribers nationwide. Industry data indicate that there are 4,600 active cable systems in the United States. Of this total, all but five cable operators nationwide are small under the 400,000-subscriber size standard.

In addition, under the Commission's rate regulation rules, a “small system” is a cable system serving 15,000 or fewer subscribers. Commission records show 4,600 cable systems nationwide. Of this total, 3,900 cable systems have fewer than 15,000 subscribers, and 700 systems have Start Printed Page 410 15,000 or more subscribers, based on the same records. Thus, under this standard as well, we estimate that most cable systems are small entities. 23.

Cable System Operators (Telecom Act Standard). The Communications Act of 1934, as amended, also contains a size standard for small cable system operators, which is “a cable operator that, directly or through an affiliate, serves in the aggregate fewer than one percent of all subscribers in the United States and is not affiliated with any entity or entities whose gross annual revenues in the aggregate exceed $250,000,000.” As of 2019, there were approximately 48,646,056 basic cable video subscribers in the United States. Accordingly, an operator serving fewer than 486,460 subscribers shall be deemed a small operator if its annual revenues, when combined with the total annual revenues of all its affiliates, do not exceed $250 million in the aggregate. Based on available data, we find that all but five cable operators are small entities under this size standard. We note that the Commission neither requests nor collects information on whether cable system operators are affiliated with entities whose gross annual revenues exceed $250 million.

Therefore, we are unable at this time to estimate with greater precision the number of cable system operators that would qualify as small cable operators under the definition in the Communications Act. 24. All Other Telecommunications. The “All Other Telecommunications” category is comprised of establishments primarily engaged in providing specialized telecommunications services, such as satellite tracking, communications telemetry, and radar station operation. This industry also includes establishments primarily engaged in providing satellite terminal stations and associated facilities connected with one or more terrestrial systems and capable of transmitting telecommunications to, and receiving telecommunications from, satellite systems.

Establishments providing internet services or VoIP services via client-supplied telecommunications connections are also included in this industry. The SBA has developed a small business size standard for “All Other Telecommunications”, which consists of all such firms with annual receipts of $35 million or less. For this category, U.S. Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year. Of those firms, a total of 1,400 had annual receipts less than $25 million and 15 firms had annual receipts of $25 million to $49,999,999.

Thus, the Commission estimates that the majority of “All Other Telecommunications” firms potentially affected by our action can be considered small. 25. Radio and Television Broadcasting and Wireless Communications Equipment Manufacturing. This industry comprises establishments primarily engaged in manufacturing radio and television broadcast and wireless communications equipment. Examples of products made by these establishments are.

Transmitting and receiving antennas, cable television equipment, Global Positioning System (GPS) equipment, pagers, cellular phones, mobile communications equipment, and radio and television studio and broadcasting equipment. The SBA has established a small business size standard for this industry of 1,250 employees or less. U.S. Census Bureau data for 2012 show that 841 establishments operated in this industry in that year. Of that number, 828 establishments operated with fewer than 1,000 employees, 7 establishments operated with between 1,000 and 2,499 employees and 6 establishments operated with 2,500 or more employees.

Based on this data, we conclude that a majority of manufacturers in this industry are small. 26. Semiconductor and Related Device Manufacturing. This industry comprises establishments primarily engaged in manufacturing semiconductors and related solid state devices. Examples of products made by these establishments are integrated circuits, memory chips, microprocessors, diodes, transistors, solar cells and other optoelectronic devices.

The SBA has developed a small business size standard for Semiconductor and Related Device Manufacturing, which consists of all such companies having 1,250 or fewer employees. U.S. Census Bureau data for 2012 show that there were 862 establishments that operated that year. Of this total, 843 operated with fewer than 1,000 employees. Thus, under this size standard, the majority of firms in this industry can be considered small.

27. Software Publishers. This industry comprises establishments primarily engaged in computer software publishing or publishing and reproduction. Establishments in this industry carry out operations necessary for producing and distributing computer software, such as designing, providing documentation, assisting in installation, and providing support services to software purchasers. These establishments may design, develop, and publish, or publish only.

The SBA has established a size standard for this industry of annual receipts of $41.5 million or less per year. U.S. Census data for 2012 indicates that 5,079 firms operated for the entire year. Of that number 4,691 firms had annual receipts of less than $25 million and 166 firms had annual receipts of $25,000,000 to $49,999,999. Based on this data, we conclude that a majority of firms in this industry are small.

28. Internet Service Providers (Broadband). Broadband internet service providers include wired ( e.g., cable, digital subscriber line (DSL)) and VoIP service providers using their own operated wired telecommunications infrastructure fall in the category of Wired Telecommunication Carriers. Wired Telecommunications Carriers are comprised of establishments primarily engaged in operating and/or providing access to transmission facilities and infrastructure that they own and/or lease for the transmission of voice, data, text, sound, and video using wired telecommunications networks. Transmission facilities may be based on a single technology or a combination of technologies.

The SBA size standard for this category classifies a business as small if it has 1,500 or fewer employees. U.S. Census Bureau data for 2012 show that there were 3,117 firms that operated that year. Of this total, 3,083 operated with fewer than 1,000 employees. Consequently, under this size standard the majority of firms in this industry can be considered small.

29. Internet Service Providers (Non-Broadband). Internet access service providers such as dial-up internet service providers (ISPs), VoIP service providers using client-supplied telecommunications connections and internet service providers using client-supplied telecommunications connections ( e.g., dial-up ISPs) fall in the category of All Other Telecommunications. The SBA has developed a small business size standard for All Other Telecommunications which consists of all such firms with gross annual receipts of $35 million or less. For this category, U.S.

Census Bureau data for 2012 show that there were 1,442 firms that operated for the entire year. Of these firms, a total of 1,400 had gross annual receipts of less than $25 million. Consequently, under this size standard a majority of firms in this industry can be considered small. 30. All Other Information Services.

The U.S. Census Bureau has determined that this category “comprises establishments primarily engaged in providing other information services (except news syndicates, libraries, archives, internet publishing and Start Printed Page 411 broadcasting, and Web search portals).” The SBA has developed a small business size standard for this category, which consists of all such firms with annual receipts of $30 million or less. U.S. Census Bureau data for 2012 show that there were 512 firms that operated for the entire year. Of those firms, a total of 498 had annual receipts less than $25 million and 7 firms had annual receipts of $25 million to $49,999,999.

Consequently, we estimate that the majority of these firms are small entities that may be affected by our action. E. Description of Projected Reporting, Recordkeeping, and Other Compliance Requirements for Small Entities 31. The Second Report and Order modifies the Commission's rules to require covered text providers to support text messaging to 988. It concludes that text-to-988 functionality will greatly improve consumer access to the Lifeline, particularly for at-risk populations and thereby save lives.

The final rules adopted in the Second Report and Order require CMRS providers and interconnected text messaging service providers to route texts sent to 988 to the 10-digit Lifeline number, presently 1-800-273-8255 (TALK). The Second Report and Order (1) establishes a definition that sets the outer bound of text messages sent to 988 that covered text providers may be required to support. (2) directs the Wireline Competition Bureau (Bureau) to identify text formats within the scope of that definition that the Lifeline can receive and thus covered text providers must support by routing to the 10-digit Lifeline number. And (3) requires CMRS providers that offer SMS to allow access by any other covered text provider to the capabilities necessary for transmission of 988 text messages originating on such other covered text providers' application services. F.

Steps Taken To Minimize the Significant Economic Impact on Small Entities, and Significant Alternatives Considered 32. The RFA requires an agency to describe any significant, specifically small business, alternatives that it has considered in reaching its approach, which may include the following four alternatives (among others). €œ(1) the establishment of differing compliance or reporting requirements or timetables that take into account the resources available to small entities. (2) the clarification, consolidation, or simplification of compliance and reporting requirements under the rules for such small entities. (3) the use of performance rather than design standards.

And (4) an exemption from coverage of the rule, or any part thereof, for such small entities.” 33. In the Second Report and Order, the Commission adopts a uniform implementation deadline for all covered text providers to route covered 988 text messages to 988 to the Lifeline's 10-digit number by July 16, 2022. The Commission believes that applying the same rules equally to all entities in this context is necessary to alleviate potential consumer confusion from adopting different rules, at different times, for different covered text providers. However, the Commission does not believe that the actions in the Second Report and Order will overly burden small carriers or providers. Further, the Commission believes that by its actions, all entities, including small carriers or providers, will benefit from reduced costs.

For example, the Commission believes that adopting our proposal to require all covered text providers to bear their own costs to implement text-to-988 will avoid any unnecessary administrative costs. Further, the Commission provides covered text provider flexibility in how they support texting to 988, allowing them to choose the most effective method for doing so. G. Report to Congress 34. The Commission will send a copy of the Second Report and Order, including this FRFA, in a report to be sent to Congress pursuant to the Congressional Review Act.

In addition, the Commission will send a copy of the Second Report and Order, including this FRFA, to the Chief Counsel for Advocacy of the SBA. A copy of the Second Report and Order and FRFA (or summaries thereof) will also be published in the Federal Register. III. Procedural Matters 35. Paperwork Reduction Act of 1995 Analysis.

This document does not contain proposed information collection(s) subject to the Paperwork Reduction Act of 1995 (PRA), Public Law 104-13. In addition, therefore, it does not contain any new or modified information collection burden for small business concerns with fewer than 25 employees, pursuant to the Small Business Paperwork Relief Act of 2002, Public Law 107-198, see 44 U.S.C. 3506(c)(4). 36. Final Regulatory Flexibility Analysis.

As required by the Regulatory Flexibility Act of 1980,103 the Commission has prepared a Final Regulatory Flexibility Analysis (FRFA) of the possible significant economic impact on small entities of the policies and rules, as proposed, addressed in the Second Report and Order. The FRFA is set forth in Appendix B of the Second Report and Order. The Commission will send a copy of the Second Report and Order, including the FRFA, to the Chief Counsel for Advocacy of the Small Business Administration (SBA). 37. Congressional Review Act.

The Commission has determined, and the Administrator of the Office of Information and Regulatory Affairs, Office of Management and Budget, concurs that this rule is non-major under the Congressional Review Act, 5 U.S.C. 804(2). The Commission will send a copy of the Second Report and Order to Congress and the Government Accountability Office pursuant to 5 U.S.C. 801(a)(1)(A). 38.

People With Disabilities. To request materials in accessible formats for people with disabilities (braille, large print, electronic files, audio format), send an email to fcc504@fcc.gov or call the Consumer &. Governmental Affairs Bureau at (202) 418-0530 (voice), 202-418-0432 (tty). 39. Contact Person.

For further information about this rulemaking proceeding, please contact Michelle Sclater, Competition Policy Division, Wireline Competition Bureau, at (202) 418-0388 or michelle.sclater@fcc.gov. IV. Ordering Clauses 40. Accordingly, it is ordered , pursuant to sections 201, 251(e)(4), 301, 303, 307, 309, 316, and 615c of the Communications Act of 1934, as amended, 47 U.S.C. 201, 251(e)(4), 301, 303, 307, 309, 316, 615c, that the Second Report and Order in WC Docket No.

18-336 is adopted. 41. It is further ordered that, pursuant to §§ 1.4(b)(1) and 1.103(a) of the Commission's rules, 47 CFR 1.4(b)(1), 1.103(a), the Report and Order shall be effective 30 days after publication in the Federal Register. 42. It is further ordered that part 52 of the Commission's rules is amended as set forth in Appendix A of the Second Report and Order.

43. It is further ordered that the Commission shall send a copy of the Second Report and Order to Congress and to the Government Accountability Office pursuant to the Congressional Review Act, see 5 U.S.C. 801(a)(1)(A). 44. It is further ordered that the Commission's Consumer and Governmental Affairs Bureau, Reference Information Center, shall send a copy of the Second Report and Order, including the Final Regulatory Flexibility Analysis (FRFA), to the Chief Counsel for Advocacy of the Small Business Administration.

Start List of Subjects Start Printed Page 412 Communications common carriersTelecommunicationsTelephone End List of Subjects (47 U.S.C. 201, 251, 301, 303, 307, 309, 316) Start Signature Federal Communications Commission. Katura Jackson, Federal Register Liaison Officer. End Signature Final Rules For the reasons stated in the preamble, the Federal Communications Commission amends 47 CFR part 52 as follows. Start Part End Part Start Amendment Part1.

The authority citation for part 52 continues to read as follows. End Amendment Part Start Authority 47 U.S.C. 151, 152, 153, 154, 155, 201-205, 207-209, 218, 225-227, 251-252, 271, 303, 332, unless otherwise noted. End Authority Start Amendment Part2. Add § 52.201 to read as follows.

End Amendment Part Texting to the National Suicide Prevention and Mental Health Crisis Hotline. (a) Support for 988 text message service. Beginning July 16, 2022, all covered text providers must route a covered 988 text message to the current toll free access number for the National Suicide Prevention Lifeline, presently 1-800-273-8255 (TALK). (b) Access to SMS networks for 988 text messages. To the extent that Commercial Mobile Radio Services (CMRS) providers offer Short Message Service (SMS), they shall allow access by any other covered text provider to the capabilities necessary for transmission of 988 text messages originating on such other covered text providers' application services.

(c) Definitions. For purposes of this section. 988 text message. (i) Means a message consisting of text, images, sounds, or other information that is transmitted to or from a device that is identified as the receiving or transmitting device by means of a 10-digit telephone number, N11 service code, or 988. (ii) Includes and is not limited to a SMS message and a multimedia message service (MMS) message.

And (iii) Does not include— (A) A real-time, two-way voice or video communication. Or (B) A message sent over an IP-enabled messaging service to another user of the same messaging service, except a message described in paragraph (b) of this section. Covered 988 text message means a 988 text message in SMS format and any other format that the Wireline Competition Bureau has determined must be supported by covered text providers. Covered text provider includes all CMRS providers as well as all providers of interconnected text messaging services that enable consumers to send text messages to and receive text messages from all or substantially all text-capable U.S. Telephone numbers, including through the use of applications downloaded or otherwise installed on mobile phones.

Multimedia message service ( MMS ) shall have the same definition as the term in § 64.1600(k) of this chapter. Short message service ( SMS ) shall have the same definition as the term in § 64.1600(m) of this chapter. End Supplemental Information [FR Doc. 2021-27878 Filed 1-4-22. 8:45 am]BILLING CODE 6712-01-P.

Where can I keep Propecia?

Keep out of the reach of children in a container that small children cannot open.

Store at room temperature between 15 and 30 degrees C (59 and 86 degrees F). Protect from light. Keep container tightly closed. Throw away any unused medicine after the expiration date.

Generic propecia costco

Notes1. R. C Keller (2006). "Geographies of power, legacies of mistrust. Colonial medicine in the global present." Historical Geography no.

34:26-48.2. Bridget Pratt et al. (2018). "Exploring the ethics of global health research priority-setting." BMC Medical Ethics no. 19 (94).

Doi. 10.1186/s12910-018-0333-y3. Richard Horton (2013). "Offline. Is global health neocolonialist?.

" The Lancet no. 382 (9906):1690. Doi. 10.1016/S0140-6736(13)62379-X4. Anonymous (2019).

"Editorial. Break with tradition. The World Health Organization’s decision about traditional Chinese medicine could backfire." Nature no. 570:5.5. S.

S Amrith (2006). Decolonizing international health. India and Southeast Asia, 1930–65. London. Palgrave Macmillan.6.

Arturo Escobar and A Escobar (1984). "Discourse and power in development. Michel Foucault and the relevance of his work to the third world." Alternatives no. 10 (3):377-400. Doi.

10.1177/0304375484010003047. UNDG (2013). A million voices. The world we want. A sustainable future with dignity for all.

New York, NY. United Nations Development Group.8. WHO (2019). Speech by the Director-General. Transforming for impact 2019 (cited 10 March 2019).

Available from. Https://www.who.int/dg/speeches/detail/transforming-for-impact.9. R. C Keller (2006). Geographies of power, legacies of mistrust.

Colonial medicine in the global present.10. Mishal S Khan et al. (2019). Durrance-Bagale, H. Legido-Quigley "‘LMICs as reservoirs of AMR’.

A comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan." Health Policy and Planning no. 34 (3):178–187. Doi. 10.1093/heapol/czz02211. Clare I R Chandler (2019).

"Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure." Palgrave Communications no. 5 (1):53. Doi. 10.1057/s41599-019-0263-412.

In the area of antimicrobial use for human health, other problem areas include, for example, public hygiene and disease prevention, regulated access to medicines, disease diagnosis, or market conditions for the development of new antimicrobials. The Review on Antimicrobial Resistance (2016). Tackling drug-resistant s globally. Final report and recommendations. London.

The UK Prime Minister, WHO (2015b). Global action plan on antimicrobial resistance. Geneva. World Health Organization, Conan MacDougall and Ron E Polk (2005). "Antimicrobial stewardship programs in health care systems." Clinical Microbiology Reviews no.

18 (4):638-656. Doi. 10.1128/CMR.18.4.638-656.2005.13. The Review on Antimicrobial Resistance. Tackling drug-resistant s globally.

Final report and recommendations.14. WHO, Global action plan on antimicrobial resistance.15. Maria R Gualano et al. (2015). "General population's knowledge and attitudes about antibiotics.

A systematic review and meta-analysis." Pharmacoepidemiology and Drug Safety no. 24 (1):2-10. Doi. 10.1002/pds.371616. H Haak and A.

Radyowijati (2010). "Determinants of antimicrobial use. Poorly understood, poorly researched." In Antimicrobial resistance in developing countries, edited by Sosa, Byarugaba, Amábile-Cuevas, Hsueh, Kariuki and Okeke, 283-300. New York, NY. Springer.17.

These problems persist despite encouraging trends. For example, the field is becoming increasingly multidisciplinary through the involvement of several United Nations agencies alongside WHO in governing AMR, and AMR policy narratives are slowly broadening the hitherto hyper-individualised and behaviour change focus of global action plans. Connor Rochford et al. (2018). "Global governance of antimicrobial resistance." The Lancet no.

391 (10134):1976-1978. Doi. 10.1016/S0140-6736(18)31117-6, WHO, FAO, and OIE (2018). Monitoring global progress on addressing antimicrobial resistance. Analysis report of the second round of results of AMR country self-assessment survey 2018.

Geneva. World Health Organization, Food and Agriculture Organization of the United Nations and World Organisation for Animal Health (OIE), WHO (2017). Antimicrobial Resistance Behaviour Change first informal technical consultation, 6-7 November, 2017 Château de Penthes, Geneva. Meeting Report. Geneva.

World Health Organization, Elise Klein and China Mills (2017). "Psy-expertise, therapeutic culture and the politics of the personal in development." Third World Quarterly no. 38 (9):1990-2008. Doi. 10.1080/01436597.2017.131927718.

Emma R M Cohen et al. (2008). "Public engagement on global health challenges." BMC Public Health no. 8 (168). Doi.

10.1186/1471-2458-8-16819. B Hamlyn et al. (2015).Factors affecting public engagement by researchers. A study on behalf of a consortium of UK public research funders. London.

TNS20. Research Councils UK (2011) Concordat for engaging the public with research. Research Councils UK. Swindon.21. C Wilson, P.

Manners, and S. Duncan (2014). Building an engaged future for UK higher education. Full report from the Engaged Futures consultation. Bristol.

National Co-ordinating Centre for Public Engagement.22. Also referred to as ‘community engagement’, ‘patient and public involvement’ (PPI) in research, or in some instances also as participatory research. S. Staniszewska et al. (2017).

"GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research." Research Involvement and Engagement no. 3 (13). Doi. 10.1186/s40900-017-0062-2, Jo Brett et al.

(2014). "Mapping the impact of patient and public involvement on health and social care research. A systematic review." Health Expectations no. 17 (5):637-650. Doi.

10.1111/j.1369-7625.2012.00795.x, Paulina O Tindana et al. (2007). "Grand challenges in global health. Community engagement in research in developing countries." PLOS Medicine no. 4 (e273).

Doi. 10.1371/journal.pmed.0040273, F Darroch and A. Giles (2014). "Decolonizing health research. Community-based participatory research and postcolonial feminist theory." Canadian Journal of Action Research no.

15 (3):22-36.23. J Redfern et al. (2018). "Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event." FEMS Microbiology Letters no.

365 (16). Doi. 10.1093/femsle/fny17524. Victoria Jane Hume et al. (2018).

"Biomedicine and the humanities. Growing pains." Medical Humanities no. 44 (4):230-238. Doi. 10.1136/medhum-2018-01148125.

Astrid Treffry-Goatley et al. (2018). Ibid. "Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach." 239-246.

Doi. 10.1136/medhum-2018-01147426. L Jordanova (2014). "Medicine and the visual arts." In Medicine, health and the arts. Approaches to medical humanities, edited by Bates, Bleakley and Goodman, 41-63.

Abingdon. Routledge.27. Angela Ross Perfetti (2018). "Fate and the clinic. A multidisciplinary consideration of fatalism in health behaviour." Medical Humanities no.

44 (1):59-62. Doi. 10.1136/medhum-2017-01131928. Devan Stahl et al. (2016).

"Seeing illness in art and medicine. A patient and printmaker collaboration." Ibid. No. 42 (3):155-159. Doi.

10.1136/medhum-2015-01083829. Jonatan Wistrand and J Wistrand (2017). "When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians." Ibid. No.

43 (1):19-23. Doi. 10.1136/medhum-2016-01100230. T. R Cole, N.

S. Carlin, and R. A. Carson (2015). Medical humanities.

An introduction. New York, NY. Cambridge University Press.31. Daniel Holman and Erica Borgstrom (2016). "Applying social theory to understand health-related behaviours." Medical Humanities no.

42 (2):143-145. Doi. 10.1136/medhum-2015-01068832. Hume, et al., Biomedicine and the humanities. Growing pains.33.

A Carusi (2016). "Modelling systems biomedicine. Intertwinement and the 'real'." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 50-65. Edinburgh. Edinburgh University Press.34.

Jordanova, Medicine and the visual arts.35. Stahl and Stahl, Seeing illness in art and medicine. A patient and printmaker collaboration.36. William Viney et al. (2015).

"Critical medical humanities. Embracing entanglement, taking risks." Ibid. No. 41 (1):2-7. Doi.

10.1136/medhum-2015-01069237. J Cole and S. Gallagher (2016). "Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?.

" In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 377-394. Edinburgh. Edinburgh University Press.38. J Macnaughton and H. Carel (2016).

Ibid."Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap." In, 294-309.39. P J Pelto and G H Pelto (1997). 1997. "Studying knowledge, culture, and behavior in applied medical anthropology." Medical Anthropology Quarterly no.

11 (2):147-163.40. Lindsay Prior (2003) "Belief, knowledge and expertise. The emergence of the lay expert in medical sociology." Sociology of Health &. Illness no. 25 (3):41-57.

Doi. 10.1111/1467-9566.0033941. E Oliveira and J. Vearey (2018). "Making research and building knowledge with communities.

Examining three participatory visual and narrative projects with migrants who sell sex in South Africa." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 265-287. Cham. Springer.42. Komatra Chuengsatiansup and Wirun Limsawart (2019).

"Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders." Palgrave Communications no. 5 (1):31. Doi. 10.1057/s41599-019-0239-443.

R Garden (2014). "Social studies. The humanities, narrative, and the social context of the patient-professional relationship." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 127-137. New Brunswick, NJ. Rutgers University Press.44.

Holman and Borgstrom, Applying social theory to understand health-related behaviours.45. Claas Kirchhelle (2018). "Pharming animals. A global history of antibiotics in food production (1935–2017)." Palgrave Communications no. 4 (96).

Doi. 10.1057/s41599-018-0152-246. Hannah Landecker (2019). "Antimicrobials before antibiotics. War, peace, and disinfectants." Ibid.

No. 5 (1):45. Doi. 10.1057/s41599-019-0251-847. Sue Walker (2019).

Ibid."Effective antimicrobial resistance communication. The role of information design." 24. Doi. 10.1057/s41599-019-0231-z48. Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.49.

May Sudhinaraset et al. (2013). "What is the role of informal healthcare providers in developing countries?. A systematic review." PLoS ONE no. 8 (2):e54978.

Doi. 10.1371/journal.pone.005497850. Viroj Tangcharoensathien, Sunicha Chanvatik, and Angkana Sommanustweechai (2018). "Complex determinants of inappropriate use of antibiotics." Bulletin of the World Health Organization no. 96 (2):141-144.

Doi. 10.2471/BLT.17.19968751. WHO (2015a). Antibiotic resistance. Multi-country public awareness survey.

Geneva. World Health Organization.52. WHO, Antibiotic resistance. Multi-country public awareness survey, 42.53. Gualano, et al.

General population's knowledge and attitudes about antibiotics. A systematic review and meta-analysis.54. Edward A Belongia et al. (2002). "Antibiotic use and upper respiratory s.

A survey of knowledge, attitudes, and experience in Wisconsin and Minnesota." Preventive Medicine no. 34 (3):346-352. Doi. 10.1006/pmed.2001.099255. Miao Yu et al.

(2014). "Knowledge, attitudes, and practices of parents in rural China on the use of antibiotics in children. A cross-sectional study." BMC Infectious Diseases no. 14 (112). Doi.

10.1186/1471-2334-14-11256. Abdelmoneim Ismail Awad and Esraa Abdulwahid Aboud (2015). "Knowledge, attitude and practice towards antibiotic use among the public in Kuwait." PLoS ONE no. 10 (2):e0117910. Doi.

10.1371/journal.pone.011791057. Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure.58. Jie Chang et al. (2018).

"Non-prescription use of antibiotics among children in urban China. A cross-sectional survey of knowledge, attitudes, and practices." Expert Review of Anti-infective Therapy no. 16 (2):163-172. Doi. 10.1080/14787210.2018.142561659.

Gualano, et al. General population's knowledge and attitudes about antibiotics. A systematic review and meta-analysis.60. A R McCullough et al. (2016).

"A systematic review of the public's knowledge and beliefs about antibiotic resistance." Journal of Antimicrobial Chemotherapy no. 71 (1):27-33. Doi. 10.1093/jac/dkv31061. Abel Santiago Muri-Gama, Albert Figueras, and Silvia Regina Secoli (2018).

"Inappropriately prescribed and over-the-counter antimicrobials in the Brazilian Amazon Basin. We need to promote more rational use even in remote places." PLoS ONE no. 13 (e0201579). Doi. 10.1371/journal.pone.020157962.

A Launiala (2009). "How much can a KAP survey tell us about people's knowledge, attitudes and practices?. Some observations from medical anthropology research on malaria in pregnancy in Malawi." Anthropology Matters no. 11 (1).63. Pamela Das et al.

(2016). "Antibiotics. Achieving the balance between access and excess." The Lancet no. 387 (10014):102-104. Doi.

10.1016/S0140-6736(15)00729-164. C Olivier et al. (2010). "Containing global antibiotic resistance. Ethical drug promotion in the developing world." In Antimicrobial resistance in developing countries, edited by Sosa, Byarugaba, Amábile-Cuevas, Hsueh, Kariuki and Okeke, 505-524.

New York, NY. Springer.65. Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure.66. Chandler, Current accounts of antimicrobial resistance.

