Background: Chronic kidney disease affects around 10% of the global population and is associated with significant risk of progression to end-stage renal disease and vascular events. Aldosterone receptor antagonists such as spironolactone have shown prognostic benefits in patients with heart failure, but effects on patients with chronic kidney disease are uncertain. Objectives: To determine the effect of low-dose spironolactone on mortality and cardiovascular outcomes in people with chronic kidney disease stage 3b. Design: Prospective randomised open blinded end-point trial. Settings: Three hundred and twenty-nine general practitioner practices throughout the United Kingdom. Participants: Patients meeting the criteria for chronic kidney disease stage 3b (estimated glomerular filtration rate 30\u201344 ml/minute/1.73 m2) according to National Institute for Health and Care Excellence guidelines were recruited. Due to the higher than anticipated measurement error/fluctuations, the eligible range was extended to 30\u201350 ml/ minute/1.73 m2 following the initial recruitment period. Intervention: Participants were randomised 1: 1 to receive either spironolactone 25 mg once daily in addition to standard care, or standard care only. Outcome measures: Primary outcome was the first occurring of all-cause mortality, first hospitalisation for heart disease (coronary heart disease, arrhythmia, atrial fibrillation, sudden death, failed sudden death), stroke, heart failure, transient ischaemic attack or peripheral arterial disease, or first occurrence of any condition not listed at baseline. Secondary outcome measures included changes in blood pressure, renal function, B-type natriuretic peptide, incidence of hyperkalaemia and treatment costs and benefits. Results: One thousand four hundred and thirty-four participants were randomised of the 3022 planned. We found no evidence of differences between the intervention and control groups in terms of effectiveness with the primary combined vascular end points, nor with the secondary clinical outcomes, including progression in renal decline. These results were similar for the total treatment periods or a 3-year follow-up period as originally planned. More adverse events were experienced and more participants discontinued treatment in the intervention group. Two-thirds of participants randomised to spironolactone stopped treatment within six months because they met pre-specified safety stop criteria. The addition of low-dose spironolactone was estimated to have a cost per quality-adjusted life-year gained value above the National Institute for Health and Care Excellence\u2019s threshold of \u00a330,000. Limitations: Main limitations were difficulties in recruiting eligible participants resulting in an underpowered trial with poor ethnic diversity taking twice as long as planned to complete. We have explored the data in secondary analyses that indicate that, despite these difficulties, the findings were reliable. Conclusions: The benefits of aldosterone receptor antagonism in chronic kidney disease trial found no evidence to support adding low-dose spironolactone (25 mg daily) in patients with chronic kidney disease stage 3b: there were no changes to cardiovascular events during the trial follow-up, either for the combined primary or individual components. There was also no evidence of benefit observed in rates of renal function decline over the trial, but much higher initial creatinine rise and estimated glomerular filtration rate decline, and to a higher percentage rate, in the intervention arm in the first few weeks of spironolactone treatment, which resulted in a high proportion of participants discontinuing spironolactone treatment at an early stage. These higher rates of negative renal change reduced in scale over the study but did not equalise between arms. The addition of 25 mg of spironolactone therefore provided no reno-or cardioprotection and was associated with an increase in adverse events. Future work: These findings might not be applicable to different mineralocorticoid receptor antagonists. Study registration: Current Controlled Trials ISRCTN44522369.
