Contains 2 folders and 55 resources
The current study was commissioned to inform decisions about the future commissioning of mental health services in Nottingham City to meet LGBT people’s needs.
The current study was commissioned to inform decisions about the future commissioning of mental health services in Nottingham City to meet LGBT people’s needs.
This Evidence Summary presents an overview of the health and wellbeing needs in Nottingham City using the key findings from Nottingham City's Joint Strategic Needs Assessment. Joint Strategic Needs Assessments (JSNAs) are local assessmentsof current and future health and social care needs. The aim of the JSNA is to improve the health and wellbeing of the local community and reduce inequalities for all ages through ensuring commissioned services reflect need. It is used to help to determine what actions local authorities, the NHS and other partners need to take to meet health and social care needs and to address the wider determinants that impact on health and wellbeing. Nottingham City's JSNA contains over 40 chapters each considering a particular health and social care issue or the health and social care needs of specific groups. The full JSNA can be accessed at www.nottinghaminsight.org.uk. It is only possible to present a brief overview of this information in this Evidence Summary and so it should be used in conjunction with the full JSNA.
This chapter considers Nottingham's population and how demographic, social and environmental factors impact on the health and wellbeing of its residents and influence the needs and demand for health and social care services. It also considers the impact of estimated population changes in the future. Where these factors relate to specific health and wellbeing issues, they are addressed within the relevant chapters in the body of the JSNA.
This chapter considers the impact of housing on health, in particular physical housing conditions and the relationship between cold homes and cold related mortality and illness among vulnerable people. This joint strategic needs assessment (JSNA) identifies the strategic, policy and commissioning needs that will reduce the impact of poor quality homes on negative health outcomes including excess winter deaths (EWDs) and cold-related harms in Nottingham.
Severe Multiple Disadvantage (SMD) refers to people with two or more of the following issues: mental health issues, homelessness, offending and substance misuse. SMD can include other sources of disadvantage, for instance poor physical health, and for women, domestic and sexual abuse - and for Black, Asian and Minority Ethnic (BAME) people, community isolation. Nottingham has the 8th highest prevalence of SMD in England - currently it is estimated that over 5,000 of the City’s citizens experience SMD.
Sexual health is defined by the World Health Organisation as: ‘a state of physical, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled’.
Smoking remains the single largest preventable cause of early death in the UK and worldwide. Half of all lifelong smokers will die prematurely, usually about 10 years younger than non-smokers. The main causes of death from smoking are heart disease and strokes, lung cancer and chronic obstructive pulmonary disease (COPD).
Air pollution is the top environmental risk to human health. In the UK it is ranked as the fourth greatest threat to public health after cancer, heart disease and obesity, and is a contributory factor to heart disease and some types of cancer. Human-made air pollution comes from a range of different sources including agriculture, industrial, commercial and domestic activities, and transport. Emissions from road traffic are one of the largest contributors to ambient air pollution in urban areas. Long-term exposure to air pollution, at the levels experienced in many urban centres in the UK, including Nottingham, causes respiratory and cardiovascular disease and lung cancer. It has also has been linked to other cancers. In children, air pollution reduces lung development and function and can lead to the development of asthma. Short-term exposure to elevated levels of air pollution leads to a worsening of symptoms for those with existing asthma, respiratory or cardiovascular diseases, and can trigger acute eve
Pregnancy is a particularly important period during which the physical and mental wellbeing of the mother can have lifelong impacts on the child. For example, during pregnancy, factors such as maternal stress, smoking, diet and alcohol or drug misuse can place a child's future development at risk. A wide range of research now shows that conception to age 2 is a crucial phase of human development and is the time when focused attention can reap great dividends for society.
Suicide prevention is a public health priority both nationally and locally, with a role for a wide range of statutory and community organisations. The national strategy Preventing Suicide in England was refreshed in 2017 following a detailed Health Select committee process. The strategy now aims to reduce suicide rates by 10%. Nottingham City has a Suicide Prevention Strategy and works in partnership with organisations across the City and County with the aim of reducing levels of suicide.