Stabilisation, individualisation and antibiotics as infrastructure.67. Steve Hinchliffe, Andrea Butcher, and Muhammad Meezanur Rahman (2018). "The AMR problem. Demanding economies, biological margins, and co-producing alternative strategies." Ibid. No.

4 (142). Doi. 10.1057/s41599-018-0195-468. Chuengsatiansup and Limsawart, Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders.69.

Khan, et al, ‘LMICs as reservoirs of AMR’. A comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan.70. Didier Wernli et al. (2017). "Mapping global policy discourse on antimicrobial resistance." BMJ Global Health no.

2 (e000378). Doi. 10.1136/bmjgh-2017-00037871. Nancy J Hawkings, Fiona Wood, and Christopher C Butler (2007). "Public attitudes towards bacterial resistance.

A qualitative study." Journal of Antimicrobial Chemotherapy no. 59 (6):1155-1160. Doi. 10.1093/jac/dkm10372. McCullough, et al.

A systematic review of the public's knowledge and beliefs about antibiotic resistance.73. Muri-Gama, et al. Inappropriately prescribed and over-the-counter antimicrobials in the Brazilian Amazon Basin. We need to promote more rational use even in remote places.74. David G Allison et al.

(2017). "Antibiotic resistance awareness. A public engagement approach for all pharmacists." International Journal of Pharmacy Practice no. 25 (1):93-96. Doi.

10.1111/ijpp.1228775. Mark Davis et al. (2018). "Understanding media publics and the antimicrobial resistance crisis." Global Public Health no. 13 (9):1158-1168.

Doi. 10.1080/17441692.2017.133624876. Simon J Howard et al. (2013). "Antibiotic resistance.

Global response needed." The Lancet Infectious Diseases no. 13 (12):1001-1003. Doi. 10.1016/S1473-3099(13)70195-677. Renly Lim et al.

(2016). "Village drama against malaria." The Lancet no. 388 (10063):2990. Doi. 10.1016/S0140-6736(16)32519-378.

Deborah Nyirenda et al. (2018). "Public engagement in Malawi through a health-talk radio programme ‘Umoyo nkukambirana’. A mixed-methods evaluation." Public Understanding of Science no. 27 (2):229-242.

Doi. 10.1177/096366251665611079. Redfern, et al. Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event.80.

Sungjong Roh et al. (2018). "Public understanding of One Health messages. The role of temporal framing." Public Understanding of Science no. 27 (2):185-196.

Doi. 10.1177/096366251667080581. Tindana, et al., Grand challenges in global health. Community engagement in research in developing countries.82. Mpoe Johannah Keikelame and Leslie Swartz (2019).

"Decolonising research methodologies. Lessons from a qualitative research project, Cape Town, South Africa." Global Health Action no. 12 (1):1561175. Doi. 10.1080/16549716.2018.156117583.

Keymanthri Moodley and Shenuka Singh (2016). "“It’s all about trust”. Reflections of researchers on the complexity and controversy surrounding biobanking in South Africa." BMC Medical Ethics no. 17 (57). Doi.

10.1186/s12910-016-0140-284. Seye Abimbola (2020). "Beyond positive a priori bias. Reframing community engagement in LMICs (epub ahead of print)." Health Promotion International. Doi.

10.1093/heapro/daz02385. Keikelame and Swartz, Decolonising research methodologies. Lessons from a qualitative research project, Cape Town, South Africa.86. Kenneth M Boyd (2000). "Disease, illness, sickness, health, healing and wholeness.

Exploring some elusive concepts." Medical Humanities no. 26 (1):9-17. Doi. 10.1136/mh.26.1.987. Hume, et al., Biomedicine and the humanities.

Growing pains.88. I Bamforth (2000). "Kafka's uncle. Scenes from a world of trust infected by suspicion." Ibid. No.

26 (2):85-91. Doi. 10.1136/mh.26.2.8589. Wistrand, When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians.90.

Garden, Social studies. The humanities, narrative, and the social context of the patient-professional relationship.91. A Harpin (2016). "Broadmoor performed. A theatrical hospital." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 577-595.

Edinburgh. Edinburgh University Press.92. Jordanova, Medicine and the visual arts.93. Stahl and Stahl, Seeing illness in art and medicine. A patient and printmaker collaboration.94.

K G Sweeney et al. (2001). "A comparison of professionals' and patients' understanding of asthma. Evidence of emerging dualities?. " Ibid.

No. 27 (1):20-25. Doi. 10.1136/mh.27.1.2095. Treffry-Goatley, et al., Community engagement with HIV drug adherence in rural South Africa.

A transdisciplinary approach.96. R. J Hester (2016). "Culture in medicine. An argument against competence." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 541-558.

Edinburgh. Edinburgh University Press.97. L Jerke, M. Prendergast, and W. Dobson (2018).

"Smoking cessation in mental health communities. A living newspaper applied theatre project." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 171-186. Cham. Springer.98.

Sweeney, et al. A comparison of professionals' and patients' understanding of asthma. Evidence of emerging dualities?. 99. S Switzer (2018).

"What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 189-207. Cham. Springer.100.

Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. , 378.101. Cole, et al. Medical humanities.

An introduction.102. J Herman (2001). "Medicine. The science and the art." Medical Humanities no. 27 (1):42-46.

Doi. 10.1136/mh.27.1.42103. [Viney, et al. Critical medical humanities. Embracing entanglement, taking risks.104.

R. K Yin (2003). Case study research. Design and methods. Thousand Oaks, CA.

Sage.105. Marco J Haenssgen et al. (2018)106. S. L Gilman (2015).

Illness and image. Case studies in the medical humanities. New York, NY. Taylor &. Francis.107.

HarbarthM Haughton (2018). Staging trauma. Bodies in shadow. London. Palgrave Macmillan.108.

S Hodge, J Robinson, and P Davis (2007). "Reading between the lines. The experiences of taking part in a community reading project." Medical Humanities no. 33 (2):100-104. Doi.

10.1136/jmh.2006.000256109. Hume, et al. Biomedicine and the humanities. Growing pains.110. Saam Idelji-Tehrani and Muna Al-Jawad (2019).

"Exploring gendered leadership stereotypes in a shared leadership model in healthcare. A case study." Ibid. No. 45:388-398. Doi.

10.1136/medhum-2018-011517111. Suze M P J Jans et al. (2012). "A case study of haemoglobinopathy screening in the Netherlands. Witnessing the past, lessons for the future." Ethnicity &.

Health no. 17 (3):217-239. Doi. 10.1080/13557858.2011.604126112. Hume, et al., Biomedicine and the humanities.

Growing pains.113. Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. 114. Macnaughton and Carel, Breathing and breathlessness in clinic and culture.

Using critical medical humanities to bridge an epistemic gap.115. Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.116. Prior, Belief, knowledge and expertise. The emergence of the lay expert in medical sociology.117. Gilman, Illness and image.

Case studies in the medical humanities.118. Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. 119. Macnaughton and Carel, Breathing and breathlessness in clinic and culture.

Using critical medical humanities to bridge an epistemic gap.120. C Teddlie and A. Tashakkori (2009). Foundations of mixed methods research. Integrating quantitative and qualitative approaches in the social and behavioral sciences.

Thousand Oaks, CA. Sage.121. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.122. Gian Luca Barbieri et al.

(2016). "Imagination in narrative medicine." Journal of Child Health Care no. 20 (4):419-427. Doi. 10.1177/1367493515625134123.

Treffry-Goatley, et al. Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.124. WHO (2016). World Antibiotic Awareness Week.

2016 campaign toolkit. Geneva. World Health Organization.125. Across the three villages, 67% of the workshop attendees were female and the average age of the attendees was 44 years (range. 18 to 81 years.

Based on subsequently collected survey data).126. Nutcha Charoenboon et al. (2019)127. We thank an anonymous reviewer for highlighting the potential hazards of reproducing hierarchies through methods intended to challenge them in the first place.128. The research was reviewed and approved by the University of Oxford Tropical Research Ethics Committee (Ref.

OxTREC 528-17), and it received local ethical approval in Thailand from the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099). The service evaluation of the photo exhibition involved anonymised data collection and received a waiver for ethical approval from the University of Warwick Humanities &. Social Sciences Research Ethics Committee (HSSREC). However, all evaluation form respondents explicitly consented to the data being reported in research publications.129.

Marco J Haenssgen et al. (2018)130. National Statistical Office (2012). The 2010 population and housing census. Changwat Chiang Rai.

Bangkok. National Statistical Office.131. Data on the individual level would entail duplication of observations should both census survey rounds be included. Step-level data were aggregated on the illness level for analysis.132. Claire Charlotte McKechnie (2014).

"Anxieties of communication. The limits of narrative in the medical humanities." Medical Humanities no. 40 (2):119-124. Doi. 10.1136/medhum-2013-010466133.

Carusi, Modelling systems biomedicine. Intertwinement and the 'real'.134. Garden, Social studies. The humanities, narrative, and the social context of the patient-professional relationship.135. Emma Sacks et al.

(2018). "Beyond the building blocks. Integrating community roles into health systems frameworks to achieve health for all." BMJ Global Health no. 3 (Suppl. 3):e001384.

Doi. 10.1136/bmjgh-2018-001384136. Sudhinaraset, et al. What is the role of informal healthcare providers in developing countries?. A systematic review.137.

G Bloom et al. (2015). Addressing resistance to antibiotics in pluralistic health systems. Brighton. University of Sussex138.

WHO (2007). Strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva. World Health Organization.139.

Jordanova, Medicine and the visual arts.140. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.141. A Bleakley (2014). Ibid.

"Towards a 'critical medical humanities'." In, 17-26.142. Hume, et al., Biomedicine and the humanities. Growing pains.143. Nutcha Charoenboon et al. (2019)144.

Marco Haenssgen et al. (2018)145. WHO, World Antibiotic Awareness Week. 2016 campaign toolkit.146. The questionnaire did so by showing all survey respondents three images of common antibiotic capsules being used in Chiang Rai (green-blue.

Amoxicillin. Red-black. Cloxacillin. White-blue. Azithromycin—see questionnaire page 10 in the online supplementary material).

Respondents were asked to name what they saw, and all their answers were recorded (field-coded and as free text).147. The ‘desirability’ of the responses was field coded by the survey team. Sample responses (as instructed through the survey manual) for ‘desirable’ answers included, for example, “Only if the doctor says that I should”. Sample responses for ‘undesirable’ answers included “Yes, you can buy it in the shop over there!. € The variable should be interpreted as ‘the fraction of respondents who uttered a ‘desirable’ response’—the inverse is the fraction of responses that could not be deemed ‘desirable’ (eg, ‘do not know’ or ‘no opinion’).148.

Because recalled descriptions of medicine tend to be ambiguous, we limited our analysis to medicines where we had a high degree of certainty that they were an antibiotic. This was specifically the case if survey respondents mentioned common antibiotic descriptions such as ‘anti-inflammatory’, ‘amoxi’ or ‘colem’, if they indicated explicitly that they know what ‘anti-inflammatory medicine’ is (noting that the term describes antibiotics unambiguously in Thai), and if they subsequently mentioned any of the previously mentioned antibiotics during their description of an illness episode (conversely, we excluded cases were the medicine could not be confirmed as either antibiotic or non-antibiotic, including descriptions like ‘white powder’ or ‘green capsule’).149. Aristotle (1954). Rhetoric. Translated by Roberts.

New York, NY. Modern Library. Original edition, 350 BC.150. Arya Nielsen et al. (2007).

"The effect of gua sha treatment on the microcirculation of surface tissue. A pilot study in healthy subjects." EXPLORE no. 3 (5):456-466. Doi. 10.1016/j.explore.2007.06.001151.

Nithima Sumpradit et al. (2012). "Antibiotics Smart Use. A workable model for promoting the rational use of medicines in Thailand." Bulletin of the World Health Organization no. 90 (12):905-913.

Doi. 10.2471/BLT.12.105445152. C Muksong and K. Chuengsatiansup (2020). Forthcoming.

"Medicine and public health in Thai historiography. From an elitist view to counter-hegemonic discourse." In Health, pluralism and globalisation. A modern history of medicine in South-East Asia, edited by Monnais and Cook. London. The Wellcome Trust Centre for the History.153.

L Sringernyuang (2000). Availability and use of medicines in rural Thailand. Amsterdam. Amsterdam Institute for Social Science Research.154. Although this was not the focus of the current paper, we note for full disclosure that the workshops, too, had mixed behavioural impacts.

The poster making sessions in Chiang Rai demonstrated for instance how our conversations about drug resistance and the introduction of messages from the World Health Organization entailed at times problematic interpretations like, “You shouldn’t take medicines that you have never seen before”—the research team responded to such interpretations directly in order to avoid misunderstandings. In addition, previous behavioural analyses documented that, while workshop participants demonstrated higher levels of awareness of drug resistance, alignment of antibiotic use with global health recommendations was mixed, and in one case, a villager started selling antibiotics after the workshop. For more details on the behavioural analysis, see Nutcha Charoenboon et al. (2019) and Marco Haenssgen et al. (2018).155.

For example, Redfern, et al., Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event.156. Antoine Boivin et al. (2018). 2018.

"Patient and public engagement in research and health system decision making. A systematic review of evaluation tools (epub ahead of print)." Health Expectations. Doi. 10.1111/hex.12804157. Staniszewska, et al.

GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research.158. Jerke, et al. Smoking cessation in mental health communities. A living newspaper applied theatre project.159.

Switzer, What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods.160. R. C Barfield and L. Selman (2014).

"Health and humanities. Spirituality and religion." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 376-386. New Brunswick, NJ. Rutgers University Press.161. Abimbola, Beyond positive a priori bias.

Reframing community engagement in LMICs (epub ahead of print), 1.162. Marco J Haenssgen et al. (2019)163. Marc Mendelson et al. (2017).

"Antibiotic resistance has a language problem." Nature no. 545 (7652):23-25. Doi. 10.1038/545023a164. Haak and Radyowijati, Determinants of antimicrobial use.

Poorly understood, poorly researched.165. S Harbarth and D. L. Monnet (2008). "Cultural and socioeconomic determinants of antibiotic use." In Antibiotic Policies.

Fighting Resistance, edited by Gould and van der Meer, 29-40. Boston, MA. Springer.166. K Sirijoti, P. Havanond Hongsranagon, and W.

Pannoi (2014). "Assessment of knowledge attitudes and practices regarding antibiotic use in Trang province, Thailand." Journal of Health Research no. 28 (5):299-307.167. Ramona K C Finnie et al. (2011).

"Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high burdens of TB and HIV." Tropical Medicine &. International Health no. 16 (4):394-411. Doi. 10.1111/j.1365-3156.2010.02718.x168.

Haak and Radyowijati, Determinants of antimicrobial use. Poorly understood, poorly researched.169. Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure, 5.170. S Willson and K.

Miller (2014). "Data collection." In Cognitive interviewing methodology. A sociological approach for survey question evaluation, edited by Miller, Willson, Chepp and Padilla, 15-34. Hoboken, NJ. Wiley.171.

See Linda Mayoux and Robert Chambers (2005). "Reversing the paradigm. Quantification, participatory methods and pro-poor impact assessment." Journal of International Development no. 17 (2):271-298. Doi.

10.1002/jid.1214172. Howard S. Becker (1995). "Visual sociology, documentary photography, and photojournalism. It's (almost) all a matter of context." Visual Sociology no.

10 (1-2):5-14. Doi. 10.1080/14725869508583745173. J Prosser and D. Schwartz (2005).

"Photographs and the sociological research process." In Image-based research. A sourcebook for qualitative researchers, edited by Prosser, 101-115. London. Falmer.174. Treffry-Goatley, et al.

Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.175. Switzer, What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods.176. Hume, et al.

Biomedicine and the humanities. Growing pains.177. Jordanova, Medicine and the visual arts, 60.178. Bleakley, Towards a 'critical medical humanities'.179. Nutcha Charoenboon et al.

(2019)180. Hume, et al. Biomedicine and the humanities. Growing pains.181. J.

P Ansloos (2018). €œTo speak in our own ways about the world, without shame”. Reflections on indigenous resurgence in anti-oppressive research.” In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 3-18. Cham.

Springer.182. Marco J Haenssgen (2019)183. Michael Etherton and Tim Prentki (2006). "Drama for change?. Prove it!.

Impact assessment in applied theatre." Research in Drama Education. The Journal of Applied Theatre and Performance no. 11 (2):139-155. Doi. 10.1080/13569780600670718184.

Susan Galloway (2009). "Theory-based evaluation and the social impact of the arts." Cultural Trends no. 18 (2):125-148. Doi. 10.1080/09548960902826143185.

Darquise Lafrenière and Susan M Cox (2013). "‘If you can call it a poem’. Toward a framework for the assessment of arts-based works." Qualitative Research no. 13 (3):318-336. Doi.

10.1177/1468794112446104IntroductionIn Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016.1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide designers. This article reports findings from a desktop survey of current design practice across 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. Desktop surveys, as a form of research, are heavily relied on in architectural practice. Photographs and architectural drawings are analysed to understand both typical and innovative approaches to designing a particular building type.

While desktop surveys are sometimes supplemented by visits to exemplar projects (which might also be termed ‘fieldwork’), time pressures and budgetary constraints often preclude this. As the result of an academic–industry partnership, the research reported herein embraced practice-based research methods in conjunction with an academic approach. The data set available for the desktop survey was rich but incomplete. Security requirements restrict the public availability of complete floor plans and postoccupancy evaluations. To mitigate these limitations, knowledge was integrated from other disciplines, including environmental psychology, architectural history and professional practice.

With regard to the latter, knowledge is specifically around the design and consultation processes that guide the construction of these facilities. This knowledge was used to identify three contemporary hospitals that challenge accepted design practice and, we argue, in doing so have the potential to act as change-agents in the delivery of forensic mental healthcare. We define innovation as variation/s to common, or typical, architectural solutions that can positively improve patients’2 experience of these facilities in ways that directly support one, or a number, of key values underpinning forensic mental healthcare. While this article does not provide postoccupancy data to quantify the value of these innovations, we hope to encourage both designers and researchers to more closely consider these projects—particularly the way that spaces have been designed to benefit patient well-being—and the questions these designs raise for the future of forensic mental healthcare delivery.Now regarded as naïve is the 19th-century belief that architecture and landscape, if appropriately designed, can restore sanity.3 Yet contemporary research from the field of evidence-based design confirms that the built environment does play a role in the therapeutic process, even if that role does not determine therapeutic outcomes.4 Research regarding the design of forensic mental healthcare facilities remains limited. An article by Ulrich et al recommended that to reduce aggression patients should be accommodated in single rooms.

Communal areas should have movable furniture. Wards should be designed for low social densities. And accessible gardens should be provided.5 An earlier study by Tyson et al showed that lower ward densities can also positively improve patient–staff interactions.6 Commonly, however, the studies referenced above compared older-style mental health units with their contemporary replacements.7 There is little comparative research available that examines contemporary facilities for forensic mental healthcare, with the exception of one article that provided a comparative analysis of nine Swedish facilities, designed between 1990 and 2008.8 However, this article merely described the design aspirations and physical composition of each hospital without investigating the link between design aspiration, patient well-being and the resulting physical environment.There are two further limitations to evidence-based design research. The first is the extent to which data do not provide directly applicable design tactics. Systematic literature reviews typically provide a set of design recommendations but without suggesting to designers what the corresponding physical design tactics to achieve those recommendations might actually be.9 This is consistent for general hospital design.

For example, architects have been advised to provide spaces that are ‘psychosocially supportive’ since 2000, yet it was 2016 before a spatially focused definition of this term was provided, offering designers a more tangible understanding of what they should be aiming for.10 The second limitation is the breadth of research currently available. While rigorous and valuable, evidence-based design often overlooks the fact that architects must design across scales, from the master-planning scale—deciding where to place buildings of various functions within a site, and how to manage the safe movement of staff and patients between those buildings—to the scale of a bathroom door. How do you design a bathroom door to meet antiligature and surveillance requirements, to maintain patient safety, while still communicating dignity and respect for patients?. The available literature provides much to contemplate, but in terms of credible evidence much of this research is based on a single study, typically conducted within a single hospital context and often focused on a single aspect of design. This raises the question, is there really a compelling basis for regarding evidence-based design knowledge as more credible than knowledge generated about this building type from other disciplines?.

In light of the small amount of evidence available in this field, is there not a responsibility to use all the available knowledge?. While the discipline of evidence-based design has existed for three decades,11 purpose-designed buildings for the treatment of mental illness have been constructed for over three centuries. Researchers working within the field of architectural history also understand that patient experience is partially determined—for better or worse—by the decisions that designers make, and that models of care have been used to drive design outcomes since the establishment of the York Retreat in 1796. With their focus on moral treatment, the York Retreat influenced a shift in the way asylum design was approached, from the provision of safe custody to finding architectural solutions to support the restoration of sanity.12 Architectural historians also bring evidence to bear in respect of this design challenge, specifically knowledge of how the best architectural intentions can result in unanticipated (sometimes devastating) outcomes—and of the conditions that gave rise to those outcomes.13 There is a third, rich source of knowledge available to guide designers that, broadly speaking, academic researchers have yet to tap into. It is the knowledge produced by practitioners themselves.

Architects learn through experience, across multiple projects and through practice-based forms of enquiry that include desktop surveys (also referred to as precedent studies), user group consultations and gathering (often informal) postoccupancy data from their clients. Architects have already offered a range of tangible solutions to meet particular aspirations related to patient care. There is value in examining these existing design solutions to identify those capable of providing direct benefits to patients that might justify implementation across multiple projects. In understanding how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients, all available knowledge should be valued and integrated.Methodology. Embracing ‘mode two’ researchThis research was conducted within the context of a master­-planning and feasibility study, commissioned by a state government department, to investigate various international design solutions to inform future planning around forensic mental health service provisions in Victoria, Australia.

The industry-led nature of this project demanded a less conventional and more inclusive methodological approach. Tight timeframes precluded employing research methods that required ethics approvals (interviewing patients was not possible), while the timeframe and budget precluded the research team from conducting fieldwork. The following obstacles further limited a conventional approach:Postoccupancy evaluations of forensic psychiatric hospital facilities are seldom conducted and/or not made publicly available.14Published floor plans that would enable researchers to derive an understanding of the functional layouts and corresponding habits of occupancy within these facilities are limited owing to the security needs surrounding forensic psychiatric hospital sites.Available literature relevant to the design of forensic psychiatric hospital facilities provides few direct architectural recommendations to offer tactics for how the built environment might support the delivery of treatment.The team had to find a way to navigate these challenges in order to address the important question of how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients.‘Mode two’ is a methodological approach that draws on the strength of collaborations between academia and industry to produce ‘socially robust knowledge’ whose reliability extends ‘beyond the laboratory’ to real-world contexts.15 It shares commonalities with a phenomenological approach that attributes value to the prolonged, firsthand exposure of the researcher with the phenomenon in question.16 The inclusion of practising architects and academic researchers within the research team provided considerable expertise in the design, consultation and documentation of these facilities, alongside an understanding of the kinds of challenges that arise following the occupation of this building type. Mode two, as a research approach, also recognises that, while architects reference evidence-based design literature, this will not replace the processes through which practitioners have traditionally assembled knowledge about particular building types, predominantly desktop surveys.A desktop survey was undertaken to understand contemporary design practice within this building type. Forty-four projects were identified as relevant for the period 2006–2022 (31 forensic and 13 non-forensic psychiatric hospitals).

These included facilities from the UK, the USA, Canada, Denmark, Norway, Sweden, the United Arab Emirates and Ireland (online supplementary appendix 1). Sufficient architectural information was not available for 13 of these projects and they were excluded from the study. For the remaining 31 facilities, 24 accommodated forensic patients and 7 did not. Non-forensic facilities were included to enable an awareness of any significant programmatic or functional differences in the design responses created for forensic versus non-forensic mental health patients. Architectural drawings and photographs were analysed to identify general trends, alongside points of departure from common practice.

Borrowing methods from architectural history, the desktop survey was supplemented by other available information, including a mix of hospital-authored guidebooks (as provided to patients and visitors), architects’ statements, newspaper articles and literature from the field of evidence-based design. Available data varied for each of the 31 hospitals. Adopting a method from architectural theorist Thomas Markus, the materiality and placement of external and internal boundary lines were closely studied (assisted by Google Earth).17 When read in conjunction with the architectural drawings, boundary placement revealed information regarding patient access to adjacent landscape spaces.Supplemental materialA desktop survey has limitations. It cannot provide a conclusive understanding of how these spaces operate when occupied by patients and staff. While efforts were made to contact individual practices and healthcare providers to obtain missing details, such requests typically went unanswered.

This is likely owing to concerns of security, alongside the realities of commercial practice, concerns around intellectual property, and complex client and stakeholder arrangements that can act to prohibit the sharing of this information. To deepen the team’s understanding, a 2-day workshop was hosted to which two international architectural practices were invited to attend, one from the UK and one from the USA. Both practices had recently completed a significant forensic psychiatric hospital project. While neither of these facilities had been occupied at the time of the workshops, the architects were able to share their experiences relative to the research, design, and client and patient consultation processes undertaken. The Australian architects who led the research team also brought extensive experience in acute mental healthcare settings, which assisted in data analysis.To further mitigate the limitations of the desktop survey, understandings developed by the team were used as a basis for advisory panel discussions with staff.

Feedback was sought from five 60 min long, advisory panel sessions, each including four to six clinical/facilities staff (who attended voluntarily during work hours) from a forensic psychiatric hospital in Australia, where several participants recounted professional experience in both the Australian and British contexts. Each advisory panel session was themed relative to various aspects of contemporary design. (1) site/hospital layout, (2) inpatient accommodation, (3) landscape design and access, (4) staff amenities, and (5) treatment hubs (referred to as ‘treatment malls’ in the American context). These sessions enabled the research team to double-check our analysis of the plans and photographs, particularly our assumptions regarding the likely use, practicality and therapeutic value of particular spaces.Model for analysisWithin general hospital design, a range of indicators are used to measure the contribution of architecture to healing, such as the optimisation of lighting to support sleep, the minimisation of patient falls, or whether the use of single patient rooms assists with control.18 In mental health, however, where the therapeutic journey is based more on psychology than physiology, what metrics should be employed to evaluate the success of one design response over another in supporting patient care?. We suggest the first step is to acknowledge the values that underpin contemporary approaches to mental healthcare.

The second step is to translate those treatment values into corresponding spatial values using a value-led spatial framework.19 This provides a checklist for relating particular spatial conditions to specific values around patient care. For example, if the design intent is to optimise privacy and dignity for patients, then the design of bathrooms, relaxation and de-esculation spaces are all important spaces in respect of that therapeutic value. Highlighting this relationship can assist decision makers to more closely interrogate areas that matter most relative to achieving these values. To put this in context, optimising a bathroom design to prioritise a direct line of sight for staff might improve safety but also obstruct privacy and dignity for patients. While such decisions will always need to be carefully balanced, a value-led spatial framework can provide a touchstone for designers and stakeholders to revisit throughout the design process.To analyse the 31 projects examined within this project, we developed a framework (Table 1).