\n \n\n \n \nBACKGROUND: Whilst interest in efficient trial design has grown with the use of electronic health records (EHRs) to collect trial outcomes, practical challenges remain. Commonly raised concerns often revolve around data availability, data quality and issues with data validation. This study aimed to assess the agreement between data collected on clinical trial participants from different sources to provide empirical evidence on the utility of EHRs for follow-up in randomised controlled trials (RCTs). METHODS: This retrospective, participant-level data utility comparison study was undertaken using data collected as part of a UK primary care-based, randomised controlled trial (OPTiMISE). The primary outcome measure was the recording of all-cause hospitalisation or mortality within 3 years post-randomisation and was assessed across (1) Coded primary care data; (2) Coded-plus-free-text primary care data; and (3) Coded secondary care and mortality data. Agreement levels across data sources were assessed using Fleiss' Kappa (K). Kappa statistics were interpreted using an established framework, categorising agreement strength as follows: <0 (poor), 0.00-0.20 (slight), 0.21-0.40 (fair), 0.41-0.60 (moderate), 0.61-0.80 (substantial), and 0.81-1.00 (almost perfect) agreement. The impact of using different data sources to determine trial outcomes was assessed by replicating the trial's original analyses. RESULTS: Almost perfect agreement was observed for mortality outcome across the three data sources (K\u2009=\u20090.94, 95%CI 0.91-0.98). Fair agreement (weak consistency) was observed for hospitalisation outcomes, including all-cause hospitalisation or mortality (K\u2009=\u20090.35, 95%CI 0.28-0.42), emergency hospitalisation (K\u2009=\u20090.39, 95%CI 0.33-0.46), and hospitalisation or mortality due to cardiovascular disease (K\u2009=\u20090.32, 95%CI 0.19-0.45). The overall trial results remained consistent across data sources for the primary outcome, albeit with varying precision. CONCLUSION: Significant discrepancies according to data sources were observed in recording of secondary care outcomes. Investigators should be cautious when choosing which data source(s) to use to measure outcomes in trials. Future work on linking participant-level data across healthcare settings should consider the variations in diagnostic coding practices. Standardised definitions for outcome measures when using healthcare systems data and using data from different data sources for cross-checking and verification should be encouraged.
\n \n\n \n \nBackground Heart failure (HF) is not included in atrial fibrillation (AF) bleeding risk prediction scores, reflecting uncertainty regarding its importance as a risk factor for major haemorrhage. We aimed to report the relative risk of first major haemorrhage in people with HF and AF compared with people with AF without HF ( \u20ac AF only'). Methods English primary care cohort study of 2 178 162 people aged \u226545 years in the Clinical Practice Research Datalink from January 2000 to December 2018, linked to secondary care and mortality databases. We used traditional survival analysis and competing risks methods, accounting for all-cause mortality and anticoagulation. Results Over 7.56 years median follow-up, 60 270 people were diagnosed with HF and AF of whom 4996 (8.3%) had a major haemorrhage and 36 170 died (60.0%), compared with 8256 (6.4%) and 34 375 (27.2%), respectively, among 126 251 people with AF only. Less than half those with AF were prescribed an anticoagulant (45.6% from 2014 onwards), although 75.7% were prescribed an antiplatelet or anticoagulant. In a fully adjusted Cox model, the HR for major haemorrhage was higher among people with HF and AF (2.52, 95% CI 2.44 to 2.61) than AF only (1.87, 95% CI 1.82 to 1.92), even in a subgroup analysis of people prescribed anticoagulation. However, in a Fine and Gray competing risk model, the HR of major haemorrhage was similar for people with AF only (1.82, 95% CI 1.77 to 1.87) or HF and AF (1.71, 95% CI 1.66 to 1.78). Conclusions People with HF and AF are at increased risk of major haemorrhage compared with those with AF only and current prediction scores may underestimate the risk of haemorrhage in HF and AF. However, people with HF and AF are more likely to die than have a major haemorrhage and therefore an individual's expected prognosis should be carefully considered when predicting future bleeding risk.
\n \n\n \n \nBackground: Although non-pharmaceutical inventions (NPIs) were used globally to control the spread of COVID-19, their effectiveness remains uncertain. We aimed to assess the evidence on NPIs as implemented in the UK, to allow public health bodies to prepare for future pandemics. Methods: We used rapid systematic methods (search date: January 2024) to identify, critically appraise and synthesize interventional, observational and modelling studies reporting on NPI effectiveness in the UK. Results: Eighty-five modelling, nine observational and three interventional studies were included. Modelling studies had multiple quality issues; six of the 12 non-modelling studies were high quality. The best available evidence was for test and release strategies for case contacts (moderate certainty), which was suggestive of a protective effect. Although evidence for school-related NPIs and universal lockdown was also suggestive of a protective effect, this evidence was considered low certainty. Evidence certainty for the remaining NPIs was very low or inconclusive. Conclusion: The validity and reliability of evidence on the effectiveness of NPIs as implemented in the UK during the COVID-19 pandemic is weak. To improve evidence generation and support decision-making during future pandemics or other public health emergencies, it is essential to build evaluation into the design of public health interventions.