Dementia encompasses a range of brain disorders resulting in a progressive and severe loss of brain function. It affects over 5% of people over 65. The number of people living with dementia in Nottingham will reach over 4,000 by 2035, almost doubling from 2017. Dementia has superseded cardiovascular disease as the leading cause of death. This needs analysis considers dementia of all causes. There is significant overlap with the Carers and Care Homes JSNAs, and there is signposting to these where appropriate. The Department of HealthÂ¿s Living Well With Dementia (2009) strategy on dementia provides a framework through which this needs analysis will be conducted. The Prime MinisterÂ¿s Challenge on Dementia 2020 requires action on 5 themes: global leadership, risk reduction, healthcare, social action and research.
Oral health is an important part of general health and wellbeing and should not be considered in isolation. Whilst there have been welcome improvements in the oral health of children in England, significant inequalities remain. Oral disease can have detrimental effects on an individualÂ¿s physical and psychological well-being and reduces quality of life.
Safeguarding is everyoneÂ¿s responsibility. All partners have a duty to safeguard children and young people who are at risk of abuse, neglect and/or exploitation. Abuse can be physical, sexual and/or emotional. Neglect is the ongoing failure to meet a child's basic needs. Exploitation includes child sexual exploitation (CSE), trafficking and/or modern slavery.
This chapter considers women and girls resident in Nottingham City who are at risk of or who have undergone Female Genital Mutilation (FGM), either in the UK or abroad. Female Genital mutilation can affect women of all ages, however FGM is mostly carried out on girls sometime between infancy and adolescence. FGM is a form of child abuse and is illegal in the UK and is described by the World Health Organisation as: `all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non -medical reasonsÂ¿.
The term `teenage pregnancy' includes under-18 conceptions that lead to a legal termination of pregnancy or birth. Teenage pregnancy is an issue of inequality as early parenthood is associated with poor health, wellbeing and wider life chances such as education and economic outcomes as well as increased levels of social exclusion, for both teenage parents and their children (Hadley, Chandra-Mouli and Ingham et al. 2016).
This assessment examines end of life care in Nottingham City which encompasses the holistic assessment and management of the full range of physical, psychological, social, spiritual, cultural and environmental needs of patients and their families and carers in their place of choice, during the last years, months or days of life and after death. End of life care focused on achieving quality of life for patients and their families, friends and carers is provided by a range of people including informal carers, medical, nursing and other health and social care professionals and within a range of settings including peopleÂ¿s homes, hospitals, hospices, palliative care units and care homes. End of life care provision must be person-centred and coordinated and commissioning should place citizens at the heart of its approach.
Children and young people who have special educational needs (SEN) experience significant barriers to learning but do not necessarily have a disability. Children and young people with disabling conditions do not necessarily have SEN, however, there is a significant overlap between disabled children and young people and those with SEN. Porter et al (2008) estimate that approximately three-quarters of `disabled' children are also identified as SEN. The number of disabled children (0-18) in England is estimated to be between 288,000 and 513,000 (Porter et al 2008). The mean percentage of disabled children in English local authorities has likewise been estimated to be between 3.0% and 5.4%. This estimate is based on a 2008 study which has not been repeated and thus may underestimate `true' numbers given demographic changes in the population such as an increase in neonatal survivors and inward migration of children with disabilities.
Defining obesity: Obesity is 'a term used to describe somebody who is very overweight, with a lot of body fat' (NHS Choices 2014). The World Health Organisation's (WHO's) definition of overweight and obesity is 'abnormal or excessive fat accumulation that may impair health'. (WHO 2015) These definitions are important as they indicate what to measure when investigating obesity. This chapter provides information about obesity in Nottingham in relation to the national picture.
Cardiovascular disease (CVD) includes coronary heart disease (CHD), stroke and peripheral arterial disease. These conditions are frequently brought about by the development of atheroma and thrombosis (blockages in the arteries). This chapter covers issues relating to cardiovascular disease risk and overall mortality, CHD and heart failure.
This JSNA chapter focuses on these leading and most common causes of musculoskeletal morbidity and mortality: low back and neck pain and osteoarthritis. It excludes osteoporosis and fracture as this is covered in the separate JSNA chapter `Falls and Bone HealthÂ¿[v]. Rheumatoid arthritis and MSK pain or damage as a result of trauma are also excluded, since in Nottingham these follow slightly different patient pathways and these conditions are less prevalent than neck and back pain, and osteoarthritis.