It recognises that a common approach to patient care can be identified across contemporary Australian, British and Canadian models:View this table:Table 1 Value-led spatial framework. Correlating treatment values with corresponding spaces within the hospital’s physical environmentThat patients be extended privacy and dignity to the broadest degree possible without impacting their personal safety or that of other patients or staff.That patients be treated within the least restrictive environment possible relative to the severity of their illness and the legal (or security) requirements attached to their care.That patients be afforded choice and independence relative to freedom of movement within the hospital campus (as appropriate to the individual), extending to a choice of social, recreational and treatment spaces.That patients’ progression through their treatment journey is reflected in the way the architecture communicates to hospital users.That opportunities for peer-led therapeutic processes and involvement of family and community-based care providers be optimised within a hospital campus. 20Table 1 assigns a range of architectural spaces and features that are relevant to each of the five treatment values listed. Architectural decisions related to these values operate across three scales. Context, hospital and individual.

Context decisions are those made in respect of a hospital’s location, including proximity to allied services, connections to public transport and distances to major metropolitan hubs. Decisions of this type are important relative to staffing recruitment and retention, and opportunities for research relative to the psychiatric hospital’s proximity to general (teaching) hospitals or university precincts. Architectural decisions operating at the hospital scale include considerations of how secure site boundaries are provided. How buildings are laid out on a site. And how spatial and functional links are set up between those buildings.

This is important relative to the movement of patients and staff across a site, including the location and functionality of therapeutic hubs. But it can also impact patient and community psychology. The design of external fences, in particular, can compound feelings of confinement for patients. Focus community attention on the custodial role of a facility over and above its therapeutic function. And influence perceptions of safety and security for the community immediately surrounding the hospital.

Architectural decisions operating at the ‘individual’ scale are those that more closely impact the daily experience of a hospital for patients and staff. These include the various arrangements for inpatient accommodation. Tactics for providing patients with landscape access and views. And the question of staff spaces relative to safety, ease of communication and collaboration. Approaches to landscape, inpatient accommodation and concerns of staff supervision are closely intertwined.Findings.

What we learnt from 31 contemporary psychiatric hospital projectsForensic psychiatric hospitals treat patients who require mental health treatment in addition to a history of criminal offending or who are at risk of committing a criminal offence. Primarily, these include patients who are unfit to stand trial and those found not guilty on account of their illness.21 Accommodation is typically arranged according to low, medium or high security needs, alongside clinical need, and whether an acute, subacute, extended or translational rehabilitation setting is required. Security needs are determined based on the risk a patient presents to themselves and/or others, alongside their risk of absconding from the facility. The challenge that has proven intractable for centuries is how can architects balance privacy and dignity for patients, while maintaining supervision for their own safety, alongside that of their fellow patients, the staff providing care and, in some cases, the community beyond.22 In this section we present overall trends regarding the layout of buildings within hospital sites, including the placement of treatment hubs and the design of inpatient wards. Access to landscape is not explicitly addressed in this section but is implicit in decisions around site layout and inpatient accommodation.Design approaches to site layoutWe identified two approaches to site layout—the ‘village’ (4 from 31 hospitals) and the ‘campus’ (27 from 31 hospitals) (figure 1).

Similar in their functional arrangement, these are differentiated according to the degree of exterior circulation required to move between patient-occupied spaces. Village hospitals comprise a number of buildings sitting within the landscape, while campus hospitals have interconnected buildings with access provided by internal corridors that prevent the need to go outside. Neither approach is new. Both follow the models first used within the 19th century. The village hospital follows the model designed by Dr Albrecht Paetz in 1878 (Alt Scherbitz, Germany), which included detached cottages accommodating patients in groups of between 24 and 100, set within gardens.23 Paetz created this design in response to his belief that upwards of 1000 patients should not be accommodated in a single building, with security measures determined in relation to those patients whose behaviour was the least predictable.24 The resulting monotony of the daily routine and restrictions on patient movement were believed to ‘cripple the intelligence and depress the spirit’.25 Paetz’s model allowed doctors to classify patients into smaller groups and unlock doors to allow patients with predictable behaviour to wander freely within the secure outer boundaries of the hospital.26 This remained the preferred approach to patient accommodation for over a century, as endorsed by the WHO in their report of 1953.27 Broadmoor Hospital (UK, 2019) provides an example of the village model.The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub.

The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub." data-icon-position data-hide-link-title="0">Figure 1 The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub. The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub.The campus model is not dissimilar to the approach propagated by Dr Henry Thomas Kirkbride, a 19th-century psychiatrist who was active in the design of asylums and whose influence saw this planning arrangement dominate asylum constructions in the USA for many decades.28 Asylums of the ‘Kirkbride plan’ arranged patient accommodation in a series of pavilions linked by corridors. While corridors can be heavily glazed, where this action is not taken, the campus approach can compromise patient and staff connections to landscape views. Examples of campus hospitals include the Worcester Recovery Center and Hospital (USA, 2012) and the Nixon Forensic Center (USA, under construction).Treatment hubs are a contemporary addition to forensic psychiatric hospitals. These cluster a range of shared patient spaces, including recreational, treatment and vocational training facilities, and thus drive patient movement around or through a hospital site.

Two different treatment hub arrangements are in use. €˜internal’ and ‘on-edge’. Those arranged internally typically place these functions at the heart of the campus and at a significant distance from the secure boundary line. Those arranged on-edge are placed at the far end of campus-model hospitals and, in the most extreme cases, occur adjacent to one of the site’s external boundaries (refer to Figure 1). Both arrangements aspire to make life within the hospital resemble life beyond the hospital as closely as possible, as the daily practice of walking from an accommodation area to a treatment hub mimics the practice of travelling from home to a place of work or study.With evidence mounting regarding the psychological benefits to patients of landscape access, it should not be assumed that the current preference for campus hospitals over the village model indicates ‘best practice’.

A campus arrangement offers security benefits for the movement of patients across a hospital site, while avoiding the associated risks of contraband concealed within landscaped spaces. However, the existence of village hospitals for forensic cohorts suggests it is possible to successfully manage these challenges. Why then do we see such a strong persistence of the campus hospital?. This preference may be driven by cultural expectations. From 24 forensic psychiatric hospitals surveyed, 10 were located within the USA and all employed the campus model.

Yet nine of those hospitals occupied rural sites where the village model could have been used, suggesting the influence of the Kirkbride plan prevails. The four village hospitals within the broader sample of 31, spanning forensic and non-forensic settings, all occurred within the UK3 and Ireland1. Paetz’s villa model had been the preferred approach to new constructions in these countries since its introduction at close of the 19th century.29 However, a look at UK hospitals in isolation revealed a more even spread of village and campus arrangements, with two of the four UK-based campus hospitals occupying constrained urban sites that required multi-story solutions. The village model would be inappropriate for achieving this as it does not lend well to urban locations where land availability is scarce.Design approaches to inpatient accommodationThree approaches to inpatient accommodation were identified. €˜peninsula’, ‘race-track’ and ‘courtyard’ (Figure 2).

The peninsula model is characterised by rows of inpatient wings, along a single-loaded or double-loaded corridor that stretches into the surrounding landscape. This typically enables an exterior view from all patient bedrooms and is not dissimilar to the traditional ‘pavilion’ model that emerged within 19th-century hospital design.30 In the racetrack model bedrooms are arranged around a cluster of staff-only (or service) spaces, still enabling exterior views from all patient bedrooms. The courtyard model is similar to the racetrack but includes a central landscape space. Information on the design of inpatient room layouts was available for 24 of the 31 projects analysed (15 of these 24 were forensic).Common inpatient accommodation configurations. (1) Peninsula.

Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey." data-icon-position data-hide-link-title="0">Figure 2 Common inpatient accommodation configurations. (1) Peninsula.

Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey.Ten forensic hospitals employed a peninsula plan and five employed a courtyard plan. Of the non-forensic psychiatric hospitals five employed the courtyard, three the racetrack and only one the peninsula plan.

While the sample size is too small to generalise, the peninsula plan appears to be favoured for a forensic cohort. However, cultural trends again emerge. Of the 10 peninsula plan hospitals, 6 were located within the USA, and among the broader sample of 24 (including the non-forensic facilities) none of the courtyard hospitals were located there. Courtyard layouts for forensic patients occurred within the UK, Ireland, Denmark and Sweden. However, within these countries, a mix of courtyard and peninsula plans were used, suggesting no clear preference for one plan over the other.Each plan type has advantages and disadvantages (Table 2).

Courtyard accommodation provides the following benefits. Greater opportunity for patient access to landscape since these are easier for staff to maintain surveillance over. Additional safety for staff owing to continuous circulation (staff cannot get caught in ‘dead-ends’. However, the presence of corners which are difficult to see around is a drawback). Natural light is more easily available.

And ‘swing bedrooms’ can be supported (this is the ability to reconfigure the number of observable bedrooms on a nursing ward by opening and closing doors at different points within a corridor). However, courtyard accommodation requires a larger site area so is better suited to rural locations than urban and is not well suited to multi-story facilities. Peninsula accommodation enables geographical separation, giving medical teams greater opportunity to manage which patients are housed together (‘cohorting’). Blind corners can be avoided to assist safety and surveillance. Travel distances can be minimised.

Finally, the absence of continuous circulation provides greater flexibility for creating social spaces for patients with graduated degrees of (semi-)privacy.View this table:Table 2 Advantages and disadvantages of peninsula versus courtyard accommodationAnother important consideration related to inpatient accommodation is ward size. The number of bedrooms clustered together, alongside the amount of dedicated living space associated with these bedrooms. Ward size can influence patient agitation and aggression, alongside ease of supervision, staff anxiety and safety.31 The most common ward sizes were 24 or 32 beds, further subdivided into subclusters of 8 beds. Typically, each ward was provided with one large living space that all 24 or 32 patients used together. More advanced approaches gave patients a choice of living spaces.

For example, at Coalinga Hospital, patients could occupy a small living space available to only 8 patients, or a larger space that all 24 patients had access to. We describe this approach as more advanced since both 19th-century understandings alongside recent research by Ulrich et al confirm that social density (the number of persons per room) is ‘the most consistently important variable for predicting crowding stress and aggressive behaviour’.32 Only six hospitals had plans detailed enough to calculate the square-metre provision of living space per patient, and this varied between 5 and 8 square metres.Limitations of the desktop surveyData from a desktop survey are insufficient to obtain a comprehensive understanding of how design contributes to patient experience. To overcome this limitation, the following sections combine knowledge about how people use space from environmental psychology, knowledge about the design and consultation processes that guide the construction of these facilities, and understandings from architectural history. History suggests that seemingly small changes to typical design practice can effect significant change in the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. This integrated approach is used to identify three forensic psychiatric hospitals that challenge accepted design practice to varying degrees and, in doing so, have the potential to act as change-agents in the delivery of forensic mental healthcare.

But first it is important to understand the context in which architectural innovation is able, or unable, to emerge relative to forensic mental healthcare.Accepting the challenge. Using history to help us see beyond the roadblocks to innovationArchitects tasked with designing forensic mental health facilities respond to what is called a ‘functional brief’. This documents the specific performance requirements of the hospital in question. Much consultation goes into formulating and refining a functional brief through the initial and developed design stages. Consultation is typically undertaken with a variety of different user groups, and in a sequential fashion that includes a greater cross-section of users as the design progresses, including patients, families, and clinical and security staff.

Despite the focus on patient experience within contemporary models of care, functional briefs tend to prioritise safety and security, making them the basis on which most major architectural decisions are made.33 In large part this is simply the reality of accommodating a patient cohort who pose a risk of harm towards themselves and/or others. A comment from Tom Brooks-Pilling, a member of the design team for the Nixon Forensic Center (Fulton, Missouri), provides insight into this approach and the concerns that drive it. He explained that borrowing a ‘spoked wheel’ arrangement from prison design eliminated blind spots and hiding places to enable a centrally located staff member to:see everything that’s going on in that unit…[they are] basically watching the other staff’s back [sic] to make sure that they can focus on treatment and not worry about who might be sneaking up on them or what activities might be going on behind their backs.34Advisory panel feedback confirmed that when the architectural design of a facility heightens staff anxiety this has direct ramifications for the therapeutic process. For example, in spaces where staff could become isolated from one another, and where clear lines of sight were obstructed, such as ill-designed elevators or stairwells, this can lead to movement being reduced across the patient cohort to avoid putting staff in those spaces where they feel unsafe.The architects consulted during the course of this research, including those who were part of the research team, articulated how the necessary prioritisation of safety, in turn, leads to compromises in the attainment of an ideal environment to support treatment. In the various forensic and acute psychiatric hospital projects they had been involved with, all observed a sincere commitment on the part of those engaged in project briefing to upholding ideals around privacy, dignity, autonomy and freedom of movement for patients.

They reported, however, that the commitment to these ideals was increasingly obstructed as the design process progressed by the more pressing concerns of safety. Examples of the kinds of architectural implications of this prioritisation are things like spatially separated nursing stations (enclosed, often fully glazed), when a desire for less-hierarchical interactions between patients and staff had been expressed at the beginning of the briefing process. Or the substitution of harder-wearing materials, with a more ‘institutional’ feel when a ‘home-like’ atmosphere had been prioritised initially. There is nothing surprising or unusual about this process since design is, by its nature, a process of seeking improvements on accepted practice while systematically checking the suitability of proposed solutions against a set of performance requirements. In the context of forensic psychiatric hospitals, safety is the performance requirement that most often frustrates the implementation of innovative design.

Thus, amid the complexities of design and procurement relative to forensic psychiatric hospitals, innovation, however humble, and particularly where it can be seen to contribute positively to the patient experience, is worth a closer look.In the historical development of the psychiatric hospital as a building type, two significant departures from accepted design practice facilitated positive change in the treatment of mental illness. The first was Paetz’s development of the village hospital which sought to replace high fences, locked doors and barred windows with ‘humane but stringent supervision’.35 While this planning approach may not have significantly altered models of care, it was regarded as ‘an essential, vital development’, providing architectural support to the prevailing approach to treatment of the time—that of moral treatment—which aimed to extend kindness and respect to patients, in an environment that was as unrestrictive as possible. The York Retreat is worthy of acknowledgement here as a leading proponent of moral treatment whose influence shifted approaches to asylum design, from focusing on the provision of safe custody to supporting the restoration of sanity. Architecturally, however, the differences in the York Retreat’s approach were mainly focused on interior details that encouraged patients to maintain civil habits. Dining rooms had white tablecloths and flower vases adorned mantelpieces, door locks were custom-made to close quietly, and window bars fashioned to look like domestic window frames.36 The York Retreat was originally a small institution, in line with Samuel Tuke’s preference for a maximum asylum size of 30 patients.

History confirms the extent to which this approach was not scalable and thus unable to be replicated widely for asylum construction. For these reasons, it has not been considered here as a significant departure from accepted design practice.The second significant departure from accepted design practice was the development of acute treatment hospitals, located within cities, adjacent to general hospitals and medical research facilities. The first hospital of this type was the Maudsley Hospital, led by doctors Henry Maudsley and Frederick Mott, in London. The design intent for this hospital was announced in 1908 but it was not opened until 1923.37 In proposing this hospital, Maudsley and Mott were motivated to bring psychiatry ‘into line with the other branches of medical science’.38 This 100-bed facility, located directly across the road from the King’s College (Teaching) Hospital, emulated the general hospital typology in offering both outpatient and short-duration inpatient care, specifically targeted at patients with recent-onset illnesses. The aspirations were threefold.

To avoid the stigma associated with large public asylums. To advance the medical understanding of mental illness through research collaborations with general hospitals and medical schools and via improved teaching programmes. And to both enable and encourage patients to access early, voluntary treatment on an outpatient basis.38 Today the Maudsley appears unremarkable, an unassuming three-storied building on a busy London street. But the significance of what this building communicated at the time it was constructed, and the extent to which it challenged accepted practice, should not be underestimated. The Maudsley sent a clear message to the public that mental illness was no longer to be regarded as different from any other illness treated within a general hospital setting.

That it was no longer okay to isolate those suffering from mental illness from their families or the neighbourhoods in which they lived.39 Following the announcement of the Maudsley, the ‘psychopathic hospital’ rose to prominence within the USA with Johns Hopkins University Hospital opening the Phipps Psychiatric Clinic, in Baltimore, in 1913. The psychopathic hospital similarly promoted urban locations and closer connections to teaching and research. The Maudsley can be seen to have played a significant role in the shift to treating acute mental illness within general hospital settings.In any discussion of the history of institutional care, there is a responsibility to acknowledge that the aspiration to provide buildings that support care and recovery have not always manifested in ways that improved daily life for patients. The five treatment values that underpinned the analysis framework for this project are not new values. The extension of privacy and dignity to patients and the delivery of care within the least restrictive environment possible were both firmly embedded in the 19th-century approach of moral treatment.

Yet the rapid growth of asylum care frustrated the delivery of those values to patients.40 Choice and independence for patients, the desire for a patient’s recovery progress to be reflected in their environment, and opportunities for peer support and family involvement have been present in approaches to mental health treatment since the formal endorsement of the ‘therapeutic community’ approach to hospital construction and administration in the WHO’s report of 1953.41 History reminds us, therefore, that differences can arise between the stated values on which an institution is designed and those which it is constructed and operated. The three hospitals discussed in the following section include innovative solutions that hold the promise of positive benefits for patients. Yet we acknowledge this a theoretical analysis. For concrete evidence of a positive relationship between these design outcomes and patient well-being, postoccupancy evaluations are required.Three hospitals contributing to positive change in forensic mental healthcareBroadmoor Hospital. Optimising the value of the village model for patientsNineteenth-century beliefs and contemporary research are in accord regarding the importance of greenspace in reducing agitation within forensic psychiatric hospital environments and in promoting positive patterns of socialisation.42 It is surprising, therefore, that enshrining daily landscape access for patients is not widespread within current design practice.

The Irish National Forensic Mental Hospital and the State Hospital at Carstairs (Scotland) both follow the model of the village hospital, but only in that they comprise a number of accommodation buildings set within the landscape, enclosed by an external boundary fence. At the Irish National Forensic Mental Hospital, the scale of the landscape—the distance between buildings and the lack of intermediate boundaries within the landscape—suggests it is highly unlikely that patients are allowed to navigate this landscape on a regular basis. By comparison, the architectural response developed for Broadmoor Hospital (2019) shows an exemplary commitment to patient views and access to landscape (Figure 3).Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK)." data-icon-position data-hide-link-title="0">Figure 3 Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK).Five contemporary hospitals follow the logic of a traditional villa hospital, yet Broadmoor is the only one that optimises the benefits offered by this spatial configuration.

Comprising a gateway building and a central treatment hub, with a series of patient accommodation buildings positioned around it, the landscape becomes the only available circulation route for patients travelling off-ward to the shared therapy, recreation and vocational training spaces. Most patients will thus engage with the outdoors at least twice daily on their way to and return from these shared spaces. But in addition to accessing this central landscape, landscape views from patient rooms have been prioritised, and each ward is allocated its own large greenspace. Multiple, internal boundary fences enable patient access to the adjacent landscape to the greatest possible degree (refer to Figure 3). This approach provides patients with a diversity of landscape experiences.

This is important given the patterns of landscape use between forensic and non-forensic hospitals. In non-forensic facilities, patients are likely to have the choice of accessing multiple landscape spaces, whereas in forensic facilities access to a particular space is often restricted to one cohort, for example, a single ward group. This highlights a limitation of the courtyard model for forensic patients. Roseberry Park Hospital (2012) provides an example of how a high degree of landscape access can be similarly achieved for patients on constrained urban site, using a courtyard layout (refer to Figure 3).Providing patients with daily landscape access provides challenges to maintaining safety and security. Trees with low branches can be used as weapons, while tall branches can be used for self-harm, and ground cover landscaping increases opportunities to conceal contraband.

At the Australian hospital where advisory panel sessions were conducted (constructed in 2000), the landscape is occupied in a similar way and staff conveyed the constant effort required to ensure safe patient access to this greenspace. Significant costs are incurred annually by facilities staff in keeping the greenspace free from contraband and from several varieties of wild mushroom that grow seasonally on the site. Despite this cost, staff reported that both they and the patients value the opportunity to circulate through the landscaped grounds (even in inclement weather). Hence, the benefits to well-being are perceived as significant enough to justify this cost. These examples make evident that placing a hospital within a landscape is not enough to ensure patients are extended the well-being benefits of ongoing access.

Instead this requires that hospitals factor in the additional supervisory and maintenance requirements to maintain landscape access for patients.Worcester Recovery Center and Hospital. Spaces to support choice and a sense of controlResearch in environmental psychology, conducted within residential and hospital settings, confirms that the ability to regulate social contact can have a dramatic impact on well-being. The physical layout of spaces has been linked to both the likelihood of developing socially supportive relationships and impeding this development, with direct implications for communication, concentration, aggression and a person’s resilience to irritation.43 These problems can be more pronounced in a forensic psychiatric hospital as there is an over-representation of patients who have suffered trauma. Architects working in forensic psychiatric hospital design acknowledge that patients need space to withdraw from the busy hospital environment, spaces where they can ‘observe everything that is going on around them until they feel ready to join in’.44 It is surprising, therefore, that many contemporary forensic psychiatric hospitals still continue to provide a single social space for all 24 or 32 patients occupying a ward. The Worcester Recovery Center, by comparison, provides patients with a choice of social spaces that are designed to enable graduated degrees of social engagement.

This can support a sense of control to limit socially induced stress.Worcester is conceptualised as three distinct zones designed to resemble life beyond the hospital. The ‘house’, ‘neighbourhood’ and ‘downtown’ (Figure 4). The house zones include patient accommodation, employing a peninsula model. Each comprises 26 patient rooms, clustered into groups of 6 or 10 single bedrooms that face a collection of shared spaces dedicated to that cluster, including sitting areas, lounges and therapeutic spaces. A shared kitchen and dining room is provided for each house.

Three houses feed into a neighbourhood zone that includes shared spaces for therapy and vocational training, while the downtown zone serves a total of 14 houses. The downtown zone can be accessed by patients based on a merit system and includes a café, bank and retail spaces, music room, health club, chapel, green house, library and art rooms, alongside large interior public spaces. This array of amenities does not seem distinctly different from other contemporary facilities, where therapy and vocational training happen in a mix of on-ward and off-ward (often within a central treatment hub). The difference lies in the sensitivity of how these spaces are articulated.Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’." data-icon-position data-hide-link-title="0">Figure 4 Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’.The generosity of providing separate living spaces for every 6–10 patients and locating these directly across the corridor from the patient rooms supports a sense of control and choice for patients. Frank Pitts, an architect who worked on the Worcester project, has written that this was done to enable patients to ‘decide whether they are ready to step out and socialise or return to the privacy of their room’.45 This approach filters throughout the facility, providing a slow graduation of social engagement opportunities for patients, from opportunities to socialise with their cluster of 6–10 individuals, to their house of 26, to their neighbourhood of 78 people, to the full downtown experience.

According to the architects, the neighbourhood thus provides an intermediary zone between the quiet house and the active downtown, which can be overwhelming for some patients.46 Importantly the scale of the architecture responds to this transition from personal to public space, providing visual indicators to reflect patients’ movement through their treatment journey. Spaces become larger as they move further from the ward. This occurs because instead of providing a single, large shared living space, patients are provided a choice of smaller spaces to occupy—these are not much bigger than a patient bedroom. Dining spaces are slightly larger, while downtown spaces have a civic quality. These are double-height, providing a greater sense of light and airiness.

These are arranged in a semicircle, opening onto a large veranda and greenspace. The sensitive articulation of these spaces, with regard to both their graduated physical scale and the proximity of the social spaces to the patient bedrooms, provides spatial support to these social transitions while empowering patients to control their own level of social interaction.Margaret and Charles Juravinski Centre for Integrated Healthcare. Creating opportunities for greater public engagement and supporting readjustment to the world beyond the hospitalOne of the most significant barriers to mental health treatment is the stigma associated with admission to a psychiatric hospital. We know that discrimination poses an obstacle to recovery and that the media fuels public fears related to forensic mental health patients.47 Two further challenges to mental health delivery include the disconnection patients can experience from the community, including from family and educational opportunities, and the risk of readmission in the period immediately following discharge.48 If architecture is capable of acting as a change-agent in the delivery of mental healthcare, then it needs to show leadership, not only in the provision of a better experience for patients but more broadly in taking steps to help shift public perceptions around mental illness. The Margaret and Charles Juravinski Centre for Integrated Healthcare (MCJC) (Canada) displays several similarities with the approach taken to the Maudsley Hospital.

Its appearance communicates a modern, cutting-edge healthcare facility. It does not hide on a rural site or behind walls. At five stories, and extensively glazed, MCJC communicates a strong civic presence. Its proximity to McMaster University (6 km) and to neighbouring general hospitals, including Juravinski Hospital (4 km) and Hamilton General Hospital (4 km), positions it well for research collaborations to occur, while its proximity to the Mohawk Community College, across the road, can enable patients with leave privileges to access vocational training. More importantly, it employs three innovative design tactics to target the challenges of contemporary forensic mental healthcare, providing an example for how architecture might broker positive change.The first innovative design strategy is the co-location of support services for outpatient mental healthcare.

The risk of readmission is highest immediately following discharge. A lack of collaboration between outpatient support services can result in fragmented care when patients are most vulnerable to the stresses associated with readjustment to the world beyond.49 MCJC includes outpatient facilities allowing patients to use the hospital as a stable base, or touchstone, in adjusting to life after discharge. Bringing these services onto the same physical site can also improve opportunities for coordination between inpatient and outpatient support services which can support continuity of care. The second design strategy is the co-location of a medical ambulatory care centre which includes diagnostic imaging, educational and research facilities. This creates reasons for the general public to visit this facility, setting up the opportunity for greater public interaction.

This could potentially advance understandings of the role of this facility and the patients it treats.The third innovative design strategy was to optimise the on-edge treatment hub for public engagement. While adopted across a number of hospitals, including Hawaii State Hospital, Helix Forensic Psychiatry Clinic (Sweden) and the Worcester Recovery Center, the on-edge treatment hubs at these hospitals are buried deep inside the secure outer boundary. At MCJC, the treatment hub is placed adjacent to the public zones of the hospital—although on the second floor—and this can be viewed as extension of the public realm and enables the potential for the public to be brought right up to the secure boundary line (which occurs within the building). MCJC is divided into four zones. The public zone, the galleria (the name given to the treatment hub), the clinical corridor and inpatient accommodation (Figure 5).

The galleria functions similarly to the downtown at the Worcester Recovery Center. Patients are given graduated access to a series of spaces that support their recovery journey. These include a gym, wellness centre, spiritual centre, library, café, beauty salon, and retail and financial services, alongside patient and family support services. While the galleria was initially intended to be accessible by the general public, this was not immediately implemented on the facilities’ opening and it is unclear whether this has now occurred.50 Nonetheless, the potential for movement of patients outwards, and families inwards, has been built into the physical fabric of this building, meaning opportunities for social interaction and fostering greater public understanding are possible. If understanding is the antidote to discrimination, then exposing the public to the role of this facility and the patients it treats is an important step in the right direction.Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.

The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated." data-icon-position data-hide-link-title="0">Figure 5 Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare. The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria.