\n \n\n \n \nBACKGROUND: Postural hypotension (PH) is associated with cognitive decline, falls and allcause mortality, representing a substantial burden on the NHS. PH is often asymptomatic, making detection and treatment difficult. Currently, there is no systematic approach to measuring and managing PH in UK general practice. AIM: To explore barriers and facilitators to improving PH measurement and management. DESIGN AND SETTING: Qualitative interview study with healthcare practitioners in general practices in England. METHODS: We conducted individual, remote, semi-structured interviews with a range of healthcare practitioners (HCPs) who measure blood pressure (BP) in general practice, to explore their views and experiences of measuring and managing PH. Participants were identified from expressions of interest during a national survey. Interviews were video and audio-recorded, transcribed verbatim and analysed thematically. RESULTS: 26 HCPs in 24 practices across nine Clinical Research Networks in England were interviewed between March and July 2023. HCPs checked for PH when patients were older, reported dizziness, fatigue or had chronic conditions. Despite awareness of clinical guidelines, various diagnostic definitions were provided and measurement protocols varied between participants. Sit-to-stand rather than supine-to-stand measurements were considered more feasible due to time constraints and patient mobility. Education and training, as well as incentives and specialist clinics, were suggested as methods to improve PH measurement and management. CONCLUSIONS: This is the first study to explore barriers to, and facilitators of, PH measurement in English general practice. Findings suggest a more systematic approach to measurement is needed to improve detection and management of PH in general practice.
\n \n\n \n \nData quality in primary care is important for surveillance and research projects based on routinely collected computerised medical records data. We present the results of a targeted intervention of incentives and tools to record specific data about acute respiratory infectious disease. As part of an epidemiological study, practices received a template to code this information, which could also act as a consultation template. Use of the template was not restricted to patients taking part in the epidemiological study. We saw significant increases in coded data for patients in the study in the four areas that we examined; oxygen saturation, body temperature, respiratory rate and history of fever. For patients not included in the study we saw only small differences between study practices and non-study practices. There was an increased frequency of recording of measured body temperature in study practices but the effect was small (1.1%) 95% CI [0.56%,1.66%]. Primary care data quality can be improved with targeted interventions and support, but the effect does not transfer out of the specific patients for which it has been incentivised.
\n \n\n \n \nBackground: Data on economic costs of respiratory syncytial virus (RSV) infections among children in primary care are scarce, although most RSV-infections are managed in this setting. Aim: To estimate outpatient costs for RSV-positive childrenaged <5 years.Methods: In the RSV ComNet prospective cohort, children<5 years with acute respiratory infection were recruited for RSV testing through primary care physicians in Belgium, Italy, the Netherlands, Spain and the United Kingdom (UK) during RSV seasons 2020/21 (UK only), 2021/22 and 2022/23. Outpatient healthcare utilisation and parental work absence were assessed over 30 days through parental questionnaires. Average costs per RSV episode were calculated from outpatient healthcare sector and societal perspectives, stratified by country and age. Results: We included 3,414 children and 1,124 (33%) tested RSV-positive. Physicians completed reports for 878 episodes, with follow-up questionnaire data for 819 (93%). Outpatient costs ranged from EUR 97 (95% CI: 91\u2013104) in the Netherlands to EUR 300 (95% CI: 287\u2013312) in Spain and were higher for infants than children aged 1\u20135 years. Societal costs ranged from EUR 454 (95% CI: 418\u2013494) in the UK to EUR 994 (95% CI: 938\u20131,053) in Belgium. For children aged 1\u20135 years, societal costs were primarily driven by parental work absence. In infants, the main societal cost driver varied by country, but overall outpatient healthcare costs represented a higher proportion of societal costs vs older children. Conclusion: RSV infections in children attending primary care result in substantial economic costs per episode, although differences exist across countries. This study provides essential data to inform cost-effectiveness analyses on novel RSV immunisations.
