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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Tensions and opportunities in social prescribing. Developing a framework to facilitate its implementation and evaluation in primary care: a realist review
Background: Social prescribing (SP) involves linking patients in primary care with services provided by the voluntary and community sector (VCS). Despite growing interest within NHS primary care, it remains unclear how and under what circumstances SP might contribute to good practice. Aim: To define ‘good’ practice in SP by identifying context-specific enablers and tensions. To contribute to the development of an evidence-based framework for theorising and evaluating SP within primary care. Design & setting: Realist review of secondary data from primary care-based SP schemes. Method: Academic articles and grey literature were searched for qualitative and quantitative evidence following the Realist And Meta-narrative Evidence Syntheses — Evolving Standards (RAMESES). Common SP practices were characterised in three settings (general practice, link workers, and community sector) using archetypes that ranged from best to worst practice. Results: A total of 140 studies were included for analysis. Resources were identified influencing the type and potential impact of SP practices and four dimensions were outlined in which opportunities for good practice arise: 1) individual characteristics (stakeholder’s buy-in, vocation, and knowledge); 2) interpersonal relations (trustful, bidirectional, informed, supportive, and transparent and convenient interactions within and across sectors); 3) organisational contingencies (the availability of a predisposed practice culture, leadership, training opportunities, supervision, information governance, resource adequacy, accessibility, and continuity of care within organisations); and 4) policy structures (bottom-up and coherent policymaking, stable funding, and suitable monitoring strategies). Findings were synthesised in a multilevel, dynamic, and usable SP framework. Conclusion: The realist review and resulting framework revealed that SP is not inherently advantageous. Specific individual, interpersonal, organisational, and policy resources are needed to ensure SP best practice in primary care.
Evaluating complex interventions in context: systematic, meta-narrative review of case study approaches
Background: There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research. Methods: Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing ‘hybrid papers’ (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions. Results: We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently—respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of ‘the case’ and ‘context’ or considered the implications of such conceptualisations for methods and knowledge production. Conclusions: Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.
What happens after James Lind Alliance Priority Setting Partnerships? A qualitative study of contexts, processes and impacts
Background: The James Lind Alliance (JLA) supports priority setting partnerships (PSPs) in which patients, carers and health professionals collaborate to identify a Top 10 list of research priorities. Few studies have examined how partnerships plan for the post-prioritisation phase, or how context and post-PSP processes influence the fortunes of priorities. This evaluation aimed to explore these questions. Methods: We selected a diverse sample of 20 interviewees who had knowledge of 25 PSPs. Thirteen interviewees had led a PSP, either from a university, patient organisation or charity. Three were patients who had taken part in a PSP workshop. Four others, three researchers and one funder, had worked with JLA PSP priorities to develop research proposals. We analysed the data thematically, exploring how success was understood and achieved. Results: The JLA PSPs had different histories, funding sources, goals and stakeholders. Whilst their focus was on generating priority research topics, PSPs' wider impacts included enhanced status and greater confidence for individuals, as well as relationship-building and network strengthening for the organisations involved. To follow through on a Top 10, additional work was needed to refine broad priority topics into research questions and match them with appropriate funding sources. Commitment to post-PSP action from partners appeared to increase the chance that priority topics would be followed through to funded studies. Academic publications could alert researchers to a PSP's outputs, but not all PSPs had the capacity to produce them. A Top 10 list potentially influences funding decisions through direct funding, themed calls or as a prompt in open calls. Influence on funders appears to depend on alignment between a priority and the funder's remit, culture and values. Conclusion: The history and context of a JLA PSP have a major influence on its impact. Our findings suggest that there is no universal formula for success, but that greater resource and attention should be given to what happens after prioritisation. Further research is needed on what works best in what circumstances. Overall, we conclude that a wider cultural change in the research world is needed for JLA PSPs to achieve their goal of shaping the research agenda.