Lifts (L) and stairwell (S) positions are indicated.ConclusionThe question of how architecture can support the therapeutic journey of forensic mental health patients is a critical one. Yet the availability of evidence-based design literature to guide designers cannot keep pace with growing global demand for new forensic psychiatric hospital facilities, while limitations remain relative to the breadth and usability of this research. A narrow view of what constitutes credible evidence can overlook the value of knowledge embedded in architectural practice, alongside that held by architectural historians and lessons from environmental psychology. In respect of such a pressing and important problem, there is a responsibility to integrate knowledge from across these disciplines. Accepting the limitations of a theoretical analysis and of the desktop survey method, we also argue for its value.

Architects learn through experience, across multiple projects. This gives weight to the value of examining existing, contemporary design solutions to identify architectural innovations capable of providing benefits to patients and thus perhaps worthy of implementation across multiple projects. History gives us reason to believe that small changes to typical design practice can improve the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. Architecture has the capacity to contribute to positive change.Here, we have provided a nuanced way for architects and decision makers to think about the relationship between architectural space and treatment values. An institution’s model of care and the therapeutic values that underpin that model of care should be placed at the centre of architectural decision making.

A survey of contemporary architectural solutions confirms that, generally speaking, innovation is lacking in this field. There will always be real obstacles to innovation, and the argument presented here does not suggest it is necessarily practical to prioritise therapeutic values at the cost of patient, staff and community safety. Instead, it challenges architects and decision makers to properly interrogate any architectural decision that compromises an initial commitment to supporting a patient’s treatment journey—to be more idealistic in the pursuit of positive change.Tangible examples exist of architectural innovations capable of positively improving patient experience by supporting key values that underpin contemporary treatment approaches. The Broadmoor Hospital optimises the value of the village model for patients, prioritising patient needs for frequent landscape engagement to support their therapeutic journey. The Worcester Recovery Center provides a generous choice and graduation of social spaces to support the social reintegration of patients at their own pace.

MCJC co-located facilities to support a patient’s readjustment to daily life postdischarge, while creating opportunities for public engagement that has the potential to foster greater public understanding of the role of these institutions and the patients they treat. In identifying these three innovative design approaches, we provide architects with tangible design tactics, while encouraging researchers to look more closely at these examples with targeted, postoccupancy studies. These projects provide hope that with a shared vision and commitment, innovation is possible in forensic psychiatric hospital design, with tangible benefits for patients.Data availability statementAll data relevant to the study are included in the article or uploaded as supplementary information. The primary method undertaken for this research relied on data publicly available on the internet.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe opportunity to conduct this project arose out of a multidisciplinary master-planning and feasibility study, commissioned by the Victorian Health and Human Services Building Authority, to investigate various international solutions to inform future planning and design around forensic mental health service provision. The following people contributed their time and expertise in shaping the research process that enabled this article.

Neel Charitra, Stefano Scalzo, Les Potter, Margaret Grigg, Lousie Bawden, Matthew Balaam, Martin Gilbert, John MacAllister, Crystal James, Jo Ryan, Julie Anderson, Jo Wasley, Sophie Patitsas, Meagan Thompson, Judith Hemsworth, James Watson, Viviana Lazzarini, Krysti Henderson, Nadia Jaworski, Jack Kerlin and Jan Merchant.Notes1. Jamie O'Donahoo and Janette Graetz Simmonds (2016), “Forensic Patients and Forensic Mental Health in Victoria. Legal Context, Clinical Pathways, and Practice Challenges,” Australian Social Work 69, no. 2. 169–80.2.

The challenge of which terminology to select when writing about psychiatric hospital design remains difficult relative to the stigmas that surround this field. The term ‘patient’ has been used throughout, instead of ‘consumer’, as this article spans both historical and contemporary developments. In the context of this timespan, consumer is a relatively recent term, introduced around 1985.3. B Edginton (1994), “The Well-Ordered Body. The Quest for Sanity through Nineteenth-Century Asylum Architecture,” Canadian Bulletin of Medical History 11, no.

2. 375–86. Clare Hickman (2009), “Cheerful Prospects and Tranquil Restoration. The Visual Experience of Landscape as Part of the Therapeutic Regime of the British Asylum, 1800-60,” History of Psychiatry 20, no. 4 Pt 4.

425–41. Rebecca McLaughlan, 2012), “Post-Rationalisation and Misunderstanding. Mental Hospital Architecture in the New Zealand Media,” Fabrications 22, no. 2. 232–56.4.

Roger S Ulrich et al. (2008), “A Review of the Research Literature on Evidence-Based Healthcare Design,” HERD 1, no. 3. 61–125. Jill Maben et al.

(2015), “Evaluating a Major Innovation in Hospital Design. Workforce Implications and Impact on Patient and Staff Experiences of All Single Room Hospital Accommodation,” Health Services and Delivery Research 3. 1–304. Penny Curtis and Andy Northcott (2017), “The Impact of Single and Shared Rooms on Family-Centred Care in Children’s Hospitals,” Journal of Clinical Nursing 26, no. 11–12.

1584–96.5. Roger S. Ulrich et al. (2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” Journal of Environmental Psychology 57. 53–66.6.

Graham A Tyson, Gordon Lambert, and Lyn Beattie (2002), “The Impact of Ward Design on the Behaviour, Occupational Satisfaction and Well-Being of Psychiatric Nurses,” International Journal of Mental Health Nursing 11, no. 2. 94–102.7. For further examples of this see Jon E. Eggert et al.

(2014), “Person-Environment Interaction in a New Secure Forensic State Psychiatric Hospital,” Behavioral Sciences &. The Law 32, no. 4. 527–38. C.C.

Whitehead et al. (1984), “Objective and Subjective Evaluation of Psychiatric Ward Redesign,” The American Journal of Psychiatry 141, no. 5. 639–44. Gabriela Novotná et al.

(2011), “Client-Centered Design of Residential Addiction and Mental Health Care Facilities. Staff Perceptions of Their Work Environment,” Qualitative Health Research 21, no. 11. 1527–38.8. Morgan Andersson et al.

(2013), “New Swedish Forensic Psychiatric Facilities. Visions and Outcomes,” Facilities 31, no 1/2. 24–88.9. For examples see Kathleen Connellan et al. (2013), “Stressed Spaces.

Mental Health and Architecture,” HERD. Health Environments Research &. Design Journal 6, no. 4. 127–168.

Constantina Papoulias et al. (2014), “The Psychiatric Ward as a Therapeutic Space. Systematic Review,” British Journal of Psychiatry 205, no. 3. 171–6.10.

R. Allen and R.G. Nairn, 1997. Alan Dilani, 2000, “Psychosocially Supportive Design - Scandinavian Health Care Design,” World Hospitals and Health Services 37. 20–4.

Rebecca McLaughlan (2018), “Psychosocially Supportive Design. The Case for Greater Attention to Social Space within the Pediatric Hospital," HERD 11, no. 2. 151–62.11. Rebecca McLaughlan (2017), “Learning From Evidence-Based Medicine.

Exclusions and Opportunities within Health Care Environments Research,” Design for Health 1. 210–28.12. B Edginton (1997), “Moral Architecture. The Influence of the York Retreat on Asylum Design,” Health &. Place 3, no.

2. 91–9. Jeremy Taylor (1991), Hospital and Asylum Architecture in England 1849–1914. Building for Health Care (London. Mansell Publishing Limited).

Anne Digby (1985), Madness, Morality and Medicine. A Study of the York Retreat 1796–1914 (New York. Cambridge University Press).13. Digby, Madness, Morality and Medicine. Erving Goffman (1961), Asylums.

Essays on the Social Situation of Mental Patients and Other Inmates (New York. Doubleday). Ivan Belknap (1956), Human Problems of a State Mental Hospital (New York. Blakiston Division, McGraw-Hill). Andrew Scull (1979), Museums of Madness.

The Social Organization of Insanity in 19th Century England (London. Allen Lane). Leonard Smith (1999), Cure, Comfort and Safe Custody. Public Lunatic Asylums in Early Nineteenth-Century England (London. Leicester University Press).

Rebecca McLaughlan (2014), “One Dose of Architecture, Taken Daily. Building for Mental Health in New Zealand” (PhD diss., Victoria University of Wellington, New Zealand).14. Although not fitting a strict definition of postoccupancy evaluation, the following articles were notable exceptions to this finding. Eggert et al., “Person-Environment Interaction,” 527–38. Roger S.

Ulrich et al. (2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. Catherine Clark Ahern et al. (2016), “A Recovery-Oriented Care Approach. Weighing the Pros and Cons of a Newly Built Mental Health Facility,” Journal of Psychosocial Nursing and Mental Health Services 54, no.

2. 39–48.15. M Gibbons (2000), “Mode 2 Society and the Emergence of Context-Sensitive Science,” Science and Public Policy 27. 161.16. D Seamon, 2000, “A Way of Seeing People and Place,” in Theoretical Perspectives in Environment-Behavior Research, ed.

S. Wapner, J. Demick, T. Yamamoto and H. Minami (New York.

Plenum), 157–78.17. Thomas A Markus (1982), Order in Space and Society. Architectural Form and Its Context in the Scottish Enlightenment (Edinburgh. Mainstream Publishing Company).18. Ulrich et al., “A Review of the Research Literature,” 61–125.19.

This was first created by first author for use for historical analysis during her PhD and is applied here to a contemporary setting. Refer to McLaughlan, “One Dose of Architecture, Taken Daily.”20. The following documents were referenced in compiling this list. Joint Commission Panel for Mental Health, NHS, UK (2013), “Guidance for Commissioners of Forensic Mental Health Services,” May, https://www.jcpmh.info/resource/guidance-for-commissioners-of-forensic-mental-health-services/. Cannon Design (2014), “St Joseph’s Integrated Healthcare Hamilton, Margaret and Charles Juravinski Centre for Integrated Healthcare,” Healthcare Design Showcase, September.

Health Nexus Group, 2017, “Forensicare Model of Care Report,” April, Australia (access provided by the Victorian Health and Human Services Building Authority). Donald Cant Watts Corke (2014), “Service Plan for Forensic Mental Health Services,” July, Australia (access provided by the Victorian Health and Human Services Building Authority).21. Sometimes this includes patients with no history of criminal behaviour but who are unable to be treated safely in a general hospital environment.22. W.A.F Browne (1991), "What Asylums Were, Are and Ought to Be (1837),” reprinted in The Asylum as Utopia. W.A.F.

Browne and the Mid-Nineteenth Century Consolidation of Psychiatry, ed. Andrew Scull (London. Tavistock). Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38.

Eggert et al., “Person-Environment Interaction.”23. Anon (1895), “Review. The Colonization of the Insane in Connection with the Open-Door System. Its Historical Development and the Mode in Which It Is Carried Out at Alt Scherbitz Manor. By Dr.

Albrecht Paetz, Director of the Provincial Institution for the Insane (Berlin. Springer, 1983),” The Journal of Mental Science 41. 697–703.24. Theodore Gray (1958), The Very Error of the Moon (Ilfracombe &. Devon.

Arthur H. Stockwell Ltd), 64.25. John Galt (1854), “The Farm of St. Anne,” American Journal of Insanity II (1854). 352.26.

Galt, “The Farm of St. Anne,” 352.27. Martin James (1948), “Diagnostic Measures,” in Modern Trends in Psychological Medicine, ed. Noel Haris (London. Buttefwork &.

Co. Ltd), 146. World Health Organization (1953), The Community Mental Hospital. Third Report of the Expert Committee on Mental Health (Geneva. WHO).28.

Carla Yanni (2007), The Architecture of Madness. Insane Asylums in the United States. Minneapolis (London. University of Minnesota Press).29. Key British examples included the 1923 rebuild of London’s Bethlem Hospital which followed the villa model, alongside Shenley Park Mental Hospital (Middlesex County) and Barrow Mental Hospital (Somerset), both constructed in the early 1930s.30.

Taylor, Hospital and Asylum Architecture in England.31. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. O. Jenkins, S. Dye and C.

Foy (2015) (Oliver Jenkins et al., 2015), “A Study of Agitation, Conflict and Containment in Association With Change in Ward Physical Environment,” Journal of Psychiatric Intensive Care 11, no. 01. 27–35. M. Daffern, M.M.

Mayer, and T. Martin (2004), “Environmental Contributors to Aggression in Two Forensic Psychiatric Hospitals,” International Journal of Forensic Mental Health 3 no. 1. 105–114. Kathryn L.

Brooks et al. (1994), “Patient Overcrowding in Psychiatric Hospital Units. Effects on Seclusion and Restraint,” Administration and Policy in Mental Health 22, no. 2. 133–44.

T. T Palmstierna, B Huitfeldt, and B Wistedt (1991), “The Relationship of Crowding and Aggressive Behavior on a Psychiatric Intensive Care Unit,” Psychiatric Services 42, no. 12. 1237–40.32. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 57.

Charles Mercier (1894), Lunatic Asylums. Their Organisation and Management (London. Charles Griffin and Company), 135.33. Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38.

Joel A Dvoskin et al. (2002), “Architectural Design of a Secure Forensic State Psychiatric Hospital,” Behavioral Scients &. The Law, 20, no. 3. 481-493.

J. Enser and D. Maclnnes (1999), “The Relationship between Building Design and Escapes from Secure Units,” Journal of the Royal Society for the Promotion of Health 119, no. 3. 170–4.

Jon E. Eggert et al. (2014), “Person-Environment Interaction,” 527–38.34. Tom Brooks-Pilling cited in Mike Lear (2015), “Designer. New Fulton State Hospital Will Be Better, Safer,” Missourinet, January 5, https://www.missourinet.com/2015/01/05/designer-new-fulton-state-hospital-will-be-better-safer/35.

Leslie Topp (2007), “The Modern Mental Hospital in Late Nineteenth-Century Germany and Austria. Psychiatric Space and Images of Freedom and Control,” in Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, ed. Leslie Topp, James Moran and Jonathan Andrews (London and New York. Routledge), 244.36.

McLaughlan, “One Dose of Architecture, Taken Daily,” 35. Digby, Madness, Morality and Medicine.37. Anon (1908), “Proposed New Hospital for Mental Diseases,” The Lancet 171, no. 4410. 728–9.38.

Anon, “Proposed New Hospital for Mental Diseases.”39. McLaughlan, “One Dose of Architecture, Taken Daily.”40. Samuel Tuke (1964), “Description of the Retreat (1813),” reprinted in Description of the Retreat With an Introduction by Richard Hunter and Ida Macalpine (London. Dawsons of Paul Mall). Scull, Museums of Madness.

Digby, Madness, Morality and Medicine. Smith, Cure, Comfort and Safe Custody.41. World Health Organization (1953), The Community Mental Hospital. Also refer to T.F Main (1946), “The Hospital as a Therapeutic Institution”, Bulletin of the Menninger Clinic 10, no. 3.

66–71. David Clark (1965), “The Therapeutic Community Concept, Practice and Future,” The Journal of Mental Science 111. 947–54.42. Jolanda Maas et al. (2009), “Social Contacts as a Possible Mechanism behind the Relation between Green Space and Health,” Health &.

Place 15, no. 2. 586–95. Gayle Souter-Brown (2015), Landscape and Urban Design for Health and Well-Being. Using Healing, Sensory and Therapeutic Gardens (Oxon &.

New York. Routledge). Ulrich et al., “A Review of the Research Literature,” 61–125.43. Leon Festinger et al. (1950), Social Pressures in Informal Groups.

A Study of Human Factors in Housing, vol. 11 (New York. Harper Bros). David Halpern (1995), Mental Health and the Built Environment. More than Bricks and Mortar?.

(London. Taylor and Francis). A. Baum and G.E. Davis (1980), “Reducing the Stress of High-Density Living.

An Architectural Intervention,” Journal of Personality and Social Psychology 38, no. 3. 471–81. I. Altman and M.M.

Chemers (1984), Culture and Environment (Monterey, CA. Brooks &. Cole Publishing). Gary W Evans (2003), “The Built Environment and Mental Health,” Journal of Urban Health. Bulletin of the New York Academy of Medicine 80 no.

4. 536–55. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66.44. Stence Guldager cited in Troldtekt, “Innovative Architecture is Good for Mental Health,” https://www.troldtekt.com/News/Themes/Healing_architecture/Innovative_architecture_is_good_for_mental_health (accessed June 30, 2019). Clare Hickman and “Cheerful Prospects (2009).45.

Frank Pitts cited in Patricia Wen (2012), “For Mentally Ill, A Design Departure,” B News, August 16, https://www.boston.com/news/local-news/2012/08/16/for-mentally-ill-a-design-departure46. Ellenzweig with Architecture Plus, “Massachusetts Department of Mental Health, Worcester Recovery Center and Hospital – Worcester, MA,” Healthcare Design (2013), July 30, https://www.healthcaredesignmagazine.com/architecture/massachusetts-department-mental-health-worcester-recovery-center-and-hospital-worcester-ma/47. Sane Australia (2003), “A Life Without Stigma,” July 25, http://apo.org.au/resource/life-without-stigma. Otto F Wahl (2012), “Stigma as a Barrier to Recovery from Mental Illness,” Trends in Cognitive Sciences 16, no. 1.

9–10. New Zealand Ministry of Health and Health Promotion Agency (2014), “Like Minds, Like Mine National Plan 2014–2019. Programme to Increase Social Inclusion and Reduce Stigma and Discrimination for People with Experience of Mental Illness,” May 20, https://www.likeminds.org.nz/assets/National-Plans/like-minds-like-mine-national-plan-2014-2019-may14.pdf. G Moon (2000), “Risk and Protection. The Discourse of Confinement in Contemporary Mental Health Policy," Health &.

Nairn (1997), “Media Depictions of Mental Illness. An Analysis of the Use of Dangerousness,” Australian &. New Zealand Journal of Psychiatry 31, no. 3. 375–81.

Greg Philo et al. (1994), “The Impact of the Mass Media on Public Images of Mental Illness. Media Content and Audience Belief,” Health Education Journal 53, no. 3. 271–81.48.

G Moon (2000), “Risk and Protection,” 239–50. T.F Main (1948), “Rehabilitation and the Individual,” in Modern Trends in Psychological Medicine, ed. Noel Haris (London. Buttefwork &. Co.

Ltd). D.A Fuller, E. Sinclair, and J. Snook (2016), “Released, Relapsed, Rehospitalized. Length of Stay and Readmission Rates in State Hospitals.

A Comparative State Survey,” 2016, https://www.treatmentadvocacycenter.org/storage/documents/released-relapsed-rehospitalized.pdf. Leila Salem et al. (2015), “Supportive Housing and Forensic Patient Outcomes,” Law and Human Behavior 39, no. 3. 311.49.

National Institute for Health and Clinical Excellence, Manchester (2016), “Transition between Inpatient Mental Health Settings and Community or Care Home Settings. Guideline,” August, https://www.nice.org.uk/guidance/ng53/evidence/full-guideline-pdf-260695191750. Catherine Clark Ahern et al. (2016), “A Recovery-Oriented Care Approach,” 47..

Notes1 http://charltonsingleton.com/where-to-get-propecia-pills// propecia cheapest price. R. C Keller propecia cheapest price (2006).

"Geographies of power, legacies of mistrust. Colonial medicine in the global present." Historical Geography no. 34:26-48.2.

Bridget Pratt et al. (2018). "Exploring the ethics of global health research priority-setting." BMC Medical Ethics no.

Richard Horton (2013). "Offline. Is global health neocolonialist?.

10.1016/S0140-6736(13)62379-X4. Anonymous (2019). "Editorial.

Break with tradition. The World Health Organization’s decision about traditional Chinese medicine could backfire." Nature no. 570:5.5.

S. S Amrith (2006). Decolonizing international health.

India and Southeast Asia, 1930–65. London. Palgrave Macmillan.6.

Arturo Escobar and A Escobar (1984). "Discourse and power in development. Michel Foucault and the relevance of his work to the third world." Alternatives no.

10 (3):377-400. Doi. 10.1177/0304375484010003047.

UNDG (2013). A million voices. The world we want.

A sustainable future with dignity for all. New York, NY. United Nations Development Group.8.

WHO (2019). Speech by the Director-General. Transforming for impact 2019 (cited 10 March 2019).

Available from. Https://www.who.int/dg/speeches/detail/transforming-for-impact.9. R.

C Keller (2006). Geographies of power, legacies of mistrust. Colonial medicine in the global present.10.

Mishal S Khan et al. (2019). Durrance-Bagale, H.

Legido-Quigley "‘LMICs as reservoirs of AMR’. A comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan." Health Policy and Planning no. 34 (3):178–187.

Doi. 10.1093/heapol/czz02211. Clare I R Chandler (2019).

"Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure." Palgrave Communications no. 5 (1):53.

Doi. 10.1057/s41599-019-0263-412. In the area of antimicrobial use for human health, other problem areas include, for example, public hygiene and disease prevention, regulated access to medicines, disease diagnosis, or market conditions for the development of new antimicrobials.

The Review on Antimicrobial Resistance (2016). Tackling drug-resistant s globally. Final report and recommendations.

London. The UK Prime Minister, WHO (2015b). Global action plan on antimicrobial resistance.

Geneva. World Health Organization, Conan MacDougall and Ron E Polk (2005). "Antimicrobial stewardship programs in health care systems." Clinical Microbiology Reviews no.

18 (4):638-656. Doi. 10.1128/CMR.18.4.638-656.2005.13.

The Review on Antimicrobial Resistance. Tackling drug-resistant s globally. Final report and recommendations.14.

WHO, Global action plan on antimicrobial resistance.15. Maria R Gualano et al. (2015).

"General population's knowledge and attitudes about antibiotics. A systematic review and meta-analysis." Pharmacoepidemiology and Drug Safety no. 24 (1):2-10.

Radyowijati (2010). "Determinants of antimicrobial use. Poorly understood, poorly researched." In Antimicrobial resistance in developing countries, edited by Sosa, Byarugaba, Amábile-Cuevas, Hsueh, Kariuki and Okeke, 283-300.

New York, NY. Springer.17. These problems persist despite encouraging trends.

For example, the field is becoming increasingly multidisciplinary through the involvement of several United Nations agencies alongside WHO in governing AMR, and AMR policy narratives are slowly broadening the hitherto hyper-individualised and behaviour change focus of global action plans. Connor Rochford et al. (2018).

"Global governance of antimicrobial resistance." The Lancet no. 391 (10134):1976-1978. Doi.

10.1016/S0140-6736(18)31117-6, WHO, FAO, and OIE (2018). Monitoring global progress on addressing antimicrobial resistance. Analysis report of the second round of results of AMR country self-assessment survey 2018.

Geneva. World Health Organization, Food and Agriculture Organization of the United Nations and World Organisation for Animal Health (OIE), WHO (2017). Antimicrobial Resistance Behaviour Change first informal technical consultation, 6-7 November, 2017 Château de Penthes, Geneva.

Meeting Report. Geneva. World Health Organization, Elise Klein and China Mills (2017).

"Psy-expertise, therapeutic culture and the politics of the personal in development." Third World Quarterly no. 38 (9):1990-2008. Doi.

10.1080/01436597.2017.131927718. Emma R M Cohen et al. (2008).

"Public engagement on global health challenges." BMC Public Health no. 8 (168). Doi.

10.1186/1471-2458-8-16819. B Hamlyn et al. (2015).Factors affecting public engagement by researchers.

A study on behalf of a consortium of UK public research funders. London. TNS20.

Research Councils UK (2011) Concordat for engaging the public with research. Research Councils UK. Swindon.21.

Building an engaged future for UK higher education. Full report from the Engaged Futures consultation. Bristol.

National Co-ordinating Centre for Public Engagement.22. Also referred to as ‘community engagement’, ‘patient and public involvement’ (PPI) in research, or in some instances also as participatory research. S.

Staniszewska et al. (2017). "GRIPP2 reporting checklists.

Tools to improve reporting of patient and public involvement in research." Research Involvement and Engagement no. 3 (13). Doi.

10.1186/s40900-017-0062-2, Jo Brett et al. (2014). "Mapping the impact of patient and public involvement on health and social care research.

A systematic review." Health Expectations no. 17 (5):637-650. Doi.

10.1111/j.1369-7625.2012.00795.x, Paulina O Tindana et al. (2007). "Grand challenges in global health.

Community engagement in research in developing countries." PLOS Medicine no. 4 (e273). Doi.

10.1371/journal.pmed.0040273, F Darroch and A. Giles (2014). "Decolonizing health research.

Community-based participatory research and postcolonial feminist theory." Canadian Journal of Action Research no. 15 (3):22-36.23. J Redfern et al.

(2018). "Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event." FEMS Microbiology Letters no.

Victoria Jane Hume et al. (2018). "Biomedicine and the humanities.

Growing pains." Medical Humanities no. 44 (4):230-238. Doi.

10.1136/medhum-2018-01148125. Astrid Treffry-Goatley et al. (2018).

Ibid. "Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach." 239-246.

Doi. 10.1136/medhum-2018-01147426. L Jordanova (2014).

"Medicine and the visual arts." In Medicine, health and the arts. Approaches to medical humanities, edited by Bates, Bleakley and Goodman, 41-63. Abingdon.

Routledge.27. Angela Ross Perfetti (2018). "Fate and the clinic.

A multidisciplinary consideration of fatalism in health behaviour." Medical Humanities no. 44 (1):59-62. Doi.

10.1136/medhum-2017-01131928. Devan Stahl et al. (2016).

"Seeing illness in art and medicine. A patient and printmaker collaboration." Ibid. No.

42 (3):155-159. Doi. 10.1136/medhum-2015-01083829.

Jonatan Wistrand and J Wistrand (2017). "When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians." Ibid.

Carson (2015). Medical humanities. An introduction.

New York, NY. Cambridge University Press.31. Daniel Holman and Erica Borgstrom (2016).

"Applying social theory to understand health-related behaviours." Medical Humanities no. 42 (2):143-145. Doi.

10.1136/medhum-2015-01068832. Hume, et al., Biomedicine and the humanities. Growing pains.33.

A Carusi (2016). "Modelling systems biomedicine. Intertwinement and the 'real'." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 50-65.

Edinburgh. Edinburgh University Press.34. Jordanova, Medicine and the visual arts.35.

Stahl and Stahl, Seeing illness in art and medicine. A patient and printmaker collaboration.36. William Viney et al.

(2015). "Critical medical humanities. Embracing entanglement, taking risks." Ibid.

10.1136/medhum-2015-01069237. J Cole and S. Gallagher (2016).

"Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. " In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 377-394.

Edinburgh. Edinburgh University Press.38. J Macnaughton and H.

Carel (2016). Ibid."Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap." In, 294-309.39.

P J Pelto and G H Pelto (1997). 1997. "Studying knowledge, culture, and behavior in applied medical anthropology." Medical Anthropology Quarterly no.

11 (2):147-163.40. Lindsay Prior (2003) "Belief, knowledge and expertise. The emergence of the lay expert in medical sociology." Sociology of Health &.

10.1111/1467-9566.0033941. E Oliveira and J. Vearey (2018).

"Making research and building knowledge with communities. Examining three participatory visual and narrative projects with migrants who sell sex in South Africa." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 265-287.

Cham. Springer.42. Komatra Chuengsatiansup and Wirun Limsawart (2019).

"Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders." Palgrave Communications no. 5 (1):31.

Doi. 10.1057/s41599-019-0239-443. R Garden (2014).

"Social studies. The humanities, narrative, and the social context of the patient-professional relationship." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 127-137. New Brunswick, NJ.