Mental wellbeing has been defined by the World Health Organisation (WHO) as 'a state of wellbeing in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community' (WHO, 2014).
One of the most important foundations for building caring, productive and healthy families and communities is the nurturing of children in early life. For this reason, helping children get a better start is both good for them and good for society.The first five years of a child's life are critical to their future development and opportunities. There is mounting evidence that shows the benefits and cost effectiveness of focusing on the development and health of infants and children. Conception to age two has been described as a crucial phase of human development and is the time when focused attention can reap great dividends for society.
University students make up a significant proportion of Nottingham City's population and are increasing in number. Their health needs have been assessed in partnership with the two universities and associated healthcare commissioners. The scope of this chapter covers students studying at either The University of Nottingham or Nottingham Trent University in full time or part time undergraduate and postgraduate `higher' education on any University campus across the city and county. It includes students from the UK and overseas, those who originate from Nottingham and those who have moved to Nottingham to study. Students at the China and Malaysian campuses of the University of Nottingham are not included in this work.
Drug misuse is associated with a range of psychological, physical and social issues and addressing these remain a key national and local priority. Whilst solid progress has been made in improving the impact of drug misuse, the changing nature of drug misuse represents further challenges for the City. This JSNA chapter describes local need in relation to drug misuse, outlines services in place to address misuse issues in adults and also identifies unmet needs and gaps in provision. This JSNA chapter focuses on drug misuse in adults.
Migrants are a diverse group consisting of those who migrate for work, education, family, socio-political reasons, persecution and war. The health needs of the migrant population are very heterogeneous, reflecting the great diversity of where people come from, the circumstances of their migration and the environment in which they live post migration. What is an Asylum Seeker? An asylum seeker is someone who has applied for protection through the legal process of claiming asylum and is waiting for a decision as to whether or not they are a refugee. In other words, in the UK an asylum seeker is someone who has asked the Government for refugee status and is waiting to hear the outcome of their application. What is a Refugee? A refugee is a person who: 'owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country'
Falls and fall-related injuries are a common and serious problem for older people. People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year. The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falling also affects the family members and carers of people who fall. Falls are estimated to cost the NHS more than Â£2.3 billion per year. Therefore falling has an impact on quality of life, health and healthcare costs.
The term 'Excess Winter Deaths' (EWD) describes the additional number of people who die in winter compared with the spring summer and autumn months. The Excess Winter Death Index (EWDI) explains EWD as a proportion of the expected deaths based on the number of non-winter deaths (commonly expressed as a percentage). EWD are affected by a variety of aspects through each level. A higher excess winter mortality rate is found in the UK than in many European countries which experience colder winters. Out of the total population of 330,734 in Nottingham, an average of 3,000 people died per year between 2007/8 and 2012/13. Of those, an average 140 were excess winter deaths. Public Health Mortality Files ONS (2015). A full list of the groups of people at greater risk of harm from cold weather, are identified in the main section.
Despite great improvements in air quality in the UK since the Clean Air Act of 1956, current background levels of air pollution still pose a significant risk to health. Long term exposure to air pollution at the levels experienced in many urban centres in the UK is now known to cause respiratory and cardiovascular disease and lung cancer. Short term exposure to episodes of elevated air pollution also leads to a worsening of symptoms for those with existing asthma, respiratory or cardiovascular disease, and can trigger acute events such as heart attacks in vulnerable individuals. This has been superseded by Air Quality and Health (2019) - Nottingham City JSNA.
Good mental and emotional health is essential to enable children and young people to fulfil their potential. Mental and emotional health problems are an important and common group of disorders affecting about 1 in 10 children and young people living in the UK. Mental health is best seen as a continuum, ranging from mental wellbeing, to severe and enduring mental disorders that cause considerable distress and interfere with relationships and daily functioning. Mental health problems vary in their nature and severity, and affect individuals differently over time. The factors that affect mental and emotional health are complex, ranging from individual biological factors to complex societal issues. Mental health conditions in childhood and adolescence are particularly important due to the far reaching consequences on health, social and educational outcomes. Mental health problems unlike other health problems tend to start early and persist into and throughout adulthood. It is recognised that by the age of 14 about half of all lifetime mental health problems start. This highlights the long term nature of mental illness and the importance of intervening early to prevent mental illness alongside early recognition and treatment.