What is the Efficacy and Safety of Rapid Exercise Tests for Exertional Desaturation in Covid-19: A Rapid Systematic Review
Abstract BackgroundEven when resting pulse oximetry is normal in the patient with acute Covid-19, hypoxia can manifest on exertion. We sought to summarise the literature on the performance of different rapid tests for exertional desaturation. Main research questionWhat tests have been formally evaluated for the rapid assessment of exertional hypoxia in patients with lung disease against a gold standard exercise test such as the 6MWT and CPET? MethodAMED, CINAHL, EMBASE MEDLINE, Cochrane and PubMed using LitCovid, Scholar and Google databases were searched to September 2020. Studies where participants had Covid-19 or another lung disease and underwent any form of exercise test which was compared to a reference standard were eligible. Risk of bias was assessed using QUADAS 2. Heterogeneity of study design precluded meta-analysis. ResultsOf 47 relevant papers, 15 were empirical studies, of which 11 described an attempt to validate one or more exercise desaturation tests in lung diseases other than Covid-19. In all but one of these, methodological quality was poor or impossible to fully assess. None had been designed as a formal validation study (most used simple tests of correlation). Only one validation study (comparing a 1-minute sit-to-stand test [1MSTST] with the reference standard 6-minute walk test [6MWT] in 107 patients with interstitial lung disease) contained sufficient raw data for us to calculate the sensitivity (88%), specificity (81%), and positive and negative predictive value (79% and 89% respectively) of the 1MSTST. The other 4 empirical studies included two predictive studies on patients with Covid-19, and two on HIV-positive patients with suspected pneumocystis pneumonia. We found no studies on the 40-step walk test (a less demanding test that is widely used in clinical practice to assess Covid-19 patients). DiscussionExertional desaturation tests have not yet been validated in patients with (or suspected of having) Covid-19. Whilst there is limited evidence for the diagnostic accuracy of the 1MSTST in other diseases, specific features of this disease (e.g. exertional hypoxia is common and many assessments are done remotely with no clinician present to resuscitate) may raise safety issues. The less strenuous 40-step walk test should be urgently evaluated.
What items should be included in an early warning score for remote assessment of suspected COVID-19? qualitative and Delphi study
Background To develop items for an early warning score (RECAP: REmote COVID-19 Assessment in Primary Care) for patients with suspected COVID-19 who need escalation to next level of care. Methods The study was based in UK primary healthcare. The mixed-methods design included rapid review, Delphi panel, interviews, focus groups and software development. Participants were 112 primary care clinicians and 50 patients recovered from COVID-19, recruited through social media, patient groups and snowballing. Using rapid literature review, we identified signs and symptoms which are commoner in severe COVID-19. Building a preliminary set of items from these, we ran four rounds of an online Delphi panel with 72 clinicians, the last incorporating fictional vignettes, collating data on R software. We refined the items iteratively in response to quantitative and qualitative feedback. Items in the penultimate round were checked against narrative interviews with 50 COVID-19 patients. We required, for each item, at least 80% clinician agreement on relevance, wording and cut-off values, and that the item addressed issues and concerns raised by patients. In focus groups, 40 clinicians suggested further refinements and discussed workability of the instrument in relation to local resources and care pathways. This informed design of an electronic template for primary care systems. Results The prevalidation RECAP-V0 comprises a red flag alert box and 10 assessment items: pulse, shortness of breath or respiratory rate, trajectory of breathlessness, pulse oximeter reading (with brief exercise test if appropriate) or symptoms suggestive of hypoxia, temperature or fever symptoms, duration of symptoms, muscle aches, new confusion, shielded list and known risk factors for poor outcome. It is not yet known how sensitive or specific it is. Conclusions Items on RECAP-V0 align strongly with published evidence, clinical judgement and patient experience. The validation phase of this study is ongoing. Trial registration number NCT04435041.
Twitter Women’s Tips on Academic Writing: A Female Response to Gioia’s Rules of the Game
This article, intended in a spirit of good humor, offers a critique of a paper by Gioia on how to get published. Based on a social media discussion to which 46 women academics from around the world contributed, we ask whether the recommendations in Gioia’s original paper are based on gendered assumptions and stereotypes (the “lone wolf” male academic competing with colleagues for a slot in a prestigious journal). Drawing on feminist scholars such as Mary Wollstonecraft (“Virtue can only flourish among equals”), we offer some additional recommendations which emphasize the importance of reflection, collaboration, acceptance of ambiguity, attention to audience and context, and nurturing self and others.
Knowing in general dental practice: Anticipation, constraint, and collective bricolage
Rationale, aims, and objectives: Much of the literature concerned with health care practice tends to focus on a decision-making model in which knowledge sits within the minds and bodies of health care workers. Practice theories de-centre knowledge from human actors, instead situating knowing in the interactions between all human and non-human actors. The purpose of this study was to explore how practice arises in the moment-to-moment interactions between general dental practitioners (GDPs), patients, nurses, and things. Method: Eight GDPs in two dental practices, their respective nurses, 23 patients, and material things were video-recorded as they interacted within clinical encounters. Videos were analysed using a performative approach. Several analytic methods were used: coding of interactions in-video; pencil drawings with transcripts; and dynamic transcription. These were used pragmatically and in combination. Detailed reflective notes were recorded at all stages of the analysis, and, as new insights developed, theory was sought to help inform these. Results: We theorized that knowing in dental practice arises as actors translate embodied knowing through sayings and doings that anticipate but cannot predict responses, that knowing is constrained by the interactions of the practice but that the interactions at the same time are a collective bricolage—using the actors' respective embodied knowing to generate and solve problems together. Conclusion: Practices are ongoing ecological accomplishments to which people and things skilfully contribute through translation of their respective embodied knowing of multiple practices. Based on this, we argue that practices are more likely to improve if people and things embody practices of improvement.