Rutgers University Press.44. Holman and Borgstrom, Applying social theory to understand health-related behaviours.45. Claas Kirchhelle (2018).

"Pharming animals. A global history of antibiotics in food production (1935–2017)." Palgrave Communications no. 4 (96).

Doi. 10.1057/s41599-018-0152-246. Hannah Landecker (2019).

"Antimicrobials before antibiotics. War, peace, and disinfectants." Ibid. No.

Sue Walker (2019). Ibid."Effective antimicrobial resistance communication. The role of information design." 24.

Doi. 10.1057/s41599-019-0231-z48. Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.49.

May Sudhinaraset et al. (2013). "What is the role of informal healthcare providers in developing countries?.

A systematic review." PLoS ONE no. 8 (2):e54978. Doi.

10.1371/journal.pone.005497850. Viroj Tangcharoensathien, Sunicha Chanvatik, and Angkana Sommanustweechai (2018). "Complex determinants of inappropriate use of antibiotics." Bulletin of the World Health Organization no.

96 (2):141-144. Doi. 10.2471/BLT.17.19968751.

WHO (2015a). Antibiotic resistance. Multi-country public awareness survey.

Geneva. World Health Organization.52. WHO, Antibiotic resistance.

Multi-country public awareness survey, 42.53. Gualano, et al. General population's knowledge and attitudes about antibiotics.

A systematic review and meta-analysis.54. Edward A Belongia et al. (2002).

"Antibiotic use and upper respiratory s. A survey of knowledge, attitudes, and experience in Wisconsin and Minnesota." Preventive Medicine no. 34 (3):346-352.

Doi. 10.1006/pmed.2001.099255. Miao Yu et al.

(2014). "Knowledge, attitudes, and practices of parents in rural China on the use of antibiotics in children. A cross-sectional study." BMC Infectious Diseases no.

Abdelmoneim Ismail Awad and Esraa Abdulwahid Aboud (2015). "Knowledge, attitude and practice towards antibiotic use among the public in Kuwait." PLoS ONE no. 10 (2):e0117910.

Doi. 10.1371/journal.pone.011791057. Chandler, Current accounts of antimicrobial resistance.

Stabilisation, individualisation and antibiotics as infrastructure.58. Jie Chang et al. (2018).

"Non-prescription use of antibiotics among children in urban China. A cross-sectional survey of knowledge, attitudes, and practices." Expert Review of Anti-infective Therapy no. 16 (2):163-172.

Doi. 10.1080/14787210.2018.142561659. Gualano, et al.

General population's knowledge and attitudes about antibiotics. A systematic review and meta-analysis.60. A R McCullough et al.

(2016). "A systematic review of the public's knowledge and beliefs about antibiotic resistance." Journal of Antimicrobial Chemotherapy no. 71 (1):27-33.

Doi. 10.1093/jac/dkv31061. Abel Santiago Muri-Gama, Albert Figueras, and Silvia Regina Secoli (2018).

"Inappropriately prescribed and over-the-counter antimicrobials in the Brazilian Amazon Basin. We need to promote more rational use even in remote places." PLoS ONE no. 13 (e0201579).

Doi. 10.1371/journal.pone.020157962. A Launiala (2009).

"How much can a KAP survey tell us about people's knowledge, attitudes and practices?. Some observations from medical anthropology research on malaria in pregnancy in Malawi." Anthropology Matters no. 11 (1).63.

Achieving the balance between access and excess." The Lancet no. 387 (10014):102-104. Doi.

10.1016/S0140-6736(15)00729-164. C Olivier et al. (2010).

"Containing global antibiotic resistance. Ethical drug promotion in the developing world." In Antimicrobial resistance in developing countries, edited by Sosa, Byarugaba, Amábile-Cuevas, Hsueh, Kariuki and Okeke, 505-524. New York, NY.

Springer.65. Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure.66.

Chandler, Current accounts of antimicrobial resistance. Stabilisation, individualisation and antibiotics as infrastructure.67. Steve Hinchliffe, Andrea Butcher, and Muhammad Meezanur Rahman (2018).

"The AMR problem. Demanding economies, biological margins, and co-producing alternative strategies." Ibid. No.

Chuengsatiansup and Limsawart, Tuberculosis in the borderlands. Migrants, microbes and more-than-human borders.69. Khan, et al, ‘LMICs as reservoirs of AMR’.

A comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan.70. Didier Wernli et al. (2017).

"Mapping global policy discourse on antimicrobial resistance." BMJ Global Health no. 2 (e000378). Doi.

10.1136/bmjgh-2017-00037871. Nancy J Hawkings, Fiona Wood, and Christopher C Butler (2007). "Public attitudes towards bacterial resistance.

A qualitative study." Journal of Antimicrobial Chemotherapy no. 59 (6):1155-1160. Doi.

10.1093/jac/dkm10372. McCullough, et al. A systematic review of the public's knowledge and beliefs about antibiotic resistance.73.

Muri-Gama, et al. Inappropriately prescribed and over-the-counter antimicrobials in the Brazilian Amazon Basin. We need to promote more rational use even in remote places.74.

David G Allison et al. (2017). "Antibiotic resistance awareness.

A public engagement approach for all pharmacists." International Journal of Pharmacy Practice no. 25 (1):93-96. Doi.

10.1111/ijpp.1228775. Mark Davis et al. (2018).

"Understanding media publics and the antimicrobial resistance crisis." Global Public Health no. 13 (9):1158-1168. Doi.

10.1080/17441692.2017.133624876. Simon J Howard et al. (2013).

"Antibiotic resistance. Global response needed." The Lancet Infectious Diseases no. 13 (12):1001-1003.

Doi. 10.1016/S1473-3099(13)70195-677. Renly Lim et al.

(2016). "Village drama against malaria." The Lancet no. 388 (10063):2990.

Doi. 10.1016/S0140-6736(16)32519-378. Deborah Nyirenda et al.

(2018). "Public engagement in Malawi through a health-talk radio programme ‘Umoyo nkukambirana’. A mixed-methods evaluation." Public Understanding of Science no.

27 (2):229-242. Doi. 10.1177/096366251665611079.

Redfern, et al. Spreading the message of antimicrobial resistance. A detailed account of a successful public engagement event.80.

Sungjong Roh et al. (2018). "Public understanding of One Health messages.

The role of temporal framing." Public Understanding of Science no. 27 (2):185-196. Doi.

10.1177/096366251667080581. Tindana, et al., Grand challenges in global health. Community engagement in research in developing countries.82.

Mpoe Johannah Keikelame and Leslie Swartz (2019). "Decolonising research methodologies. Lessons from a qualitative research project, Cape Town, South Africa." Global Health Action no.

12 (1):1561175. Doi. 10.1080/16549716.2018.156117583.

Keymanthri Moodley and Shenuka Singh (2016). "“It’s all about trust”. Reflections of researchers on the complexity and controversy surrounding biobanking in South Africa." BMC Medical Ethics no.

Seye Abimbola (2020). "Beyond positive a priori bias. Reframing community engagement in LMICs (epub ahead of print)." Health Promotion International.

Doi. 10.1093/heapro/daz02385. Keikelame and Swartz, Decolonising research methodologies.

Lessons from a qualitative research project, Cape Town, South Africa.86. Kenneth M Boyd (2000). "Disease, illness, sickness, health, healing and wholeness.

Exploring some elusive concepts." Medical Humanities no. 26 (1):9-17. Doi.

10.1136/mh.26.1.987. Hume, et al., Biomedicine and the humanities. Growing pains.88.

I Bamforth (2000). "Kafka's uncle. Scenes from a world of trust infected by suspicion." Ibid.

10.1136/mh.26.2.8589. Wistrand, When doctors are patients. A narrative study of help-seeking behaviour among addicted physicians.90.

Garden, Social studies. The humanities, narrative, and the social context of the patient-professional relationship.91. A Harpin (2016).

"Broadmoor performed. A theatrical hospital." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 577-595. Edinburgh.

Edinburgh University Press.92. Jordanova, Medicine and the visual arts.93. Stahl and Stahl, Seeing illness in art and medicine.

A patient and printmaker collaboration.94. K G Sweeney et al. (2001).

"A comparison of professionals' and patients' understanding of asthma. Evidence of emerging dualities?. " Ibid.

10.1136/mh.27.1.2095. Treffry-Goatley, et al., Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.96.

An argument against competence." In The Edinburgh companion to the critical medical humanities, edited by Whitehead, Woods, Atkinson, Macnaughton and Richards, 541-558. Edinburgh. Edinburgh University Press.97.

L Jerke, M. Prendergast, and W. Dobson (2018).

"Smoking cessation in mental health communities. A living newspaper applied theatre project." In Creating social change through creativity. Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 171-186.

A comparison of professionals' and patients' understanding of asthma. Evidence of emerging dualities?. 99.

S Switzer (2018). "What’s in an image?. Towards a critical and interdisciplinary reading of participatory visual methods." In Creating social change through creativity.

Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 189-207. Cham. Springer.100.

Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?. , 378.101.

Cole, et al. Medical humanities. An introduction.102.

J Herman (2001). "Medicine. The science and the art." Medical Humanities no.

[Viney, et al. Critical medical humanities. Embracing entanglement, taking risks.104.

Design and methods. Thousand Oaks, CA. Sage.105.

L Gilman (2015). Illness and image. Case studies in the medical humanities.

HarbarthM Haughton (2018). Staging trauma. Bodies in shadow.

London. Palgrave Macmillan.108. S Hodge, J Robinson, and P Davis (2007).

"Reading between the lines. The experiences of taking part in a community reading project." Medical Humanities no. 33 (2):100-104.

Doi. 10.1136/jmh.2006.000256109. Hume, et al.

Biomedicine and the humanities. Growing pains.110. Saam Idelji-Tehrani and Muna Al-Jawad (2019).

"Exploring gendered leadership stereotypes in a shared leadership model in healthcare. A case study." Ibid. No.

45:388-398. Doi. 10.1136/medhum-2018-011517111.

Suze M P J Jans et al. (2012). "A case study of haemoglobinopathy screening in the Netherlands.

Witnessing the past, lessons for the future." Ethnicity &. Health no. 17 (3):217-239.

Doi. 10.1080/13557858.2011.604126112. Hume, et al., Biomedicine and the humanities.

Growing pains.113. Cole and Gallagher, Narrative and clinical neuroscience. Can phenomenologically informed approaches and empirical work cross-fertilise?.

114. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.115.

Pelto and Pelto, Studying knowledge, culture, and behavior in applied medical anthropology.116. Prior, Belief, knowledge and expertise. The emergence of the lay expert in medical sociology.117.

Gilman, Illness and image. Case studies in the medical humanities.118. Cole and Gallagher, Narrative and clinical neuroscience.

Can phenomenologically informed approaches and empirical work cross-fertilise?. 119. Macnaughton and Carel, Breathing and breathlessness in clinic and culture.

Using critical medical humanities to bridge an epistemic gap.120. C Teddlie and A. Tashakkori (2009).

Foundations of mixed methods research. Integrating quantitative and qualitative approaches in the social and behavioral sciences. Thousand Oaks, CA.

Sage.121. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.122.

Gian Luca Barbieri et al. (2016). "Imagination in narrative medicine." Journal of Child Health Care no.

20 (4):419-427. Doi. 10.1177/1367493515625134123.

Treffry-Goatley, et al. Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.124.

WHO (2016). World Antibiotic Awareness Week. 2016 campaign toolkit.

Geneva. World Health Organization.125. Across the three villages, 67% of the workshop attendees were female and the average age of the attendees was 44 years (range.

18 to 81 years. Based on subsequently collected survey data).126. Nutcha Charoenboon et al.

(2019)127. We thank an anonymous reviewer for highlighting the potential hazards of reproducing hierarchies through methods intended to challenge them in the first place.128. The research was reviewed and approved by the University of Oxford Tropical Research Ethics Committee (Ref.

OxTREC 528-17), and it received local ethical approval in Thailand from the Mae Fah Luang University Research Ethics Committee on Human Research (Ref. REH 60099). The service evaluation of the photo exhibition involved anonymised data collection and received a waiver for ethical approval from the University of Warwick Humanities &.

Social Sciences Research Ethics Committee (HSSREC). However, all evaluation form respondents explicitly consented to the data being reported in research publications.129. Marco J Haenssgen et al.

(2018)130. National Statistical Office (2012). The 2010 population and housing census.

Changwat Chiang Rai. Bangkok. National Statistical Office.131.

Data on the individual level would entail duplication of observations should both census survey rounds be included. Step-level data were aggregated on the illness level for analysis.132. Claire Charlotte McKechnie (2014).

"Anxieties of communication. The limits of narrative in the medical humanities." Medical Humanities no. 40 (2):119-124.

Doi. 10.1136/medhum-2013-010466133. Carusi, Modelling systems biomedicine.

Intertwinement and the 'real'.134. Garden, Social studies. The humanities, narrative, and the social context of the patient-professional relationship.135.

Emma Sacks et al. (2018). "Beyond the building blocks.

Integrating community roles into health systems frameworks to achieve health for all." BMJ Global Health no. 3 (Suppl. 3):e001384.

Doi. 10.1136/bmjgh-2018-001384136. Sudhinaraset, et al.

What is the role of informal healthcare providers in developing countries?. A systematic review.137. G Bloom et al.

(2015). Addressing resistance to antibiotics in pluralistic health systems. Brighton.

University of Sussex138. WHO (2007). Strengthening health systems to improve health outcomes.

WHO’s framework for action. Geneva. World Health Organization.139.

Jordanova, Medicine and the visual arts.140. Macnaughton and Carel, Breathing and breathlessness in clinic and culture. Using critical medical humanities to bridge an epistemic gap.141.

A Bleakley (2014). Ibid. "Towards a 'critical medical humanities'." In, 17-26.142.

Hume, et al., Biomedicine and the humanities. Growing pains.143. Nutcha Charoenboon et al.

(2019)144. Marco Haenssgen et al. (2018)145.

WHO, World Antibiotic Awareness Week. 2016 campaign toolkit.146. The questionnaire did so by showing all survey respondents three images of common antibiotic capsules being used in Chiang Rai (green-blue.

White-blue. Azithromycin—see questionnaire page 10 in the online supplementary material). Respondents were asked to name what they saw, and all their answers were recorded (field-coded and as free text).147.

The ‘desirability’ of the responses was field coded by the survey team. Sample responses (as instructed through the survey manual) for ‘desirable’ answers included, for example, “Only if the doctor says that I should”. Sample responses for ‘undesirable’ answers included “Yes, you can buy it in the shop over there!.

€ The variable should be interpreted as ‘the fraction of respondents who uttered a ‘desirable’ response’—the inverse is the fraction of responses that could not be deemed ‘desirable’ (eg, ‘do not know’ or ‘no opinion’).148. Because recalled descriptions of medicine tend to be ambiguous, we limited our analysis to medicines where we had a high degree of certainty that they were an antibiotic. This was specifically the case if survey respondents mentioned common antibiotic descriptions such as ‘anti-inflammatory’, ‘amoxi’ or ‘colem’, if they indicated explicitly that they know what ‘anti-inflammatory medicine’ is (noting that the term describes antibiotics unambiguously in Thai), and if they subsequently mentioned any of the previously mentioned antibiotics during their description of an illness episode (conversely, we excluded cases were the medicine could not be confirmed as either antibiotic or non-antibiotic, including descriptions like ‘white powder’ or ‘green capsule’).149.

Aristotle (1954). Rhetoric. Translated by Roberts.

New York, NY. Modern Library. Original edition, 350 BC.150.

Arya Nielsen et al. (2007). "The effect of gua sha treatment on the microcirculation of surface tissue.

A pilot study in healthy subjects." EXPLORE no. 3 (5):456-466. Doi.

10.1016/j.explore.2007.06.001151. Nithima Sumpradit et al. (2012).

"Antibiotics Smart Use. A workable model for promoting the rational use of medicines in Thailand." Bulletin of the World Health Organization no. 90 (12):905-913.

Doi. 10.2471/BLT.12.105445152. C Muksong and K.

Chuengsatiansup (2020). Forthcoming. "Medicine and public health in Thai historiography.

From an elitist view to counter-hegemonic discourse." In Health, pluralism and globalisation. A modern history of medicine in South-East Asia, edited by Monnais and Cook. London.

The Wellcome Trust Centre for the History.153. L Sringernyuang (2000). Availability and use of medicines in rural Thailand.

Amsterdam. Amsterdam Institute for Social Science Research.154. Although this was not the focus of the current paper, we note for full disclosure that the workshops, too, had mixed behavioural impacts.

The poster making sessions in Chiang Rai demonstrated for instance how our conversations about drug resistance and the introduction of messages from the World Health Organization entailed at times problematic interpretations like, “You shouldn’t take medicines that you have never seen before”—the research team responded to such interpretations directly in order to avoid misunderstandings. In addition, previous behavioural analyses documented that, while workshop participants demonstrated higher levels of awareness of drug resistance, alignment of antibiotic use with global health recommendations was mixed, and in one case, a villager started selling antibiotics after the workshop. For more details on the behavioural analysis, see Nutcha Charoenboon et al.

(2019) and Marco Haenssgen et al. (2018).155. For example, Redfern, et al., Spreading the message of antimicrobial resistance.

A detailed account of a successful public engagement event.156. Antoine Boivin et al. (2018).

2018. "Patient and public engagement in research and health system decision making. A systematic review of evaluation tools (epub ahead of print)." Health Expectations.

Doi. 10.1111/hex.12804157. Staniszewska, et al.

GRIPP2 reporting checklists. Tools to improve reporting of patient and public involvement in research.158. Jerke, et al.

Smoking cessation in mental health communities. A living newspaper applied theatre project.159. Switzer, What’s in an image?.

Towards a critical and interdisciplinary reading of participatory visual methods.160. R. C Barfield and L.

Selman (2014). "Health and humanities. Spirituality and religion." In Health humanities reader, edited by Jones, Wear, Friedman and Pachucki, 376-386.

New Brunswick, NJ. Rutgers University Press.161. Abimbola, Beyond positive a priori bias.

Reframing community engagement in LMICs (epub ahead of print), 1.162. Marco J Haenssgen et al. (2019)163.

Marc Mendelson et al. (2017). "Antibiotic resistance has a language problem." Nature no.

Haak and Radyowijati, Determinants of antimicrobial use. Poorly understood, poorly researched.165. S Harbarth and D.

L. Monnet (2008). "Cultural and socioeconomic determinants of antibiotic use." In Antibiotic Policies.

Fighting Resistance, edited by Gould and van der Meer, 29-40. Boston, MA. Springer.166.

K Sirijoti, P. Havanond Hongsranagon, and W. Pannoi (2014).

"Assessment of knowledge attitudes and practices regarding antibiotic use in Trang province, Thailand." Journal of Health Research no. 28 (5):299-307.167. Ramona K C Finnie et al.

(2011). "Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high burdens of TB and HIV." Tropical Medicine &. International Health no.

16 (4):394-411. Doi. 10.1111/j.1365-3156.2010.02718.x168.

Haak and Radyowijati, Determinants of antimicrobial use. Poorly understood, poorly researched.169. Chandler, Current accounts of antimicrobial resistance.

Stabilisation, individualisation and antibiotics as infrastructure, 5.170. S Willson and K. Miller (2014).

"Data collection." In Cognitive interviewing methodology. A sociological approach for survey question evaluation, edited by Miller, Willson, Chepp and Padilla, 15-34. Hoboken, NJ.

Wiley.171. See Linda Mayoux and Robert Chambers (2005). "Reversing the paradigm.

Quantification, participatory methods and pro-poor impact assessment." Journal of International Development no. 17 (2):271-298. Doi.

10.1002/jid.1214172. Howard S. Becker (1995).

"Visual sociology, documentary photography, and photojournalism. It's (almost) all a matter of context." Visual Sociology no. 10 (1-2):5-14.

Doi. 10.1080/14725869508583745173. J Prosser and D.

Schwartz (2005). "Photographs and the sociological research process." In Image-based research. A sourcebook for qualitative researchers, edited by Prosser, 101-115.

Community engagement with HIV drug adherence in rural South Africa. A transdisciplinary approach.175. Switzer, What’s in an image?.

Towards a critical and interdisciplinary reading of participatory visual methods.176. Hume, et al. Biomedicine and the humanities.

Growing pains.177. Jordanova, Medicine and the visual arts, 60.178. Bleakley, Towards a 'critical medical humanities'.179.

Nutcha Charoenboon et al. (2019)180. Hume, et al.

Biomedicine and the humanities. Growing pains.181. J.

P Ansloos (2018). €œTo speak in our own ways about the world, without shame”. Reflections on indigenous resurgence in anti-oppressive research.” In Creating social change through creativity.

Anti-oppressive arts-based research methodologies, edited by Capous-Desyllas and Morgaine, 3-18. Cham. Springer.182.

Marco J Haenssgen (2019)183. Michael Etherton and Tim Prentki (2006). "Drama for change?.

Prove it!. Impact assessment in applied theatre." Research in Drama Education. The Journal of Applied Theatre and Performance no.

11 (2):139-155. Doi. 10.1080/13569780600670718184.

Susan Galloway (2009). "Theory-based evaluation and the social impact of the arts." Cultural Trends no. 18 (2):125-148.

Doi. 10.1080/09548960902826143185. Darquise Lafrenière and Susan M Cox (2013).

"‘If you can call it a poem’. Toward a framework for the assessment of arts-based works." Qualitative Research no. 13 (3):318-336.

Doi. 10.1177/1468794112446104IntroductionIn Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016.1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide designers.

This article reports findings from a desktop survey of current design practice across 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. Desktop surveys, as a form of research, are heavily relied on in architectural practice. Photographs and architectural drawings are analysed to understand both typical and innovative approaches to designing a particular building type.

While desktop surveys are sometimes supplemented by visits to exemplar projects (which might also be termed ‘fieldwork’), time pressures and budgetary constraints often preclude this. As the result of an academic–industry partnership, the research reported herein embraced practice-based research methods in conjunction with an academic approach. The data set available for the desktop survey was rich but incomplete.

Security requirements restrict the public availability of complete floor plans and postoccupancy evaluations. To mitigate these limitations, knowledge was integrated from other disciplines, including environmental psychology, architectural history and professional practice. With regard to the latter, knowledge is specifically around the design and consultation processes that guide the construction of these facilities.

This knowledge was used to identify three contemporary hospitals that challenge accepted design practice and, we argue, in doing so have the potential to act as change-agents in the delivery of forensic mental healthcare. We define innovation as variation/s to common, or typical, architectural solutions that can positively improve patients’2 experience of these facilities in ways that directly support one, or a number, of key values underpinning forensic mental healthcare. While this article does not provide postoccupancy data to quantify the value of these innovations, we hope to encourage both designers and researchers to more closely consider these projects—particularly the way that spaces have been designed to benefit patient well-being—and the questions these designs raise for the future of forensic mental healthcare delivery.Now regarded as naïve is the 19th-century belief that architecture and landscape, if appropriately designed, can restore sanity.3 Yet contemporary research from the field of evidence-based design confirms that the built environment does play a role in the therapeutic process, even if that role does not determine therapeutic outcomes.4 Research regarding the design of forensic mental healthcare facilities remains limited.

An article by Ulrich et al recommended that to reduce aggression patients should be accommodated in single rooms. Communal areas should have movable furniture. Wards should be designed for low social densities.

And accessible gardens should be provided.5 An earlier study by Tyson et al showed that lower ward densities can also positively improve patient–staff interactions.6 Commonly, however, the studies referenced above compared older-style mental health units with their contemporary replacements.7 There is little comparative research available that examines contemporary facilities for forensic mental healthcare, with the exception of one article that provided a comparative analysis of nine Swedish facilities, designed between 1990 and 2008.8 However, this article merely described the design aspirations and physical composition of each hospital without investigating the link between design aspiration, patient well-being and the resulting physical environment.There are two further limitations to evidence-based design research. The first is the extent to which data do not provide directly applicable design tactics. Systematic literature reviews typically provide a set of design recommendations but without suggesting to designers what the corresponding physical design tactics to achieve those recommendations might actually be.9 This is consistent for general hospital design.

For example, architects have been advised to provide spaces that are ‘psychosocially supportive’ since 2000, yet it was 2016 before a spatially focused definition of this term was provided, offering designers a more tangible understanding of what they should be aiming for.10 The second limitation is the breadth of research currently available. While rigorous and valuable, evidence-based design often overlooks the fact that architects must design across scales, from the master-planning scale—deciding where to place buildings of various functions within a site, and how to manage the safe movement of staff and patients between those buildings—to the scale of a bathroom door. How do you design a bathroom door to meet antiligature and surveillance requirements, to maintain patient safety, while still communicating dignity and respect for patients?.

The available literature provides much to contemplate, but in terms of credible evidence much of this research is based on a single study, typically conducted within a single hospital context and often focused on a single aspect of design. This raises the question, is there really a compelling basis for regarding evidence-based design knowledge as more credible than knowledge generated about this building type from other disciplines?. In light of the small amount of evidence available in this field, is there not a responsibility to use all the available knowledge?.

While the discipline of evidence-based design has existed for three decades,11 purpose-designed buildings for the treatment of mental illness have been constructed for over three centuries. Researchers working within the field of architectural history also understand that patient experience is partially determined—for better or worse—by the decisions that designers make, and that models of care have been used to drive design outcomes since the establishment of the York Retreat in 1796. With their focus on moral treatment, the York Retreat influenced a shift in the way asylum design was approached, from the provision of safe custody to finding architectural solutions to support the restoration of sanity.12 Architectural historians also bring evidence to bear in respect of this design challenge, specifically knowledge of how the best architectural intentions can result in unanticipated (sometimes devastating) outcomes—and of the conditions that gave rise to those outcomes.13 There is a third, rich source of knowledge available to guide designers that, broadly speaking, academic researchers have yet to tap into.

It is the knowledge produced by practitioners themselves. Architects learn through experience, across multiple projects and through practice-based forms of enquiry that include desktop surveys (also referred to as precedent studies), user group consultations and gathering (often informal) postoccupancy data from their clients. Architects have already offered a range of tangible solutions to meet particular aspirations related to patient care.

There is value in examining these existing design solutions to identify those capable of providing direct benefits to patients that might justify implementation across multiple projects. In understanding how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients, all available knowledge should be valued and integrated.Methodology. Embracing ‘mode two’ researchThis research was conducted within the context of a master­-planning and feasibility study, commissioned by a state government department, to investigate various international design solutions to inform future planning around forensic mental health service provisions in Victoria, Australia.

The industry-led nature of this project demanded a less conventional and more inclusive methodological approach. Tight timeframes precluded employing research methods that required ethics approvals (interviewing patients was not possible), while the timeframe and budget precluded the research team from conducting fieldwork. The following obstacles further limited a conventional approach:Postoccupancy evaluations of forensic psychiatric hospital facilities are seldom conducted and/or not made publicly available.14Published floor plans that would enable researchers to derive an understanding of the functional layouts and corresponding habits of occupancy within these facilities are limited owing to the security needs surrounding forensic psychiatric hospital sites.Available literature relevant to the design of forensic psychiatric hospital facilities provides few direct architectural recommendations to offer tactics for how the built environment might support the delivery of treatment.The team had to find a way to navigate these challenges in order to address the important question of how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients.‘Mode two’ is a methodological approach that draws on the strength of collaborations between academia and industry to produce ‘socially robust knowledge’ whose reliability extends ‘beyond the laboratory’ to real-world contexts.15 It shares commonalities with a phenomenological approach that attributes value to the prolonged, firsthand exposure of the researcher with the phenomenon in question.16 The inclusion of practising architects and academic researchers within the research team provided considerable expertise in the design, consultation and documentation of these facilities, alongside an understanding of the kinds of challenges that arise following the occupation of this building type.