Viral hepatitis is inflammation of the liver due to a viral infection. There are several types of hepatitis viruses including types A, B, C, D and E. Hepatitis B and C are known as blood borne viruses (BBVs) as they are spread via blood or other body fluids. They can both result in chronic disease which can lead to liver cirrhosis and failure. This can lead to considerable cost to the individualÂ¿s health and cost to health care services.
According to the Health and Social Care Act 2008 a care home is a place where personal care and accommodation are provided together. People may live in the service for short or long periods. For many people, it is their sole place of residence and so it becomes their home, although they do not legally own or rent it. Both the care that people receive and the premises are regulated. In addition, in care home services with nursing, qualified nursing care is provided, to ensure that the full needs of the person using the service are met.
Immunisation is, after clean water, the most effective public health intervention in the world for saving lives and promoting good health. It is the process of protecting individuals from infection through passive or active immunity and protects individuals and the population against serious diseases. If a person is not immunised, they will be at risk from catching the disease and will rely on other people being immunised to avoid becoming infected. If people choose not to be immunised, then the number of people at risk of catching a disease will increase and outbreaks of the disease will occur. Low uptake of immunisations puts others at risk and when there is herd immunity of less than the recommended percentage uptake for public protection.
These families are defined as those where there are a wide range of social, educational, financial and other issues affecting both children and adults, leading to poor outcomes (including, but not restricted to, poor health and wellbeing outcomes) for all members of the families, and intense use of resources across all partners with low chance of improvement.
Health inequalities are endemic in our society. Where a person is born still influences how long they will live. This is fundamentally unfair and unacceptable. Our vision is to end health inequalities in our City. We will do this by using our resources to deliver equitable health outcomes for our CityÂ¿s residents. We will ensure that we focus effort on those disadvantaged communities with the highest health need. An overarching outcome measure of this inequality is life expectancy. Life expectancy is a useful indicator of the general state of health of the local population. It is the number of years that a person can expect to live on average in a given population. It is a commonly used summary measure based on death rates of the population in a given year. As this mortality rate changes over time, so will the life expectancy of an area.
This chapter focuses on those children in the care of Nottingham City Council, and for whom Nottingham City Council is the Corporate Parent. This chapter looks at children in care (CiC) and their identified needs, and examines the challenges these needs pose for Nottingham City Council as Corporate Parent. The chapter details the characteristics of children in care, placement types and outcomes. It also identifies key challenges and how these impact on commissioning arrangements/requirements of local authorities for the future.
Addressing the harm caused by alcohol is crucial to the improvement of public health and health inequalities. Reducing alcohol-related harm is one of the seven public health priorities and is considered key to achieving the National Health ServiceÂ¿s Five Year Forward View. The misuse of alcohol can take a range of forms and affects citizens across the range of demographics in Nottingham. Both short and longer-term health harms resulting from the misuse of alcohol and especially dependence on alcohol are responded to by the cityÂ¿s commissioned alcohol treatment model alongside primary and secondary care services. This Joint Strategic Needs Assessment (JSNA) identifies that, while solid progress has been made in improving the functioning of the commissioned model, there remains a substantial degree of need among the population. Where alcohol misuse intersects with other social and health issues there are also further public health concerns to be addressed. This JSNA chapter focuses on alcohol use in adults. A chapter on substance misuse in young people is also available. .
The child poverty chapter will no longer be updated as part of the Nottingham City JSNA.