How to improve success of technology projects in health and social care
Technologies are often viewed as the route to better, safer and more efficient care, but technology projects rarely deliver all the anticipated benefits. This is usually because they are too complex - and because the complexity is suboptimally handled. This article summarises a new framework to improve the success of technology projects: the nonadoption, abandonment, scale-up, spread and sustainability (NASSS) framework. The framework is based on a narrative systematic review and empirical work, and addresses the different domains in technology projects and how different aspects of complexity may be handled in each of them.
Unfulfilled potential of primary care in Europe
The Alma Ata declaration's compelling vision of health for all will not be realised until we take community level prevention seriously, argue Luke Allen and colleagues.
Moral uncertainty: A case study of Covid-19
Background: Most writing about uncertainty in healthcare has addressed empirical uncertainty – that is, resulting from insufficient or conflicting facts. Objective: To consider moral uncertainty by exploring how different theories apply to a single clinical case. Method: In this philosophical reflection, I briefly acknowledge empirical uncertainty before introducing and exploring the topic of moral uncertainty – defined as the question of what to do when we do not know what (morally) to do—using a case study of my own mother's deterioration and death from Covid-19. Results: I identify and apply a number of philosophical theories relevant to managing moral uncertainty, including utilitarianism, deontology, practical rationality and feminist philosophy. Conclusion: Different moral theories lead to different conclusions about the best course of action in situations of moral uncertainty. Practice implications: Detailed analysis and close reading of a single case can provide insights into how to act in morally complex situations, but learning is in the form of enriched understanding, not formulaic rules.
Twitter Analytics to Inform Provisional Guidance for COVID-19 Challenges in the Meatpacking Industry
The COVID-19 pandemic raised considerable challenges to obtain reliable guidance to help occupational health practitioners, workers, and stakeholders building up efficient prevention strategies at the workplace, between the constant increase of publications in the domain, the time required to run high-quality research and systematic reviews, and the urgent need to identify areas for prevention at the workplace. Social Media and Twitter, in particular, have already been used in research and constitute a useful source of information to identify community needs and topics of interest for prevention in the meatpacking industry. In this commentary, we introduce the methods and tools we used to screen relevant posts on Twitter. Twitter analytics is a way to capture real-time concerns of the community and help ensure compliance with the notion of social accountability. As such research has limitations in terms of exhaustiveness and level of evidence, it should be considered as provisional guidance to direct both actions at the workplace and further conventional research projects.
SCALS: A fourth-generation study of assisted living technologies in their organisational, social, political and policy context
Introduction: Research to date into assisted living technologies broadly consists of 3 generations: technical design, experimental trials and qualitative studies of the patient experience. We describe a fourthgeneration paradigm: studies of assisted living technologies in their organisational, social, political and policy context. Fourth-generation studies are necessarily organic and emergent; they view technology as part of a dynamic, networked and potentially unstable system. They use co-design methods to generate and stabilise local solutions, taking account of context. Methods and analysis: SCALS (Studies in Cocreating Assisted Living Solutions) consists (currently) of 5 organisational case studies, each an English health or social care organisation striving to introduce technology-supported services to support independent living in people with health and/or social care needs. Treating these cases as complex systems, we seek to explore interdependencies, emergence and conflict. We employ a co-design approach informed by the principles of action research to help participating organisations establish, refine and evaluate their service. To that end, we are conducting in-depth ethnographic studies of people's experience of assisted living technologies (micro level), embedded in evolving organisational case studies that use interviews, ethnography and document analysis (meso level), and exploring the wider national and international context for assisted living technologies and policy (macro level). Data will be analysed using a sociotechnical framework developed from structuration theory. Ethics and dissemination: Research ethics approval for the first 4 case studies has been granted. An important outcome will be lessons learned from individual co-design case studies. We will document the studies' credibility and rigour, and assess the transferability of findings to other settings while also recognising unique aspects of the contexts in which they were generated. Academic outputs will include a cross-case analysis and progress in theory and method of fourth-generation assisted living technology research. We will produce practical guidance for organisations, policymakers, designers and service users.