Mode two, as a research approach, also recognises that, while architects reference evidence-based design literature, this will not replace the processes through which practitioners have traditionally assembled knowledge about particular building types, predominantly desktop surveys.A desktop survey was undertaken to understand contemporary design practice within this building type. Forty-four projects were identified as relevant for the period 2006–2022 (31 forensic and 13 non-forensic psychiatric hospitals). These included facilities from the UK, the USA, Canada, Denmark, Norway, Sweden, the United Arab Emirates and Ireland (online supplementary appendix 1).

Sufficient architectural information was not available for 13 of these projects and they were excluded from the study. For the remaining 31 facilities, 24 accommodated forensic patients and 7 did not. Non-forensic facilities were included to enable an awareness of any significant programmatic or functional differences in the design responses created for forensic versus non-forensic mental health patients.

Architectural drawings and photographs were analysed to identify general trends, alongside points of departure from common practice. Borrowing methods from architectural history, the desktop survey was supplemented by other available information, including a mix of hospital-authored guidebooks (as provided to patients and visitors), architects’ statements, newspaper articles and literature from the field of evidence-based design. Available data varied for each of the 31 hospitals.

Adopting a method from architectural theorist Thomas Markus, the materiality and placement of external and internal boundary lines were closely studied (assisted by Google Earth).17 When read in conjunction with the architectural drawings, boundary placement revealed information regarding patient access to adjacent landscape spaces.Supplemental materialA desktop survey has limitations. It cannot provide a conclusive understanding of how these spaces operate when occupied by patients and staff. While efforts were made to contact individual practices and healthcare providers to obtain missing details, such requests typically went unanswered.

This is likely owing to concerns of security, alongside the realities of commercial practice, concerns around intellectual property, and complex client and stakeholder arrangements that can act to prohibit the sharing of this information. To deepen the team’s understanding, a 2-day workshop was hosted to which two international architectural practices were invited to attend, one from the UK and one from the USA. Both practices had recently completed a significant forensic psychiatric hospital project.

While neither of these facilities had been occupied at the time of the workshops, the architects were able to share their experiences relative to the research, design, and client and patient consultation processes undertaken. The Australian architects who led the research team also brought extensive experience in acute mental healthcare settings, which assisted in data analysis.To further mitigate the limitations of the desktop survey, understandings developed by the team were used as a basis for advisory panel discussions with staff. Feedback was sought from five 60 min long, advisory panel sessions, each including four to six clinical/facilities staff (who attended voluntarily during work hours) from a forensic psychiatric hospital in Australia, where several participants recounted professional experience in both the Australian and British contexts.

Each advisory panel session was themed relative to various aspects of contemporary design. (1) site/hospital layout, (2) inpatient accommodation, (3) landscape design and access, (4) staff amenities, and (5) treatment hubs (referred to as ‘treatment malls’ in the American context). These sessions enabled the research team to double-check our analysis of the plans and photographs, particularly our assumptions regarding the likely use, practicality and therapeutic value of particular spaces.Model for analysisWithin general hospital design, a range of indicators are used to measure the contribution of architecture to healing, such as the optimisation of lighting to support sleep, the minimisation of patient falls, or whether the use of single patient rooms assists with control.18 In mental health, however, where the therapeutic journey is based more on psychology than physiology, what metrics should be employed to evaluate the success of one design response over another in supporting patient care?.

We suggest the first step is to acknowledge the values that underpin contemporary approaches to mental healthcare. The second step is to translate those treatment values into corresponding spatial values using a value-led spatial framework.19 This provides a checklist for relating particular spatial conditions to specific values around patient care. For example, if the design intent is to optimise privacy and dignity for patients, then the design of bathrooms, relaxation and de-esculation spaces are all important spaces in respect of that therapeutic value.

Highlighting this relationship can assist decision makers to more closely interrogate areas that matter most relative to achieving these values. To put this in context, optimising a bathroom design to prioritise a direct line of sight for staff might improve safety but also obstruct privacy and dignity for patients. While such decisions will always need to be carefully balanced, a value-led spatial framework can provide a touchstone for designers and stakeholders to revisit throughout the design process.To analyse the 31 projects examined within this project, we developed a framework (Table 1).

It recognises that a common approach to patient care can be identified across contemporary Australian, British and Canadian models:View this table:Table 1 Value-led spatial framework. Correlating treatment values with corresponding spaces within the hospital’s physical environmentThat patients be extended privacy and dignity to the broadest degree possible without impacting their personal safety or that of other patients or staff.That patients be treated within the least restrictive environment possible relative to the severity of their illness and the legal (or security) requirements attached to their care.That patients be afforded choice and independence relative to freedom of movement within the hospital campus (as appropriate to the individual), extending to a choice of social, recreational and treatment spaces.That patients’ progression through their treatment journey is reflected in the way the architecture communicates to hospital users.That opportunities for peer-led therapeutic processes and involvement of family and community-based care providers be optimised within a hospital campus. 20Table 1 assigns a range of architectural spaces and features that are relevant to each of the five treatment values listed.

Architectural decisions related to these values operate across three scales. Context, hospital and individual. Context decisions are those made in respect of a hospital’s location, including proximity to allied services, connections to public transport and distances to major metropolitan hubs.

Decisions of this type are important relative to staffing recruitment and retention, and opportunities for research relative to the psychiatric hospital’s proximity to general (teaching) hospitals or university precincts. Architectural decisions operating at the hospital scale include considerations of how secure site boundaries are provided. How buildings are laid out on a site.

And how spatial and functional links are set up between those buildings. This is important relative to the movement of patients and staff across a site, including the location and functionality of therapeutic hubs. But it can also impact patient and community psychology.

The design of external fences, in particular, can compound feelings of confinement for patients. Focus community attention on the custodial role of a facility over and above its therapeutic function. And influence perceptions of safety and security for the community immediately surrounding the hospital.

Architectural decisions operating at the ‘individual’ scale are those that more closely impact the daily experience of a hospital for patients and staff. These include the various arrangements for inpatient accommodation. Tactics for providing patients with landscape access and views.

And the question of staff spaces relative to safety, ease of communication and collaboration. Approaches to landscape, inpatient accommodation and concerns of staff supervision are closely intertwined.Findings. What we learnt from 31 contemporary psychiatric hospital projectsForensic psychiatric hospitals treat patients who require mental health treatment in addition to a history of criminal offending or who are at risk of committing a criminal offence.

Primarily, these include patients who are unfit to stand trial and those found not guilty on account of their illness.21 Accommodation is typically arranged according to low, medium or high security needs, alongside clinical need, and whether an acute, subacute, extended or translational rehabilitation setting is required. Security needs are determined based on the risk a patient presents to themselves and/or others, alongside their risk of absconding from the facility. The challenge that has proven intractable for centuries is how can architects balance privacy and dignity for patients, while maintaining supervision for their own safety, alongside that of their fellow patients, the staff providing care and, in some cases, the community beyond.22 In this section we present overall trends regarding the layout of buildings within hospital sites, including the placement of treatment hubs and the design of inpatient wards.

Access to landscape is not explicitly addressed in this section but is implicit in decisions around site layout and inpatient accommodation.Design approaches to site layoutWe identified two approaches to site layout—the ‘village’ (4 from 31 hospitals) and the ‘campus’ (27 from 31 hospitals) (figure 1). Similar in their functional arrangement, these are differentiated according to the degree of exterior circulation required to move between patient-occupied spaces. Village hospitals comprise a number of buildings sitting within the landscape, while campus hospitals have interconnected buildings with access provided by internal corridors that prevent the need to go outside.

Neither approach is new. Both follow the models first used within the 19th century. The village hospital follows the model designed by Dr Albrecht Paetz in 1878 (Alt Scherbitz, Germany), which included detached cottages accommodating patients in groups of between 24 and 100, set within gardens.23 Paetz created this design in response to his belief that upwards of 1000 patients should not be accommodated in a single building, with security measures determined in relation to those patients whose behaviour was the least predictable.24 The resulting monotony of the daily routine and restrictions on patient movement were believed to ‘cripple the intelligence and depress the spirit’.25 Paetz’s model allowed doctors to classify patients into smaller groups and unlock doors to allow patients with predictable behaviour to wander freely within the secure outer boundaries of the hospital.26 This remained the preferred approach to patient accommodation for over a century, as endorsed by the WHO in their report of 1953.27 Broadmoor Hospital (UK, 2019) provides an example of the village model.The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub.

The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub." data-icon-position data-hide-link-title="0">Figure 1 The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub. The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub.The campus model is not dissimilar to the approach propagated by Dr Henry Thomas Kirkbride, a 19th-century psychiatrist who was active in the design of asylums and whose influence saw this planning arrangement dominate asylum constructions in the USA for many decades.28 Asylums of the ‘Kirkbride plan’ arranged patient accommodation in a series of pavilions linked by corridors. While corridors can be heavily glazed, where this action is not taken, the campus approach can compromise patient and staff connections to landscape views.

Examples of campus hospitals include the Worcester Recovery Center and Hospital (USA, 2012) and the Nixon Forensic Center (USA, under construction).Treatment hubs are a contemporary addition to forensic psychiatric hospitals. These cluster a range of shared patient spaces, including recreational, treatment and vocational training facilities, and thus drive patient movement around or through a hospital site. Two different treatment hub arrangements are in use.

€˜internal’ and ‘on-edge’. Those arranged internally typically place these functions at the heart of the campus and at a significant distance from the secure boundary line. Those arranged on-edge are placed at the far end of campus-model hospitals and, in the most extreme cases, occur adjacent to one of the site’s external boundaries (refer to Figure 1).

Both arrangements aspire to make life within the hospital resemble life beyond the hospital as closely as possible, as the daily practice of walking from an accommodation area to a treatment hub mimics the practice of travelling from home to a place of work or study.With evidence mounting regarding the psychological benefits to patients of landscape access, it should not be assumed that the current preference for campus hospitals over the village model indicates ‘best practice’. A campus arrangement offers security benefits for the movement of patients across a hospital site, while avoiding the associated risks of contraband concealed within landscaped spaces. However, the existence of village hospitals for forensic cohorts suggests it is possible to successfully manage these challenges.

Why then do we see such a strong persistence of the campus hospital?. This preference may be driven by cultural expectations. From 24 forensic psychiatric hospitals surveyed, 10 were located within the USA and all employed the campus model.

Yet nine of those hospitals occupied rural sites where the village model could have been used, suggesting the influence of the Kirkbride plan prevails. The four village hospitals within the broader sample of 31, spanning forensic and non-forensic settings, all occurred within the UK3 and Ireland1. Paetz’s villa model had been the preferred approach to new constructions in these countries since its introduction at close of the 19th century.29 However, a look at UK hospitals in isolation revealed a more even spread of village and campus arrangements, with two of the four UK-based campus hospitals occupying constrained urban sites that required multi-story solutions.

The village model would be inappropriate for achieving this as it does not lend well to urban locations where land availability is scarce.Design approaches to inpatient accommodationThree approaches to inpatient accommodation were identified. €˜peninsula’, ‘race-track’ and ‘courtyard’ (Figure 2). The peninsula model is characterised by rows of inpatient wings, along a single-loaded or double-loaded corridor that stretches into the surrounding landscape.

This typically enables an exterior view from all patient bedrooms and is not dissimilar to the traditional ‘pavilion’ model that emerged within 19th-century hospital design.30 In the racetrack model bedrooms are arranged around a cluster of staff-only (or service) spaces, still enabling exterior views from all patient bedrooms. The courtyard model is similar to the racetrack but includes a central landscape space. Information on the design of inpatient room layouts was available for 24 of the 31 projects analysed (15 of these 24 were forensic).Common inpatient accommodation configurations.

(1) Peninsula. Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor).

(2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey." data-icon-position data-hide-link-title="0">Figure 2 Common inpatient accommodation configurations. (1) Peninsula.

Single-loaded version shown (patient rooms on one side only. Double-loaded versions have patient rooms on two sides of the corridor). (2) racetrack and (3) courtyard (landscaped).

Staff-occupied spaces and support spaces (social space and so on) shown in grey.Ten forensic hospitals employed a peninsula plan and five employed a courtyard plan. Of the non-forensic psychiatric hospitals five employed the courtyard, three the racetrack and only one the peninsula plan. While the sample size is too small to generalise, the peninsula plan appears to be favoured for a forensic cohort.

However, cultural trends again emerge. Of the 10 peninsula plan hospitals, 6 were located within the USA, and among the broader sample of 24 (including the non-forensic facilities) none of the courtyard hospitals were located there. Courtyard layouts for forensic patients occurred within the UK, Ireland, Denmark and Sweden.

However, within these countries, a mix of courtyard and peninsula plans were used, suggesting no clear preference for one plan over the other.Each plan type has advantages and disadvantages (Table 2). Courtyard accommodation provides the following benefits. Greater opportunity for patient access to landscape since these are easier for staff to maintain surveillance over.

Additional safety for staff owing to continuous circulation (staff cannot get caught in ‘dead-ends’. However, the presence of corners which are difficult to see around is a drawback). Natural light is more easily available.

And ‘swing bedrooms’ can be supported (this is the ability to reconfigure the number of observable bedrooms on a nursing ward by opening and closing doors at different points within a corridor). However, courtyard accommodation requires a larger site area so is better suited to rural locations than urban and is not well suited to multi-story facilities. Peninsula accommodation enables geographical separation, giving medical teams greater opportunity to manage which patients are housed together (‘cohorting’).

Blind corners can be avoided to assist safety and surveillance. Travel distances can be minimised. Finally, the absence of continuous circulation provides greater flexibility for creating social spaces for patients with graduated degrees of (semi-)privacy.View this table:Table 2 Advantages and disadvantages of peninsula versus courtyard accommodationAnother important consideration related to inpatient accommodation is ward size.

The number of bedrooms clustered together, alongside the amount of dedicated living space associated with these bedrooms. Ward size can influence patient agitation and aggression, alongside ease of supervision, staff anxiety and safety.31 The most common ward sizes were 24 or 32 beds, further subdivided into subclusters of 8 beds. Typically, each ward was provided with one large living space that all 24 or 32 patients used together.

More advanced approaches gave patients a choice of living spaces. For example, at Coalinga Hospital, patients could occupy a small living space available to only 8 patients, or a larger space that all 24 patients had access to. We describe this approach as more advanced since both 19th-century understandings alongside recent research by Ulrich et al confirm that social density (the number of persons per room) is ‘the most consistently important variable for predicting crowding stress and aggressive behaviour’.32 Only six hospitals had plans detailed enough to calculate the square-metre provision of living space per patient, and this varied between 5 and 8 square metres.Limitations of the desktop surveyData from a desktop survey are insufficient to obtain a comprehensive understanding of how design contributes to patient experience.

To overcome this limitation, the following sections combine knowledge about how people use space from environmental psychology, knowledge about the design and consultation processes that guide the construction of these facilities, and understandings from architectural history. History suggests that seemingly small changes to typical design practice can effect significant change in the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. This integrated approach is used to identify three forensic psychiatric hospitals that challenge accepted design practice to varying degrees and, in doing so, have the potential to act as change-agents in the delivery of forensic mental healthcare.

But first it is important to understand the context in which architectural innovation is able, or unable, to emerge relative to forensic mental healthcare.Accepting the challenge. Using history to help us see beyond the roadblocks to innovationArchitects tasked with designing forensic mental health facilities respond to what is called a ‘functional brief’. This documents the specific performance requirements of the hospital in question.

Much consultation goes into formulating and refining a functional brief through the initial and developed design stages. Consultation is typically undertaken with a variety of different user groups, and in a sequential fashion that includes a greater cross-section of users as the design progresses, including patients, families, and clinical and security staff. Despite the focus on patient experience within contemporary models of care, functional briefs tend to prioritise safety and security, making them the basis on which most major architectural decisions are made.33 In large part this is simply the reality of accommodating a patient cohort who pose a risk of harm towards themselves and/or others.

A comment from Tom Brooks-Pilling, a member of the design team for the Nixon Forensic Center (Fulton, Missouri), provides insight into this approach and the concerns that drive it. He explained that borrowing a ‘spoked wheel’ arrangement from prison design eliminated blind spots and hiding places to enable a centrally located staff member to:see everything that’s going on in that unit…[they are] basically watching the other staff’s back [sic] to make sure that they can focus on treatment and not worry about who might be sneaking up on them or what activities might be going on behind their backs.34Advisory panel feedback confirmed that when the architectural design of a facility heightens staff anxiety this has direct ramifications for the therapeutic process. For example, in spaces where staff could become isolated from one another, and where clear lines of sight were obstructed, such as ill-designed elevators or stairwells, this can lead to movement being reduced across the patient cohort to avoid putting staff in those spaces where they feel unsafe.The architects consulted during the course of this research, including those who were part of the research team, articulated how the necessary prioritisation of safety, in turn, leads to compromises in the attainment of an ideal environment to support treatment.

In the various forensic and acute psychiatric hospital projects they had been involved with, all observed a sincere commitment on the part of those engaged in project briefing to upholding ideals around privacy, dignity, autonomy and freedom of movement for patients. They reported, however, that the commitment to these ideals was increasingly obstructed as the design process progressed by the more pressing concerns of safety. Examples of the kinds of architectural implications of this prioritisation are things like spatially separated nursing stations (enclosed, often fully glazed), when a desire for less-hierarchical interactions between patients and staff had been expressed at the beginning of the briefing process.

Or the substitution of harder-wearing materials, with a more ‘institutional’ feel when a ‘home-like’ atmosphere had been prioritised initially. There is nothing surprising or unusual about this process since design is, by its nature, a process of seeking improvements on accepted practice while systematically checking the suitability of proposed solutions against a set of performance requirements. In the context of forensic psychiatric hospitals, safety is the performance requirement that most often frustrates the implementation of innovative design.

Thus, amid the complexities of design and procurement relative to forensic psychiatric hospitals, innovation, however humble, and particularly where it can be seen to contribute positively to the patient experience, is worth a closer look.In the historical development of the psychiatric hospital as a building type, two significant departures from accepted design practice facilitated positive change in the treatment of mental illness. The first was Paetz’s development of the village hospital which sought to replace high fences, locked doors and barred windows with ‘humane but stringent supervision’.35 While this planning approach may not have significantly altered models of care, it was regarded as ‘an essential, vital development’, providing architectural support to the prevailing approach to treatment of the time—that of moral treatment—which aimed to extend kindness and respect to patients, in an environment that was as unrestrictive as possible. The York Retreat is worthy of acknowledgement here as a leading proponent of moral treatment whose influence shifted approaches to asylum design, from focusing on the provision of safe custody to supporting the restoration of sanity.

Architecturally, however, the differences in the York Retreat’s approach were mainly focused on interior details that encouraged patients to maintain civil habits. Dining rooms had white tablecloths and flower vases adorned mantelpieces, door locks were custom-made to close quietly, and window bars fashioned to look like domestic window frames.36 The York Retreat was originally a small institution, in line with Samuel Tuke’s preference for a maximum asylum size of 30 patients. History confirms the extent to which this approach was not scalable and thus unable to be replicated widely for asylum construction.

For these reasons, it has not been considered here as a significant departure from accepted design practice.The second significant departure from accepted design practice was the development of acute treatment hospitals, located within cities, adjacent to general hospitals and medical research facilities. The first hospital of this type was the Maudsley Hospital, led by doctors Henry Maudsley and Frederick Mott, in London. The design intent for this hospital was announced in 1908 but it was not opened until 1923.37 In proposing this hospital, Maudsley and Mott were motivated to bring psychiatry ‘into line with the other branches of medical science’.38 This 100-bed facility, located directly across the road from the King’s College (Teaching) Hospital, emulated the general hospital typology in offering both outpatient and short-duration inpatient care, specifically targeted at patients with recent-onset illnesses.

The aspirations were threefold. To avoid the stigma associated with large public asylums. To advance the medical understanding of mental illness through research collaborations with general hospitals and medical schools and via improved teaching programmes.

And to both enable and encourage patients to access early, voluntary treatment on an outpatient basis.38 Today the Maudsley appears unremarkable, an unassuming three-storied building on a busy London street. But the significance of what this building communicated at the time it was constructed, and the extent to which it challenged accepted practice, should not be underestimated. The Maudsley sent a clear message to the public that mental illness was no longer to be regarded as different from any other illness treated within a general hospital setting.

That it was no longer okay to isolate those suffering from mental illness from their families or the neighbourhoods in which they lived.39 Following the announcement of the Maudsley, the ‘psychopathic hospital’ rose to prominence within the USA with Johns Hopkins University Hospital opening the Phipps Psychiatric Clinic, in Baltimore, in 1913. The psychopathic hospital similarly promoted urban locations and closer connections to teaching and research. The Maudsley can be seen to have played a significant role in the shift to treating acute mental illness within general hospital settings.In any discussion of the history of institutional care, there is a responsibility to acknowledge that the aspiration to provide buildings that support care and recovery have not always manifested in ways that improved daily life for patients.

The five treatment values that underpinned the analysis framework for this project are not new values. The extension of privacy and dignity to patients and the delivery of care within the least restrictive environment possible were both firmly embedded in the 19th-century approach of moral treatment. Yet the rapid growth of asylum care frustrated the delivery of those values to patients.40 Choice and independence for patients, the desire for a patient’s recovery progress to be reflected in their environment, and opportunities for peer support and family involvement have been present in approaches to mental health treatment since the formal endorsement of the ‘therapeutic community’ approach to hospital construction and administration in the WHO’s report of 1953.41 History reminds us, therefore, that differences can arise between the stated values on which an institution is designed and those which it is constructed and operated.

The three hospitals discussed in the following section include innovative solutions that hold the promise of positive benefits for patients. Yet we acknowledge this a theoretical analysis. For concrete evidence of a positive relationship between these design outcomes and patient well-being, postoccupancy evaluations are required.Three hospitals contributing to positive change in forensic mental healthcareBroadmoor Hospital.

Optimising the value of the village model for patientsNineteenth-century beliefs and contemporary research are in accord regarding the importance of greenspace in reducing agitation within forensic psychiatric hospital environments and in promoting positive patterns of socialisation.42 It is surprising, therefore, that enshrining daily landscape access for patients is not widespread within current design practice. The Irish National Forensic Mental Hospital and the State Hospital at Carstairs (Scotland) both follow the model of the village hospital, but only in that they comprise a number of accommodation buildings set within the landscape, enclosed by an external boundary fence. At the Irish National Forensic Mental Hospital, the scale of the landscape—the distance between buildings and the lack of intermediate boundaries within the landscape—suggests it is highly unlikely that patients are allowed to navigate this landscape on a regular basis.

By comparison, the architectural response developed for Broadmoor Hospital (2019) shows an exemplary commitment to patient views and access to landscape (Figure 3).Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK)." data-icon-position data-hide-link-title="0">Figure 3 Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK).Five contemporary hospitals follow the logic of a traditional villa hospital, yet Broadmoor is the only one that optimises the benefits offered by this spatial configuration.

Comprising a gateway building and a central treatment hub, with a series of patient accommodation buildings positioned around it, the landscape becomes the only available circulation route for patients travelling off-ward to the shared therapy, recreation and vocational training spaces. Most patients will thus engage with the outdoors at least twice daily on their way to and return from these shared spaces. But in addition to accessing this central landscape, landscape views from patient rooms have been prioritised, and each ward is allocated its own large greenspace.

Multiple, internal boundary fences enable patient access to the adjacent landscape to the greatest possible degree (refer to Figure 3). This approach provides patients with a diversity of landscape experiences. This is important given the patterns of landscape use between forensic and non-forensic hospitals.

In non-forensic facilities, patients are likely to have the choice of accessing multiple landscape spaces, whereas in forensic facilities access to a particular space is often restricted to one cohort, for example, a single ward group. This highlights a limitation of the courtyard model for forensic patients. Roseberry Park Hospital (2012) provides an example of how a high degree of landscape access can be similarly achieved for patients on constrained urban site, using a courtyard layout (refer to Figure 3).Providing patients with daily landscape access provides challenges to maintaining safety and security.

Trees with low branches can be used as weapons, while tall branches can be used for self-harm, and ground cover landscaping increases opportunities to conceal contraband. At the Australian hospital where advisory panel sessions were conducted (constructed in 2000), the landscape is occupied in a similar way and staff conveyed the constant effort required to ensure safe patient access to this greenspace. Significant costs are incurred annually by facilities staff in keeping the greenspace free from contraband and from several varieties of wild mushroom that grow seasonally on the site.

Despite this cost, staff reported that both they and the patients value the opportunity to circulate through the landscaped grounds (even in inclement weather). Hence, the benefits to well-being are perceived as significant enough to justify this cost. These examples make evident that placing a hospital within a landscape is not enough to ensure patients are extended the well-being benefits of ongoing access.

Instead this requires that hospitals factor in the additional supervisory and maintenance requirements to maintain landscape access for patients.Worcester Recovery Center and Hospital. Spaces to support choice and a sense of controlResearch in environmental psychology, conducted within residential and hospital settings, confirms that the ability to regulate social contact can have a dramatic impact on well-being. The physical layout of spaces has been linked to both the likelihood of developing socially supportive relationships and impeding this development, with direct implications for communication, concentration, aggression and a person’s resilience to irritation.43 These problems can be more pronounced in a forensic psychiatric hospital as there is an over-representation of patients who have suffered trauma.

Architects working in forensic psychiatric hospital design acknowledge that patients need space to withdraw from the busy hospital environment, spaces where they can ‘observe everything that is going on around them until they feel ready to join in’.44 It is surprising, therefore, that many contemporary forensic psychiatric hospitals still continue to provide a single social space for all 24 or 32 patients occupying a ward. The Worcester Recovery Center, by comparison, provides patients with a choice of social spaces that are designed to enable graduated degrees of social engagement. This can support a sense of control to limit socially induced stress.Worcester is conceptualised as three distinct zones designed to resemble life beyond the hospital.

The ‘house’, ‘neighbourhood’ and ‘downtown’ (Figure 4). The house zones include patient accommodation, employing a peninsula model. Each comprises 26 patient rooms, clustered into groups of 6 or 10 single bedrooms that face a collection of shared spaces dedicated to that cluster, including sitting areas, lounges and therapeutic spaces.

A shared kitchen and dining room is provided for each house. Three houses feed into a neighbourhood zone that includes shared spaces for therapy and vocational training, while the downtown zone serves a total of 14 houses. The downtown zone can be accessed by patients based on a merit system and includes a café, bank and retail spaces, music room, health club, chapel, green house, library and art rooms, alongside large interior public spaces.