Physical inactivity is a global public health problem. Promoting an active lifestyle is a simple answer to many of the big health challenges facing our country. Â¿Increasing physical activity has the potential to improve the physical and mental health of the nation, reduce all-cause mortality and improve life expectancy.Â¿ (Department of Health, 2011) The largest gains are demonstrated in those who go from doing nothing to doing something and so promoting physical activity can save the NHS money and significantly ease the burden of chronic disease on public services. It is everyoneÂ¿s responsibility to be creative in encouraging an increase in physical activity at all stages in life. These can be offered not just by sporting activity but also through a plethora of activities such as active travel, dance, gardening and encouraging use of exercise in a natural environment.
Avoidable injuries in children and young people (CYP) are a serious public health issue and a leading cause of death and hospital admission for children in the United Kingdom. Injuries put more children in hospital than any other cause. The impact and consequences of avoidable injuries are major contributors to health inequalities with children from the most disadvantaged backgrounds at significantly increased risk. The long term effect of an injury can be significant, both physically and emotionally, for children. They may experience: Â· Disability or impairment (short or long term) Â· Scarring or disfigurement Â· Ongoing hospital appointments and operations. Avoidable childhood injuries carry significant costs to the economy, the NHS and children and families. Admitting a child to hospital following avoidable injury in the home is estimated to cost Â£16,900. The same source puts the cost of a road traffic injury at three times this, in excess of Â£50,000. The NHS spends an estimated Â£131 m per year on emergency hospital admissions because of childhood injuries.
Diabetes Mellitus (DM) is a group of disorders that results from the bodyÂ¿s inability to control blood glucose levels. The raised blood glucose levels over time lead to damage to blood vessels and organs. It is a chronic disease which causes substantial premature morbidity and mortality, and imposes a heavy burden on health services.
Substance misuse can impact on both physical and emotional health. It can be associated with poor outcomes in relation to sexual health (including risk of teenage pregnancy), mental health, education, employment and training. Misuse is also associated with involvement in anti-social and criminal activity and can have a negative impact on family life. National findings suggest that most young people will experiment with substances as part of natural curiosity, but for some this experimentation will become problematic (Fuller, et al., 2013). Evidence suggests that drug use among young people in England has reduced over the last decade by approximately one third (Her Majesty's Government, 2010). However, the harms to young people associated with drug and alcohol misuse continue to raise concerns both nationally and locally.
Oral health was defined by the Department of Health (DH) in 1994 as the `standard of health of the oral and related tissues which enables an individual to eat, speak and socialise without active disease, discomfort or embarrassment and which contributes to general well-being' (DH, 1994). Oral health is integral to general health and should not be considered in isolation.
Domestic and sexual violence and abuse (DSVA) is a worldwide public health issue, which whilst affects both sexes, disproportionately affects women and girls. DSVA can lead to a variety of physical and mental health problems, including, but not limited to, fatal outcomes like homicide or suicide, physical injuries, unintended pregnancies, gynaecological problems, mental health problems including depression and posttraumatic stress. There are also wider social and economic consequences as a result of DSVA, such as isolation, restriction in ability to work and achieve financial independence. DSVA also results in wider costs to society and can lead to higher levels of smoking, substance misuse and alcoholism amongst survivors. The consequences experienced for the survivor themselves can be severe and long lasting, as well as the consequences for their families and children.
Stroke is one of the diseases of the arteries Â¿ these are known collectively as cardiovascular disease (CVD). A stroke is a type of brain injury which usually occurs without warning, cutting off the blood supply to part of the brain, depriving brain cells of oxygen. This chapter considers the epidemiology, diagnosis and treatment of stroke
Mental health problems are common, disabling and costly. In 2014, Nottingham Health and Wellbeing Board approved the Nottingham City Mental Health and Wellbeing Strategy, Wellness in Mind. Wellness in Mind brings together the vision for improved mental health and social inclusion across the life course under five priorities. 1. Promoting mental resilience and preventing mental health problems 2. Identifying problems early and supporting effective interventions 3. Improving outcomes through effective treatment and relapse prevention 4. Ensuring adequate support for those with mental health problems 5. Improving the wellbeing and physical health of those with mental health problems. The use of the term `mental health problem' mirrors that used in the National Strategy (DH2011) and is therefore used in this chapter as an umbrella term to describe the full range of diagnosable mental illnesses and disorders, including personality disorder.