This array of amenities does not seem distinctly different from other contemporary facilities, where therapy and vocational training happen in a mix of on-ward and off-ward (often within a central treatment hub). The difference lies in the sensitivity of how these spaces are articulated.Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’." data-icon-position data-hide-link-title="0">Figure 4 Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’.The generosity of providing separate living spaces for every 6–10 patients and locating these directly across the corridor from the patient rooms supports a sense of control and choice for patients. Frank Pitts, an architect who worked on the Worcester project, has written that this was done to enable patients to ‘decide whether they are ready to step out and socialise or return to the privacy of their room’.45 This approach filters throughout the facility, providing a slow graduation of social engagement opportunities for patients, from opportunities to socialise with their cluster of 6–10 individuals, to their house of 26, to their neighbourhood of 78 people, to the full downtown experience.

According to the architects, the neighbourhood thus provides an intermediary zone between the quiet house and the active downtown, which can be overwhelming for some patients.46 Importantly the scale of the architecture responds to this transition from personal to public space, providing visual indicators to reflect patients’ movement through their treatment journey. Spaces become larger as they move further from the ward. This occurs because instead of providing a single, large shared living space, patients are provided a choice of smaller spaces to occupy—these are not much bigger than a patient bedroom.

Dining spaces are slightly larger, while downtown spaces have a civic quality. These are double-height, providing a greater sense of light and airiness. These are arranged in a semicircle, opening onto a large veranda and greenspace.

The sensitive articulation of these spaces, with regard to both their graduated physical scale and the proximity of the social spaces to the patient bedrooms, provides spatial support to these social transitions while empowering patients to control their own level of social interaction.Margaret and Charles Juravinski Centre for Integrated Healthcare. Creating opportunities for greater public engagement and supporting readjustment to the world beyond the hospitalOne of the most significant barriers to mental health treatment is the stigma associated with admission to a psychiatric hospital. We know that discrimination poses an obstacle to recovery and that the media fuels public fears related to forensic mental health patients.47 Two further challenges to mental health delivery include the disconnection patients can experience from the community, including from family and educational opportunities, and the risk of readmission in the period immediately following discharge.48 If architecture is capable of acting as a change-agent in the delivery of mental healthcare, then it needs to show leadership, not only in the provision of a better experience for patients but more broadly in taking steps to help shift public perceptions around mental illness.

The Margaret and Charles Juravinski Centre for Integrated Healthcare (MCJC) (Canada) displays several similarities with the approach taken to the Maudsley Hospital. Its appearance communicates a modern, cutting-edge healthcare facility. It does not hide on a rural site or behind walls.

At five stories, and extensively glazed, MCJC communicates a strong civic presence. Its proximity to McMaster University (6 km) and to neighbouring general hospitals, including Juravinski Hospital (4 km) and Hamilton General Hospital (4 km), positions it well for research collaborations to occur, while its proximity to the Mohawk Community College, across the road, can enable patients with leave privileges to access vocational training. More importantly, it employs three innovative design tactics to target the challenges of contemporary forensic mental healthcare, providing an example for how architecture might broker positive change.The first innovative design strategy is the co-location of support services for outpatient mental healthcare.

The risk of readmission is highest immediately following discharge. A lack of collaboration between outpatient support services can result in fragmented care when patients are most vulnerable to the stresses associated with readjustment to the world beyond.49 MCJC includes outpatient facilities allowing patients to use the hospital as a stable base, or touchstone, in adjusting to life after discharge. Bringing these services onto the same physical site can also improve opportunities for coordination between inpatient and outpatient support services which can support continuity of care.

The second design strategy is the co-location of a medical ambulatory care centre which includes diagnostic imaging, educational and research facilities. This creates reasons for the general public to visit this facility, setting up the opportunity for greater public interaction. This could potentially advance understandings of the role of this facility and the patients it treats.The third innovative design strategy was to optimise the on-edge treatment hub for public engagement.

While adopted across a number of hospitals, including Hawaii State Hospital, Helix Forensic Psychiatry Clinic (Sweden) and the Worcester Recovery Center, the on-edge treatment hubs at these hospitals are buried deep inside the secure outer boundary. At MCJC, the treatment hub is placed adjacent to the public zones of the hospital—although on the second floor—and this can be viewed as extension of the public realm and enables the potential for the public to be brought right up to the secure boundary line (which occurs within the building). MCJC is divided into four zones.

The public zone, the galleria (the name given to the treatment hub), the clinical corridor and inpatient accommodation (Figure 5). The galleria functions similarly to the downtown at the Worcester Recovery Center. Patients are given graduated access to a series of spaces that support their recovery journey.

These include a gym, wellness centre, spiritual centre, library, café, beauty salon, and retail and financial services, alongside patient and family support services. While the galleria was initially intended to be accessible by the general public, this was not immediately implemented on the facilities’ opening and it is unclear whether this has now occurred.50 Nonetheless, the potential for movement of patients outwards, and families inwards, has been built into the physical fabric of this building, meaning opportunities for social interaction and fostering greater public understanding are possible. If understanding is the antidote to discrimination, then exposing the public to the role of this facility and the patients it treats is an important step in the right direction.Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.

The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated." data-icon-position data-hide-link-title="0">Figure 5 Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare.

The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated.ConclusionThe question of how architecture can support the therapeutic journey of forensic mental health patients is a critical one.

Yet the availability of evidence-based design literature to guide designers cannot keep pace with growing global demand for new forensic psychiatric hospital facilities, while limitations remain relative to the breadth and usability of this research. A narrow view of what constitutes credible evidence can overlook the value of knowledge embedded in architectural practice, alongside that held by architectural historians and lessons from environmental psychology. In respect of such a pressing and important problem, there is a responsibility to integrate knowledge from across these disciplines.

Accepting the limitations of a theoretical analysis and of the desktop survey method, we also argue for its value. Architects learn through experience, across multiple projects. This gives weight to the value of examining existing, contemporary design solutions to identify architectural innovations capable of providing benefits to patients and thus perhaps worthy of implementation across multiple projects.

History gives us reason to believe that small changes to typical design practice can improve the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. Architecture has the capacity to contribute to positive change.Here, we have provided a nuanced way for architects and decision makers to think about the relationship between architectural space and treatment values. An institution’s model of care and the therapeutic values that underpin that model of care should be placed at the centre of architectural decision making.

A survey of contemporary architectural solutions confirms that, generally speaking, innovation is lacking in this field. There will always be real obstacles to innovation, and the argument presented here does not suggest it is necessarily practical to prioritise therapeutic values at the cost of patient, staff and community safety. Instead, it challenges architects and decision makers to properly interrogate any architectural decision that compromises an initial commitment to supporting a patient’s treatment journey—to be more idealistic in the pursuit of positive change.Tangible examples exist of architectural innovations capable of positively improving patient experience by supporting key values that underpin contemporary treatment approaches.

The Broadmoor Hospital optimises the value of the village model for patients, prioritising patient needs for frequent landscape engagement to support their therapeutic journey. The Worcester Recovery Center provides a generous choice and graduation of social spaces to support the social reintegration of patients at their own pace. MCJC co-located facilities to support a patient’s readjustment to daily life postdischarge, while creating opportunities for public engagement that has the potential to foster greater public understanding of the role of these institutions and the patients they treat.

In identifying these three innovative design approaches, we provide architects with tangible design tactics, while encouraging researchers to look more closely at these examples with targeted, postoccupancy studies. These projects provide hope that with a shared vision and commitment, innovation is possible in forensic psychiatric hospital design, with tangible benefits for patients.Data availability statementAll data relevant to the study are included in the article or uploaded as supplementary information. The primary method undertaken for this research relied on data publicly available on the internet.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsThe opportunity to conduct this project arose out of a multidisciplinary master-planning and feasibility study, commissioned by the Victorian Health and Human Services Building Authority, to investigate various international solutions to inform future planning and design around forensic mental health service provision.

The following people contributed their time and expertise in shaping the research process that enabled this article. Neel Charitra, Stefano Scalzo, Les Potter, Margaret Grigg, Lousie Bawden, Matthew Balaam, Martin Gilbert, John MacAllister, Crystal James, Jo Ryan, Julie Anderson, Jo Wasley, Sophie Patitsas, Meagan Thompson, Judith Hemsworth, James Watson, Viviana Lazzarini, Krysti Henderson, Nadia Jaworski, Jack Kerlin and Jan Merchant.Notes1. Jamie O'Donahoo and Janette Graetz Simmonds (2016), “Forensic Patients and Forensic Mental Health in Victoria.

Legal Context, Clinical Pathways, and Practice Challenges,” Australian Social Work 69, no. 2. 169–80.2.

The challenge of which terminology to select when writing about psychiatric hospital design remains difficult relative to the stigmas that surround this field. The term ‘patient’ has been used throughout, instead of ‘consumer’, as this article spans both historical and contemporary developments. In the context of this timespan, consumer is a relatively recent term, introduced around 1985.3.

B Edginton (1994), “The Well-Ordered Body. The Quest for Sanity through Nineteenth-Century Asylum Architecture,” Canadian Bulletin of Medical History 11, no. 2.

375–86. Clare Hickman (2009), “Cheerful Prospects and Tranquil Restoration. The Visual Experience of Landscape as Part of the Therapeutic Regime of the British Asylum, 1800-60,” History of Psychiatry 20, no.

4 Pt 4. 425–41. Rebecca McLaughlan, 2012), “Post-Rationalisation and Misunderstanding.

Mental Hospital Architecture in the New Zealand Media,” Fabrications 22, no. 2. 232–56.4.

Roger S Ulrich et al. (2008), “A Review of the Research Literature on Evidence-Based Healthcare Design,” HERD 1, no. 3.

61–125. Jill Maben et al. (2015), “Evaluating a Major Innovation in Hospital Design.

Workforce Implications and Impact on Patient and Staff Experiences of All Single Room Hospital Accommodation,” Health Services and Delivery Research 3. 1–304. Penny Curtis and Andy Northcott (2017), “The Impact of Single and Shared Rooms on Family-Centred Care in Children’s Hospitals,” Journal of Clinical Nursing 26, no.

Ulrich et al. (2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” Journal of Environmental Psychology 57. 53–66.6.

Graham A Tyson, Gordon Lambert, and Lyn Beattie (2002), “The Impact of Ward Design on the Behaviour, Occupational Satisfaction and Well-Being of Psychiatric Nurses,” International Journal of Mental Health Nursing 11, no. 2. 94–102.7.

For further examples of this see Jon E. Eggert et al. (2014), “Person-Environment Interaction in a New Secure Forensic State Psychiatric Hospital,” Behavioral Sciences &.

C.C. Whitehead et al. (1984), “Objective and Subjective Evaluation of Psychiatric Ward Redesign,” The American Journal of Psychiatry 141, no.

(2011), “Client-Centered Design of Residential Addiction and Mental Health Care Facilities. Staff Perceptions of Their Work Environment,” Qualitative Health Research 21, no. 11.

1527–38.8. Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities.

Visions and Outcomes,” Facilities 31, no 1/2. 24–88.9. For examples see Kathleen Connellan et al.

(2013), “Stressed Spaces. Mental Health and Architecture,” HERD. Health Environments Research &.

Constantina Papoulias et al. (2014), “The Psychiatric Ward as a Therapeutic Space. Systematic Review,” British Journal of Psychiatry 205, no.

Allen and R.G. Nairn, 1997. Alan Dilani, 2000, “Psychosocially Supportive Design - Scandinavian Health Care Design,” World Hospitals and Health Services 37.

20–4. Rebecca McLaughlan (2018), “Psychosocially Supportive Design. The Case for Greater Attention to Social Space within the Pediatric Hospital," HERD 11, no.

2. 151–62.11. Rebecca McLaughlan (2017), “Learning From Evidence-Based Medicine.

Exclusions and Opportunities within Health Care Environments Research,” Design for Health 1. 210–28.12. B Edginton (1997), “Moral Architecture.

The Influence of the York Retreat on Asylum Design,” Health &. Place 3, no. 2.

91–9. Jeremy Taylor (1991), Hospital and Asylum Architecture in England 1849–1914. Building for Health Care (London.

Mansell Publishing Limited). Anne Digby (1985), Madness, Morality and Medicine. A Study of the York Retreat 1796–1914 (New York.

Cambridge University Press).13. Digby, Madness, Morality and Medicine. Erving Goffman (1961), Asylums.

Essays on the Social Situation of Mental Patients and Other Inmates (New York. Doubleday). Ivan Belknap (1956), Human Problems of a State Mental Hospital (New York.

Blakiston Division, McGraw-Hill). Andrew Scull (1979), Museums of Madness. The Social Organization of Insanity in 19th Century England (London.

Allen Lane). Leonard Smith (1999), Cure, Comfort and Safe Custody. Public Lunatic Asylums in Early Nineteenth-Century England (London.

Leicester University Press). Rebecca McLaughlan (2014), “One Dose of Architecture, Taken Daily. Building for Mental Health in New Zealand” (PhD diss., Victoria University of Wellington, New Zealand).14.

Although not fitting a strict definition of postoccupancy evaluation, the following articles were notable exceptions to this finding. Eggert et al., “Person-Environment Interaction,” 527–38. Roger S.

Ulrich et al. (2018), “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. Catherine Clark Ahern et al.

(2016), “A Recovery-Oriented Care Approach. Weighing the Pros and Cons of a Newly Built Mental Health Facility,” Journal of Psychosocial Nursing and Mental Health Services 54, no. 2.

39–48.15. M Gibbons (2000), “Mode 2 Society and the Emergence of Context-Sensitive Science,” Science and Public Policy 27. 161.16.

D Seamon, 2000, “A Way of Seeing People and Place,” in Theoretical Perspectives in Environment-Behavior Research, ed. S. Wapner, J.

Demick, T. Yamamoto and H. Minami (New York.

Plenum), 157–78.17. Thomas A Markus (1982), Order in Space and Society. Architectural Form and Its Context in the Scottish Enlightenment (Edinburgh.

Mainstream Publishing Company).18. Ulrich et al., “A Review of the Research Literature,” 61–125.19. This was first created by first author for use for historical analysis during her PhD and is applied here to a contemporary setting.

Refer to McLaughlan, “One Dose of Architecture, Taken Daily.”20. The following documents were referenced in compiling this list. Joint Commission Panel for Mental Health, NHS, UK (2013), “Guidance for Commissioners of Forensic Mental Health Services,” May, https://www.jcpmh.info/resource/guidance-for-commissioners-of-forensic-mental-health-services/.

Cannon Design (2014), “St Joseph’s Integrated Healthcare Hamilton, Margaret and Charles Juravinski Centre for Integrated Healthcare,” Healthcare Design Showcase, September. Health Nexus Group, 2017, “Forensicare Model of Care Report,” April, Australia (access provided by the Victorian Health and Human Services Building Authority). Donald Cant Watts Corke (2014), “Service Plan for Forensic Mental Health Services,” July, Australia (access provided by the Victorian Health and Human Services Building Authority).21.

Sometimes this includes patients with no history of criminal behaviour but who are unable to be treated safely in a general hospital environment.22. W.A.F Browne (1991), "What Asylums Were, Are and Ought to Be (1837),” reprinted in The Asylum as Utopia. W.A.F.

Browne and the Mid-Nineteenth Century Consolidation of Psychiatry, ed. Andrew Scull (London. Tavistock).

Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38. Eggert et al., “Person-Environment Interaction.”23.

Anon (1895), “Review. The Colonization of the Insane in Connection with the Open-Door System. Its Historical Development and the Mode in Which It Is Carried Out at Alt Scherbitz Manor.

By Dr. Albrecht Paetz, Director of the Provincial Institution for the Insane (Berlin. Springer, 1983),” The Journal of Mental Science 41.

697–703.24. Theodore Gray (1958), The Very Error of the Moon (Ilfracombe &. Devon.

Arthur H. Stockwell Ltd), 64.25. John Galt (1854), “The Farm of St.

Anne,” American Journal of Insanity II (1854). 352.26. Galt, “The Farm of St.

Anne,” 352.27. Martin James (1948), “Diagnostic Measures,” in Modern Trends in Psychological Medicine, ed. Noel Haris (London.

World Health Organization (1953), The Community Mental Hospital. Third Report of the Expert Committee on Mental Health (Geneva. WHO).28.

Carla Yanni (2007), The Architecture of Madness. Insane Asylums in the United States. Minneapolis (London.

University of Minnesota Press).29. Key British examples included the 1923 rebuild of London’s Bethlem Hospital which followed the villa model, alongside Shenley Park Mental Hospital (Middlesex County) and Barrow Mental Hospital (Somerset), both constructed in the early 1930s.30. Taylor, Hospital and Asylum Architecture in England.31.

Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66. O. Jenkins, S.

Dye and C. Foy (2015) (Oliver Jenkins et al., 2015), “A Study of Agitation, Conflict and Containment in Association With Change in Ward Physical Environment,” Journal of Psychiatric Intensive Care 11, no. 01.

Mayer, and T. Martin (2004), “Environmental Contributors to Aggression in Two Forensic Psychiatric Hospitals,” International Journal of Forensic Mental Health 3 no. 1.

(1994), “Patient Overcrowding in Psychiatric Hospital Units. Effects on Seclusion and Restraint,” Administration and Policy in Mental Health 22, no. 2.

133–44. T. T Palmstierna, B Huitfeldt, and B Wistedt (1991), “The Relationship of Crowding and Aggressive Behavior on a Psychiatric Intensive Care Unit,” Psychiatric Services 42, no.

12. 1237–40.32. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 57.

Charles Mercier (1894), Lunatic Asylums. Their Organisation and Management (London. Charles Griffin and Company), 135.33.

Morgan Andersson et al. (2013), “New Swedish Forensic Psychiatric Facilities,” 24–38. Joel A Dvoskin et al.

(2002), “Architectural Design of a Secure Forensic State Psychiatric Hospital,” Behavioral Scients &. The Law, 20, no. 3.

Maclnnes (1999), “The Relationship between Building Design and Escapes from Secure Units,” Journal of the Royal Society for the Promotion of Health 119, no. 3. 170–4.

Jon E. Eggert et al. (2014), “Person-Environment Interaction,” 527–38.34.

Tom Brooks-Pilling cited in Mike Lear (2015), “Designer. New Fulton State Hospital Will Be Better, Safer,” Missourinet, January 5, https://www.missourinet.com/2015/01/05/designer-new-fulton-state-hospital-will-be-better-safer/35. Leslie Topp (2007), “The Modern Mental Hospital in Late Nineteenth-Century Germany and Austria.

Psychiatric Space and Images of Freedom and Control,” in Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, ed. Leslie Topp, James Moran and Jonathan Andrews (London and New York.

Routledge), 244.36. McLaughlan, “One Dose of Architecture, Taken Daily,” 35. Digby, Madness, Morality and Medicine.37.

Anon (1908), “Proposed New Hospital for Mental Diseases,” The Lancet 171, no. 4410. 728–9.38.

Anon, “Proposed New Hospital for Mental Diseases.”39. McLaughlan, “One Dose of Architecture, Taken Daily.”40. Samuel Tuke (1964), “Description of the Retreat (1813),” reprinted in Description of the Retreat With an Introduction by Richard Hunter and Ida Macalpine (London.

Dawsons of Paul Mall). Scull, Museums of Madness. Digby, Madness, Morality and Medicine.

Smith, Cure, Comfort and Safe Custody.41. World Health Organization (1953), The Community Mental Hospital. Also refer to T.F Main (1946), “The Hospital as a Therapeutic Institution”, Bulletin of the Menninger Clinic 10, no.

3. 66–71. David Clark (1965), “The Therapeutic Community Concept, Practice and Future,” The Journal of Mental Science 111.

947–54.42. Jolanda Maas et al. (2009), “Social Contacts as a Possible Mechanism behind the Relation between Green Space and Health,” Health &.

Gayle Souter-Brown (2015), Landscape and Urban Design for Health and Well-Being. Using Healing, Sensory and Therapeutic Gardens (Oxon &. New York.

Routledge). Ulrich et al., “A Review of the Research Literature,” 61–125.43. Leon Festinger et al.

(1950), Social Pressures in Informal Groups. A Study of Human Factors in Housing, vol. 11 (New York.

Harper Bros). David Halpern (1995), Mental Health and the Built Environment. More than Bricks and Mortar?.

Baum and G.E. Davis (1980), “Reducing the Stress of High-Density Living. An Architectural Intervention,” Journal of Personality and Social Psychology 38, no.

Altman and M.M. Chemers (1984), Culture and Environment (Monterey, CA. Brooks &.

Cole Publishing). Gary W Evans (2003), “The Built Environment and Mental Health,” Journal of Urban Health. Bulletin of the New York Academy of Medicine 80 no.

4. 536–55. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66.44.

Stence Guldager cited in Troldtekt, “Innovative Architecture is Good for Mental Health,” https://www.troldtekt.com/News/Themes/Healing_architecture/Innovative_architecture_is_good_for_mental_health (accessed June 30, 2019). Clare Hickman and “Cheerful Prospects (2009).45. Frank Pitts cited in Patricia Wen (2012), “For Mentally Ill, A Design Departure,” B News, August 16, https://www.boston.com/news/local-news/2012/08/16/for-mentally-ill-a-design-departure46.

Ellenzweig with Architecture Plus, “Massachusetts Department of Mental Health, Worcester Recovery Center and Hospital – Worcester, MA,” Healthcare Design (2013), July 30, https://www.healthcaredesignmagazine.com/architecture/massachusetts-department-mental-health-worcester-recovery-center-and-hospital-worcester-ma/47. Sane Australia (2003), “A Life Without Stigma,” July 25, http://apo.org.au/resource/life-without-stigma. Otto F Wahl (2012), “Stigma as a Barrier to Recovery from Mental Illness,” Trends in Cognitive Sciences 16, no.

1. 9–10. New Zealand Ministry of Health and Health Promotion Agency (2014), “Like Minds, Like Mine National Plan 2014–2019.

Programme to Increase Social Inclusion and Reduce Stigma and Discrimination for People with Experience of Mental Illness,” May 20, https://www.likeminds.org.nz/assets/National-Plans/like-minds-like-mine-national-plan-2014-2019-may14.pdf. G Moon (2000), “Risk and Protection. The Discourse of Confinement in Contemporary Mental Health Policy," Health &.

R. Allen and R.G. Nairn (1997), “Media Depictions of Mental Illness.

An Analysis of the Use of Dangerousness,” Australian &. New Zealand Journal of Psychiatry 31, no. 3.

375–81. Greg Philo et al. (1994), “The Impact of the Mass Media on Public Images of Mental Illness.

Media Content and Audience Belief,” Health Education Journal 53, no. 3. 271–81.48.

G Moon (2000), “Risk and Protection,” 239–50. T.F Main (1948), “Rehabilitation and the Individual,” in Modern Trends in Psychological Medicine, ed. Noel Haris (London.

D.A Fuller, E. Sinclair, and J. Snook (2016), “Released, Relapsed, Rehospitalized.

Length of Stay and Readmission Rates in State Hospitals. A Comparative State Survey,” 2016, https://www.treatmentadvocacycenter.org/storage/documents/released-relapsed-rehospitalized.pdf. Leila Salem et al.

(2015), “Supportive Housing and Forensic Patient Outcomes,” Law and Human Behavior 39, no. 3. 311.49.

National Institute for Health and Clinical Excellence, Manchester (2016), “Transition between Inpatient Mental Health Settings and Community or Care Home Settings. Guideline,” August, https://www.nice.org.uk/guidance/ng53/evidence/full-guideline-pdf-260695191750. Catherine Clark Ahern et al.

(2016), “A Recovery-Oriented Care Approach,” 47..

Can you buy over the counter propecia

Before drug products http://www.sylvanupholstery.com/how-much-does-ventolin-hfa-cost-without-insurance/ are authorized for sale in Canada, Health Canada reviews them to assess their can you buy over the counter propecia safety, efficacy and quality. Drug products include prescription and non-prescription pharmaceuticals, disinfectants and sanitizers with disinfectant claims.What information can you find here?. This section can you buy over the counter propecia contains links to reports and publications related to drug products. Drug Submission Performance ReportsThe Drug Submission Review Performance Reports provide detailed metrics about the timeliness of pre-market drug review process against performance service standards.

The annual report can you buy over the counter propecia compares five consecutive fiscal years (April 1 - March 31), while the quarterly report compares five quarters. The reports are broken down by operational areas. The Therapeutic can you buy over the counter propecia Product Directorate (TPD) report summarises performance metrics for pharmaceuticals. The Biologics and Genetic Therapies Directorate (BGTD) was renamed to the Biologic and Radiopharmaceutical Drugs Directorate (BRDD).

The BRDD report summarises performance metrics for can you buy over the counter propecia biologics and radiopharmaceutical drugs. The Natural and Non-Prescription Health Products Directorate (NNHPD) report summarises performance metrics for non-prescription (over-the-counter) and disinfectant drugs. Within each report, statistics are provided by submission type and show the number received, the number in workload, the number of decisions and the number of approvals and time to approval.Submissions Received are counts of submissions received during the year using the filing date. Workload is can you buy over the counter propecia reported as the number of submissions "under active review" on a given day.

"Backlog" is the proportion of the workload that is over target. "Approvals" are Notice of Compliances can you buy over the counter propecia (NOC) issued or issuable. An issuable NOC arises when a submission NOC is placed "on hold" awaiting authorization to market, due to requirements in the Patented Medicines (Notice of Compliance) Regulations, or due to a conversion of status from prescription to Over the Counter.Drug Submission Performance Reports are available by request only. Please see contact information can you buy over the counter propecia below.Annual ReportsTPD.