Good nutrition has a key role to play in both the prevention and management of diet-related diseases such as cardiovascular disease (CVD), cancer, diabetes and obesity (World Health Organisation, 2003). A childÂ¿s diet during the early years has an impact on their growth and development. Diet is linked to the incidence of many common childhood conditions such as iron-deficiency anaemia, tooth decay and vitamin D deficiency (NICE 2015). Healthy eating during childhood and adolescence is vital as a means to ensure healthy growth and development and to set up a pattern of positive eating habits in order to reduce the risk of poor health in adult life.
Learning disability is defined as the presence of : a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence, often defined as an IQ level of 70 or less), with; a reduced ability to cope independently (impaired social functioning); which started before adulthood, with a lasting effect on development.
The causes of homelessness are complex. Reasons people become homeless involve societal structures (such as the economy, access to jobs and low cost housing), changing circumstances (such as relationship breakdown or leaving an institution) as well as personal factors (such as mental health issues, age, and substance dependency).
The Care Act 2014 defines a carer as anyone who provides any amount of unpaid care. Carers are Nottingham City's largest form of `early intervention', supporting the most vulnerable citizens and preventing the people they care for from requiring greater degrees of health and social care support. By supporting carers services are able to improve the carer's quality of life and support the cared-for citizens to remain in their own homes, maintain independence and reduce their incidences of requiring hospital admissions and residential care. The greatest opportunities to improve carers' quality of life are through improving early identification, assessment and support, with recognition of the huge value that carers provide to health and social care. A key aspect of this is providing joined up support from Health and Social Care. Demand for health and social care support is expected to rise over the next 20 years, due to a range of factors including an ageing population, and an increase in the number of people living with a limiting life long illness or disability. There are approximately 27,000 carers in Nottingham City (2011 Census data) approximately 3,300 of whom are under 25 years old. Carers often don't identify themselves as such, therefore the number of carers identified through the Census is likely to be a significant under-estimation. Around 1,140 Carers Assessments were carried out in 2015/16 which represents a small proportion of the carers in Nottingham City.
Cancer is a disease caused by normal cells changing so that they grow in an uncontrolled way. There are more than 200 different types of cancer. Cancer is now one of the biggest health challenges in the UK with one in three people expected to develop some form of cancer in their lifetime. Approximately 308,000 new cases of cancer are diagnosed each year in the UK with the most common cancers being breast, lung, colorectal and prostate cancers (Cancer Research UK, 2012). In Nottingham, there were 1,259 new cases in 2012.
This chapter considers Physical and Sensory Impairment (PSI) in adults aged 18-64. Defining disability is complex and contentious. The 'social model' and the 'medical model' define two distinct models. The Government encourages the use of the social model which states that disability is created by barriers in society including the environment, people's attitudes and organisations. The medical model, in contrast, is based on a belief that disability is caused by an individual's health condition or impairment (HM Government, 2015). Most analysis tends to use limiting longstanding illness as the core definition although it should be recognised that limiting longstanding illness covers limitation at any level on activities of any kind whereas disability covers a specified set of activities, therefore prevalence of longstanding limiting illness is higher than disability (Public Health Action Support Team, 2011).
Nottingham City's children have the second worst record in England (and the worst in the East Midlands) for decayed missing and filled teeth (dmft) in the biannual national survey of 5 year olds in schools. Intermittent surveys for other ages up to 14 show similar poor oral health. As well as the obvious problems of pain or infection, poor oral health is associated with low weight and failure to thrive in infancy. Poor dental hygiene may persist into adult hood when periodontal disease is associated with heart disease, which is reversible if oral health improves. Poor maternal oral health is also associated with premature birth.
Chronic obstructive pulmonary disease (COPD) describes a collection of diseases that affect the lungs. These include chronic bronchitis and emphysema. Emphysema affects the alveoli (air sacs), and chronic bronchitis affects the bronchi (airways). Some citizens with COPD will have one of these conditions, whilst others will have more than one. COPD usually develops because of long-term damage to the lungs from breathing in harmful substances, such as cigarette smoke or chemical fumes. The most common cause of COPD is smoking tobacco (British Thoracic Society 1997). For information on smoking, see the separate smoking chapter