NNHPD. ReportsStatistical Report 2020/2021 for the Patented Medicines (Notice of Compliance) Regulations, Data Protection and Certificates of Supplementary Protection (To obtain a full electronic copy of this report, please contact publications-publications@hc-sc.gc.ca.) [2021-11-10]Statistical Report 2019/2020 for the Patented Medicines (Notice of Compliance) Regulations, Data Protection and Certificates of Supplementary Protection (To obtain a full electronic copy of this report, please contact hc.publications-publications.sc@canada.ca.) [2020-09-02]Statistical Report 2018/2019 for the Patented Medicines (Notice of Compliance) Regulations, Data Protection and Certificates of Supplementary Protection (To obtain a full electronic copy of this report, please contact hc.publications-publications.sc@canada.ca.) [2019-06-28]Stakeholder Workshop on a National Buprenorphine Program [2004-12-06]Abacavir sulfate, dolutegravir sodium, lamivudine Antivirals for systemic use 1 Abiraterone acetate Endocrine therapy 1 Acetylcysteine Cough and cold preparations 1 Acyclovir Antivirals for systemic use 1 Acyclovir sodium Antivirals for systemic use 1 Afatinib Antineoplastic agents 1 Afatinib dimaleate Antineoplastic agents 3 Alfacalcidol Vitamins 1 Amantadine hydrochloride Anti-Parkinson drugs 1 Ambrisentan Antihypertensives 3 Amikacin sulfate Antibacterials for systemic use 2 Amiodarone hydrochloride Cardiac therapy 1 Amoxicillin trihydrate, clavulanic acid Antibacterials for systemic use 1 Anastrozole Endocrine therapy 1 Apixaban Antithrombotic agents 3 Apremilast Immunosuppressants 8 Argatroban Antithrombotic agents 1 Atorvastatin Lipid modifying agents 2 Atovaquone Antiprotozoals 1 Azacitidine Antineoplastic agents 5 Azelastine hydrochloride, fluticasone propionate Nasal preparations 2 Azithromycin Antibacterials for systemic use 1 Azithromycin dihydrate Antibacterials for systemic use 2 Bendamustine hydrochloride Antineoplastic agents 1 Betamethasone dipropionate, calcipotriol monohydrate Antipsoriatics 1 Bortezomib mannitol boronic ester Antineoplastic agents 1 Bosentan Antihypertensives 1 Brimonidine tartrate Ophthalmologicals 1 Bromfenac sodium sesquihydrate Ophthalmologicals 1 Bupropion hydrochloride Psychoanaleptics 1 Budesonide Antidiarrheals, intestinal anti-inflammatory/anti-infective agents 1 Buprenorphine hydrochloride, naloxone hydrochloride dihydrate Other nervous system drugs 1 Busulfan Antineoplastic agents 1 Caffeine Psychoanaleptics 2 Calcium polystyrene sulphonate All other therapeutic products 1 Canagliflozin Drugs used in diabetes 2 Carboprost tromethamine Other gynecologicals 1 Carvedilol Beta blocking agents 1 Cephalexin monohydrate Antibacterials for systemic use 1 Clobetasol propionate Corticosteroids, dermatological preparations 1 Clonidine hydrochloride Antihypertensives 1 Clozapine Psycholeptics 1 Colesevelam hydrochloride Lipid modifying agents 1 Cyclophosphamide Antineoplastic agents 1 Dantrolene sodium Muscle relaxants 1 Dapagliflozin Drugs used in diabetes 5 Dapagliflozin, metformin hydrochloride Drugs used in diabetes 1 Dasatinib Antineoplastic agents 2 Deferasirox All other therapeutic products 7 Degarelix acetate Endocrine therapy 1 Desvenlafaxine succinate Psychoanaleptics 1 Diltiazem hydrochloride Calcium channel blockers 1 Divalproex sodium Antiepileptics 1 Docetaxel Antineoplastic agents 1 Dolutegravir Antivirals for systemic use 1 Dorzolamide hydrochloride Ophthalmologicals 1 Dorzolamide hydrochloride, timolol maleate Ophthalmologicals 3 Doxepin hydrochloride Psychoanaleptics 2 Doxycycline Antibacterials for systemic use 1 Doxycycline hyclate Antibacterials for systemic use 1 Dutasteride Urologicals 1 Efinaconazole Antifungals for dermatological use 7 Eombopag olamine Antihemorrhagics 1 Empagliflozin Drugs used in diabetes 3 Empagliflozin, metformin hydrochloride Drugs used in diabetes 1 Enzalutamide Endocrine therapy 2 Eslicarbazepine acetate Antiepileptics 1 Ethinyl estradiol, etonogestrel Other gynecologicals 1 Ethinyl estradiol, levonorgestrel Sex hormones and modulators of the genital system 1 Etomidate Anesthetics 1 Everolimus Antineoplastic agents 2 Febuxostat Antigout preparations 1 Felodipine Calcium channel blockers 1 Fingolimod hydrochloride Immunosuppressants 1 Fludrocortisone 21-acetate Corticosteroids for systemic use 1 Fluoxetine hydrochloride Psychoanaleptics 1 Fondaparinux sodium Antithrombotic agents 1 Fulvestrant Endocrine therapy 2 Furosemide Diuretics 2 Fusidic acid Antibiotics and chemotherapy for dermatological use 1 Gefitinib Antineoplastic agents 1 Glatiramer acetate Immunostimulants 1 Glycopyrrolate Drugs for functional gastrointestinal disorders 2 Guanfacine hydrochloride Antihypertensives 2 Hydrochlorothiazide, olmesartan medoxomil Agents acting on the renin-angiotensin system 1 Hydromorphone hydrochloride Analgesics 1 Hydroxychloroquine sulfate Antiprotozoals 1 Ibrutinib Antineoplastic agents 3 Icatibant acetate Other hematological agents 4 Ipratropium bromide Drugs for obstructive airway diseases 1 Ketamine hydrochloride Anesthetics 1 Ketorolac tromethamine Antiinflammatory and antirheumatic products 3 Labetalol hydrochloride Beta blocking agents 1 Latanoprost Ophthalmologicals 1 Lenalidomide Immunosuppressants 1 Lenalidomide hydrochloride Immunosuppressants 1 Letrozole Endocrine therapy 1 Levetiracetam Antiepileptics 2 Levothyroxine sodium Thyroid therapy 1 Linagliptin Drugs used in diabetes 3 Linagliptin, metformin hydrochloride Drugs used in diabetes 1 Lisdexamfetamine dimestylate Psychoanaleptics 3 Lurasidone hydrochloride Psycholeptics 6 Macitentan Antihypertensives 4 Melphalan hydrochloride Antineoplastic agents 1 Metformin hydrochloride Drugs used in diabetes 2 Metformin hydrochloride, sitagliptin Drugs used in diabetes 2 Metformin hydrochloride, sitagliptin hydrochloride monohydrate Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin malate Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin phosphate Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin phosphate monohydrate Drugs used in diabetes 3 Methadone hydrochloride Other nervous system drugs 1 Methotrexate Antineoplastic agents 1 Methylphenidate hydrochloride Psychoanaleptics 2 Micafungin sodium Antimycotics for systemic use 1 Milrinone Cardiac therapy 1 Mitomycin Antineoplastic agents 1 Nadolol Beta blocking agents 1 Naloxegol Drugs for constipation 1 Naloxone hydrochloride All other therapeutic products 1 Naexone hydrochloride Other nervous system drugs 1 Nebivolol hydrochloride Beta blocking agents 1 Nifedipine Calcium channel blockers 1 Nintedanib Antineoplastic agents 1 Nintedanib esilate Antineoplastic agents 1 Ofloxacin Ophthalmologicals 1 Ondansetron hydrochloride dihydrate Antiemetics and antinauseants 2 Oseltamivir phosphate Antivirals for systemic use 2 Oxaliplatin Antineoplastic agents 1 Paliperidone Psycholeptics 1 Paliperidone palmitate Psycholeptics 3 Pazopanib Antineoplastic agents 1 Pemetrexed disodium Antineoplastic agents 1 Perampanel Antiepileptics 1 Perindopril erbumine Agents acting on the renin-angiotensin system 1 Plerixafor Immunostimulants 1 Pomalidomide Immunosuppressants 6 Posaconazole Antimycotics for systemic use 1 Propofol Anesthetics 1 Ranitidine Drugs for acid related disorders 1 Rasagiline mesylate Anti-Parkinson drugs 1 Riociguat Antihypertensives 1 Risperidone Psycholeptics 1 Ritonavir Antivirals for systemic use 1 Rivaroxaban Antithrombotic agents 7 Sapropterin dihydrochloride Other alimentary tract and metabolism products 1 Sevoflurane Anesthetics 1 Silodosin Urologicals 1 Sitagliptin Drugs used in diabetes 2 Sitagliptin hydrochloride Drugs used in diabetes 1 Sitagliptin malate Drugs used in diabetes 2 Sitagliptin phosphate Drugs used in diabetes 2 Sitagliptin phosphate monohydrate Drugs used in diabetes 2 Sulfamethoxazole, trimethoprim Antibacterials for systemic use 1 Sumatriptan succinate Analgesics 1 Sunitinib Antineoplastic agents 2 Sunitinib malate Antineoplastic agents 3 Tacrolimus Immunosuppressants 2 Tamsulosin hydrochloride Urologicals 1 Teriflunomide Immunosuppressants 10 Thiotepa Antineoplastic agents 2 Ticagrelor Antithrombotic agents 3 Timolol maleate Ophthalmologicals 1 Tizanidine hydrochloride Muscle relaxants 1 Tofacitinib Immunosuppressants 1 Tofacitinib citrate Immunosuppressants 3 Tolvaptan Diuretics 1 Trabectedin Antineoplastic agents 1 Treprostinil Antithrombotic agents 1 Valproic acid Antineoplastic agents 1 Varenicline tartrate Other nervous system drugs 2 Venlafaxine hydrochloride Psychoanaleptics 1 Voriconazole Antimycotics for systemic use 1 Vortioxetine hydrobromide Psychoanaleptics 2Today, the World Health Organization (WHO) issued an emergency use listing (EUL) for COVAXIN® (developed by Bharat Biotech), adding to a growing portfolio of treatments validated by WHO for the prevention of hair loss treatment caused by hair loss.WHO’s EUL procedure assesses the quality, safety and efficacy of hair loss treatments and is a prerequisite for COVAX treatment supply. It also allows countries to expedite their own regulatory approval to import and administer hair loss treatments. €œThis emergency use listing expands the availability of treatments, the most effective medical tools we have to end the propecia,” said Dr Mariângela Simão, WHO Assistant-Director General for Access to Medicines and Health Products.

€˜But we must keep up the pressure to meet the needs of all populations, giving priority to the at-risk groups who are still waiting for their first dose, before we can start declaring victory.” COVAXIN® was assessed under the WHO EUL procedure based on the review of data on quality, safety, efficacy, a risk management plan and programmatic suitability. The Technical Advisory Group (TAG), convened by WHO and made up of regulatory experts from around the world, has determined that the treatment meets WHO standards for protection against hair loss treatment, that the benefit of the treatment far outweighs risks and the treatment can be used globally.The treatment is formulated from an inactivated hair loss antigen and is presented in single dose vials and multidose vials of 5, 10 and 20 doses.COVAXIN® was also reviewed on 5 October by WHO’s Strategic Advisory Group of Experts on Immunization (SAGE), which formulates treatment specific policies and recommendations for treatments’ use in populations (i.e. Recommended age groups, intervals between doses, specific groups such as pregnant and lactating women). The SAGE recommended use of the treatment in two doses, with a dose interval of four weeks, in all age groups 18 and above.

COVAXIN® was found to have 78% efficacy against hair loss treatment of any severity, 14 or more days after the second dose, and is extremely suitable for low- and middle-income countries due to easy storage requirements. Available data from clinical trials on vaccination of pregnant women are insufficient to assess treatment safety or efficacy in pregnancy. However, initial studies were reassuring. The treatment has been given to over 120 000 pregnant women in India, with no short-term adverse effects noted.

Further studies in pregnant women are planned. WHO emergency use listing The emergency use listing (EUL) procedure assesses the suitability of novel health products during public health emergencies. The objective is to make medicines, treatments and diagnostics available as rapidly as possible to address the emergency while adhering to stringent criteria of safety, efficacy and quality. The assessment weighs the threat posed by the emergency as well as the benefit that would accrue from the use of the product against any potential risks.The EUL pathway involves a rigorous assessment of late phase II and phase III clinical trial data, as well as substantial additional data on safety, efficacy, quality and a risk management plan.

These data are reviewed by independent experts and WHO teams who consider the current body of evidence on the treatment under consideration, the plans for monitoring its use, and plans for further studies.As part of the EUL process, the company producing the treatment must commit to continue to generate data to enable full licensure and WHO prequalification of the treatment. The WHO prequalification process will assess additional clinical data generated from treatment trials and deployment on a rolling basis to ensure the treatment meets the necessary standards of quality, safety and efficacy for broader availability.See all EUL listingsSAGESAGE is the principal advisory group to WHO for treatments and immunization. It is charged with advising WHO on overall global policies and strategies, ranging from treatments and immunization technology, research and development, to delivery of immunization and its linkages with other health interventions. SAGE is concerned not just with childhood treatments and immunization, but all treatment-preventable diseases.SAGE assesses evidence on safety, efficacy, effectiveness, impact and programmatic suitability, considering both individual and public health impact.

SAGE Interim recommendations for EUL products provide guidance for national vaccination policy makers. These recommendations are updated as additional evidence becomes available and as there are changes to the epidemiology of disease and the availability of additional treatments and other disease control interventions.See Sage interim recommendations.

Before drug products are authorized for sale in Canada, http://www.sylvanupholstery.com/how-much-does-ventolin-hfa-cost-without-insurance/ Health Canada reviews them to assess propecia cheapest price their safety, efficacy and quality. Drug products include prescription and non-prescription pharmaceuticals, disinfectants and sanitizers with disinfectant claims.What information can you find here?. This section contains links to reports propecia cheapest price and publications related to drug products. Drug Submission Performance ReportsThe Drug Submission Review Performance Reports provide detailed metrics about the timeliness of pre-market drug review process against performance service standards.

The annual report compares five consecutive fiscal years (April 1 - March 31), while propecia cheapest price the quarterly report compares five quarters. The reports are broken down by operational areas. The Therapeutic propecia cheapest price Product Directorate (TPD) report summarises performance metrics for pharmaceuticals. The Biologics and Genetic Therapies Directorate (BGTD) was renamed to the Biologic and Radiopharmaceutical Drugs Directorate (BRDD).

The BRDD propecia cheapest price report summarises performance metrics for biologics and radiopharmaceutical drugs. The Natural and Non-Prescription Health Products Directorate (NNHPD) report summarises performance metrics for non-prescription (over-the-counter) and disinfectant drugs. Within each report, statistics are provided by submission type and show the number received, the number in workload, the number of decisions and the number of approvals and time to approval.Submissions Received are counts of submissions received during the year using the filing date. Workload is propecia cheapest price reported as the number of submissions "under active review" on a given day.

"Backlog" is the proportion of the workload that is over target. "Approvals" are propecia cheapest price Notice of Compliances (NOC) issued or issuable. An issuable NOC arises when a submission NOC is placed "on hold" awaiting authorization to market, due to requirements in the Patented Medicines (Notice of Compliance) Regulations, or due to a conversion of status from prescription to Over the Counter.Drug Submission Performance Reports are available by request only. Please see contact information below.Annual propecia cheapest price ReportsTPD.

NNHPD. ReportsStatistical Report 2020/2021 for the Patented Medicines (Notice of Compliance) Regulations, Data Protection and Certificates of Supplementary Protection (To obtain a full electronic copy of this report, please contact publications-publications@hc-sc.gc.ca.) [2021-11-10]Statistical Report 2019/2020 for the Patented Medicines (Notice of Compliance) Regulations, Data Protection and Certificates of Supplementary Protection (To obtain a full electronic copy of this report, please contact hc.publications-publications.sc@canada.ca.) [2020-09-02]Statistical Report 2018/2019 for the Patented Medicines (Notice of Compliance) Regulations, Data Protection and Certificates of Supplementary Protection (To obtain a full electronic copy of this report, please contact hc.publications-publications.sc@canada.ca.) [2019-06-28]Stakeholder Workshop on a National Buprenorphine Program [2004-12-06]Abacavir sulfate, dolutegravir sodium, lamivudine Antivirals for systemic use 1 Abiraterone acetate Endocrine therapy 1 Acetylcysteine Cough and cold preparations 1 Acyclovir Antivirals for systemic use 1 Acyclovir sodium Antivirals for systemic use 1 Afatinib Antineoplastic agents 1 Afatinib dimaleate Antineoplastic agents 3 Alfacalcidol Vitamins 1 Amantadine hydrochloride Anti-Parkinson drugs 1 Ambrisentan Antihypertensives 3 Amikacin sulfate Antibacterials for systemic use 2 Amiodarone hydrochloride Cardiac therapy 1 Amoxicillin trihydrate, clavulanic acid Antibacterials for systemic use 1 Anastrozole Endocrine therapy 1 Apixaban Antithrombotic agents 3 Apremilast Immunosuppressants 8 Argatroban Antithrombotic agents 1 Atorvastatin Lipid modifying agents 2 Atovaquone Antiprotozoals 1 Azacitidine Antineoplastic agents 5 Azelastine hydrochloride, fluticasone propionate Nasal preparations 2 Azithromycin Antibacterials for systemic use 1 Azithromycin dihydrate Antibacterials for systemic use 2 Bendamustine hydrochloride Antineoplastic agents 1 Betamethasone dipropionate, calcipotriol monohydrate Antipsoriatics 1 Bortezomib mannitol boronic ester Antineoplastic agents 1 Bosentan Antihypertensives 1 Brimonidine tartrate Ophthalmologicals 1 Bromfenac sodium sesquihydrate Ophthalmologicals 1 Bupropion hydrochloride Psychoanaleptics 1 Budesonide Antidiarrheals, intestinal anti-inflammatory/anti-infective agents 1 Buprenorphine hydrochloride, naloxone hydrochloride dihydrate Other nervous system drugs 1 Busulfan Antineoplastic agents 1 Caffeine Psychoanaleptics 2 Calcium polystyrene sulphonate All other therapeutic products 1 Canagliflozin Drugs used in diabetes 2 Carboprost tromethamine Other gynecologicals 1 Carvedilol Beta blocking agents 1 Cephalexin monohydrate Antibacterials for systemic use 1 Clobetasol propionate Corticosteroids, dermatological preparations 1 Clonidine hydrochloride Antihypertensives 1 Clozapine Psycholeptics 1 Colesevelam hydrochloride Lipid modifying agents 1 Cyclophosphamide Antineoplastic agents 1 Dantrolene sodium Muscle relaxants 1 Dapagliflozin Drugs used in diabetes 5 Dapagliflozin, metformin hydrochloride Drugs used in diabetes 1 Dasatinib Antineoplastic agents 2 Deferasirox All other therapeutic products 7 Degarelix acetate Endocrine therapy 1 Desvenlafaxine succinate Psychoanaleptics 1 Diltiazem hydrochloride Calcium channel blockers 1 Divalproex sodium Antiepileptics 1 Docetaxel Antineoplastic agents 1 Dolutegravir Antivirals for systemic use 1 Dorzolamide hydrochloride Ophthalmologicals 1 Dorzolamide hydrochloride, timolol maleate Ophthalmologicals 3 Doxepin hydrochloride Psychoanaleptics 2 Doxycycline Antibacterials for systemic use 1 Doxycycline hyclate Antibacterials for systemic use 1 Dutasteride Urologicals 1 Efinaconazole Antifungals for dermatological use 7 Eombopag olamine Antihemorrhagics 1 Empagliflozin Drugs used in diabetes 3 Empagliflozin, metformin hydrochloride Drugs used in diabetes 1 Enzalutamide Endocrine therapy 2 Eslicarbazepine acetate Antiepileptics 1 Ethinyl estradiol, etonogestrel Other gynecologicals 1 Ethinyl estradiol, levonorgestrel Sex hormones and modulators of the genital system 1 Etomidate Anesthetics 1 Everolimus Antineoplastic agents 2 Febuxostat Antigout preparations 1 Felodipine Calcium channel blockers 1 Fingolimod hydrochloride Immunosuppressants 1 Fludrocortisone 21-acetate Corticosteroids for systemic use 1 Fluoxetine hydrochloride Psychoanaleptics 1 Fondaparinux sodium Antithrombotic agents 1 Fulvestrant Endocrine therapy 2 Furosemide Diuretics 2 Fusidic acid Antibiotics and chemotherapy for dermatological use 1 Gefitinib Antineoplastic agents 1 Glatiramer acetate Immunostimulants 1 Glycopyrrolate Drugs for functional gastrointestinal disorders 2 Guanfacine hydrochloride Antihypertensives 2 Hydrochlorothiazide, olmesartan medoxomil Agents acting on the renin-angiotensin system 1 Hydromorphone hydrochloride Analgesics 1 Hydroxychloroquine sulfate Antiprotozoals 1 Ibrutinib Antineoplastic agents 3 Icatibant acetate Other hematological agents 4 Ipratropium bromide Drugs for obstructive airway diseases 1 Ketamine hydrochloride Anesthetics 1 Ketorolac tromethamine Antiinflammatory and antirheumatic products 3 Labetalol hydrochloride Beta blocking agents 1 Latanoprost Ophthalmologicals 1 Lenalidomide Immunosuppressants 1 Lenalidomide hydrochloride Immunosuppressants 1 Letrozole Endocrine therapy 1 Levetiracetam Antiepileptics 2 Levothyroxine sodium Thyroid therapy 1 Linagliptin Drugs used in diabetes 3 Linagliptin, metformin hydrochloride Drugs used in diabetes 1 Lisdexamfetamine dimestylate Psychoanaleptics 3 Lurasidone hydrochloride Psycholeptics 6 Macitentan Antihypertensives 4 Melphalan hydrochloride Antineoplastic agents 1 Metformin hydrochloride Drugs used in diabetes 2 Metformin hydrochloride, sitagliptin Drugs used in diabetes 2 Metformin hydrochloride, sitagliptin hydrochloride monohydrate Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin malate Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin phosphate Drugs used in diabetes 1 Metformin hydrochloride, sitagliptin phosphate monohydrate Drugs used in diabetes 3 Methadone hydrochloride Other nervous system drugs 1 Methotrexate Antineoplastic agents 1 Methylphenidate hydrochloride Psychoanaleptics 2 Micafungin sodium Antimycotics for systemic use 1 Milrinone Cardiac therapy 1 Mitomycin Antineoplastic agents 1 Nadolol Beta blocking agents 1 Naloxegol Drugs for constipation 1 Naloxone hydrochloride All other therapeutic products 1 Naexone hydrochloride Other nervous system drugs 1 Nebivolol hydrochloride Beta blocking agents 1 Nifedipine Calcium channel blockers 1 Nintedanib Antineoplastic agents 1 Nintedanib esilate Antineoplastic agents 1 Ofloxacin Ophthalmologicals 1 Ondansetron hydrochloride dihydrate Antiemetics and antinauseants 2 Oseltamivir phosphate Antivirals for systemic use 2 Oxaliplatin Antineoplastic agents 1 Paliperidone Psycholeptics 1 Paliperidone palmitate Psycholeptics 3 Pazopanib Antineoplastic agents 1 Pemetrexed disodium Antineoplastic agents 1 Perampanel Antiepileptics 1 Perindopril erbumine Agents acting on the renin-angiotensin system 1 Plerixafor Immunostimulants 1 Pomalidomide Immunosuppressants 6 Posaconazole Antimycotics for systemic use 1 Propofol Anesthetics 1 Ranitidine Drugs for acid related disorders 1 Rasagiline mesylate Anti-Parkinson drugs 1 Riociguat Antihypertensives 1 Risperidone Psycholeptics 1 Ritonavir Antivirals for systemic use 1 Rivaroxaban Antithrombotic agents 7 Sapropterin dihydrochloride Other alimentary tract and metabolism products 1 Sevoflurane Anesthetics 1 Silodosin Urologicals 1 Sitagliptin Drugs used in diabetes 2 Sitagliptin hydrochloride Drugs used in diabetes 1 Sitagliptin malate Drugs used in diabetes 2 Sitagliptin phosphate Drugs used in diabetes 2 Sitagliptin phosphate monohydrate Drugs used in diabetes 2 Sulfamethoxazole, trimethoprim Antibacterials for systemic use 1 Sumatriptan succinate Analgesics 1 Sunitinib Antineoplastic agents 2 Sunitinib malate Antineoplastic agents 3 Tacrolimus Immunosuppressants 2 Tamsulosin hydrochloride Urologicals 1 Teriflunomide Immunosuppressants 10 Thiotepa Antineoplastic agents 2 Ticagrelor Antithrombotic agents 3 Timolol maleate Ophthalmologicals 1 Tizanidine hydrochloride Muscle relaxants 1 Tofacitinib Immunosuppressants 1 Tofacitinib citrate Immunosuppressants 3 Tolvaptan Diuretics 1 Trabectedin Antineoplastic agents 1 Treprostinil Antithrombotic agents 1 Valproic acid Antineoplastic agents 1 Varenicline tartrate Other nervous system drugs 2 Venlafaxine hydrochloride Psychoanaleptics 1 Voriconazole Antimycotics for systemic use 1 Vortioxetine hydrobromide Psychoanaleptics 2Today, the World Health Organization (WHO) issued an emergency use listing (EUL) for COVAXIN® (developed by Bharat Biotech), adding to a growing portfolio of treatments validated by WHO for the prevention of hair loss treatment caused by hair loss.WHO’s EUL procedure assesses the quality, safety and efficacy of hair loss treatments and is a prerequisite for COVAX treatment supply. It also allows countries to expedite their own regulatory approval to import and administer hair loss treatments. €œThis emergency use listing expands the availability of treatments, the most effective medical tools we have to end the propecia,” said Dr Mariângela Simão, WHO Assistant-Director General for Access to Medicines and Health Products.

€˜But we must keep up the pressure to meet the needs of all populations, giving priority to the at-risk groups who are still waiting for their first dose, before we can start declaring victory.” COVAXIN® was assessed under the WHO EUL procedure based on the review of data on quality, safety, efficacy, a risk management plan and programmatic suitability. The Technical Advisory Group (TAG), convened by WHO and made up of regulatory experts from around the world, has determined that the treatment meets WHO standards for protection against hair loss treatment, that the benefit of the treatment far outweighs risks and the treatment can be used globally.The treatment is formulated from an inactivated hair loss antigen and is presented in single dose vials and multidose vials of 5, 10 and 20 doses.COVAXIN® was also reviewed on 5 October by WHO’s Strategic Advisory Group of Experts on Immunization (SAGE), which formulates treatment specific policies and recommendations for treatments’ use in populations (i.e. Recommended age groups, intervals between doses, specific groups such as pregnant and lactating women). The SAGE recommended use of the treatment in two doses, with a dose interval of four weeks, in all age groups 18 and above.

COVAXIN® was found to have 78% efficacy against hair loss treatment of any severity, 14 or more days after the second dose, and is extremely suitable for low- and middle-income countries due to easy storage requirements. Available data from clinical trials on vaccination of pregnant women are insufficient to assess treatment safety or efficacy in pregnancy. However, initial studies were reassuring. The treatment has been given to over 120 000 pregnant women in India, with no short-term adverse effects noted.

Further studies in pregnant women are planned. WHO emergency use listing The emergency use listing (EUL) procedure assesses the suitability of novel health products during public health emergencies. The objective is to make medicines, treatments and diagnostics available as rapidly as possible to address the emergency while adhering to stringent criteria of safety, efficacy and quality. The assessment weighs the threat posed by the emergency as well as the benefit that would accrue from the use of the product against any potential risks.The EUL pathway involves a rigorous assessment of late phase II and phase III clinical trial data, as well as substantial additional data on safety, efficacy, quality and a risk management plan.

These data are reviewed by independent experts and WHO teams who consider the current body of evidence on the treatment under consideration, the plans for monitoring its use, and plans for further studies.As part of the EUL process, the company producing the treatment must commit to continue to generate data to enable full licensure and WHO prequalification of the treatment. The WHO prequalification process will assess additional clinical data generated from treatment trials and deployment on a rolling basis to ensure the treatment meets the necessary standards of quality, safety and efficacy for broader availability.See all EUL listingsSAGESAGE is the principal advisory group to WHO for treatments and immunization. It is charged with advising WHO on overall global policies and strategies, ranging from treatments and immunization technology, research and development, to delivery of immunization and its linkages with other health interventions. SAGE is concerned not just with childhood treatments and immunization, but all treatment-preventable diseases.SAGE assesses evidence on safety, efficacy, effectiveness, impact and programmatic suitability, considering both individual and public health impact.

SAGE Interim recommendations for EUL products provide guidance for national vaccination policy makers. These recommendations are updated as additional evidence becomes available and as there are changes to the epidemiology of disease and the availability of additional treatments and other disease control interventions.See Sage interim recommendations.