\n \n\n \n \nBACKGROUND: Ketone bodies (KBs) can serve as an alternative fuel source for the brain. Pre-clinical evidence suggests that KBs have neuroprotective properties, which lie in the pathology of depression. AIMS: This study aimed to examine the association between KBs and the risk of depression using observational and genetic approaches. METHOD: Observational studies analyzed data collected between 2006 and 2010 from 245,459 participants in the UK Biobank, with follow-up to 31 October 2022. Genetic studies were firstly performed using one-sample Mendelian randomization (MR) with individual-level data from the UK Biobank; secondly, two-sample MR was performed using summary-level data from the largest available genome-wide association studies. KBs were measured by \u03b2-hydroxybutyrate with nuclear magnetic resonance spectroscopy. Depression outcomes were measured by linked hospital-based clinical depression diagnosis and mental health questionnaires. Cox proportional hazard models and linear regression were used to examine the association of KBs with depression and depression severity and to compare the risk between individuals on light nutritional ketosis (\u22650.5\u202fmmol/L) and those not. RESULTS: Observational analyses showed that each SD increase in KBs was associated with a 6\u202f% (95\u202f% CI, 1.03-1.08) increase in PHQ-9 scores in the fully adjusted model. Patients with KBs above 0.5\u202fmmol/L had a higher risk of depression (HR 1.57; 95\u202f% CI, 1.13-2.17) compared to those with KBs <0.5\u202fmmol/L. In one-sample MR, there were no significant associations between genetically predicted KBs and depression and PHQ-9 scores. In two-sample MR analyses, we found no evidence of KBs (IVW OR1.06; 95\u202f% CI, 0.91-1.24) with the risk of depression. CONCLUSIONS: There was observational evidence that higher KB concentration was associated with an increased risk of depression, but MR suggests this is not causal. The data do not support the therapeutic role of ketogenic diets in preventing depression.
\n \n\n \n \nBackground: Acute respiratory infections increase the short-term risk of myocardial infarction (MI) and stroke in primary care patients. Clinical guidelines for acute respiratory infections in primary care do not consider the risk of cardiovascular events, and CVD risk prediction tools target long-term risk. We aimed to develop and validate a prediction tool for the risk of cardiovascular disease events within 28-days of acute respiratory infection. Methods: The design was a retrospective cohort study using two different databases of routinely collected data from electronic health records from January 1999 to December 2019. We used Clinical Practice Research Datalink (CPRD) Aurum data to derive models, and CPRD GOLD data from a different population for external validation. This data is from UK primary care, with data linkage to Hospital Episode Statistics, Office of National Statistics mortality data, and Index of Multiple Deprivation data. Participants were patients aged 40 years or older with no history of cardiovascular events, and a first diagnosis with acute respiratory infection. The outcome was a composite of new diagnoses of myocardial ischaemia (myocardial infarction, angina, acute coronary syndromes, or ischaemic cardiomyopathy), stroke or transient ischaemic attack, or deaths with these diagnoses, within 28 days of presentation with an acute respiratory infection. We derived a list of 57 potential predictors based on prior studies and asked clinical experts to rank them. We derived two logistic regression models, one with the top ranked variables, and another including additional lower ranked variables. We derived a clinical prediction score from the most parsimonious logistic regression model. We validated each model and the score in the external dataset using C statistics, calibration plots, and expected to observed ratios. We examined clinical utility using decision curve analysis. Findings: The derivation cohort comprised 3.8 million patients with an acute respiratory infection (mean age 56.5 years, (SD 13.7); 57.7% female), of whom 11,996 had a subsequent cardiovascular outcome (0.3%). The validation cohort included 2.6 million patients (mean age 56.7 years, SD 13.6, 58.0% female), of whom 6868 (0.3%) had a subsequent cardiovascular outcome. The DASHI score comprised five clinical variables: Diabetes (1 point, yes/no), Age (40\u201359, 0 points; 60\u201379, 2 points; 80+, 4 points), current Smoking (1 point, yes/no), Heart failure (1 point, yes/no), and Infection diagnosis (Upper Respiratory Tract Infection\u20130 points. Lower Respiratory Tract Infection (LRTI)\u20131 point, or LRTI with a pneumonia diagnosis\u20144 points). Upon external validation, each model and the score showed similar performance. The score showed good discrimination (AUC 0.85, IQR 0.848\u20130.849) and calibration with an expected to observed ratio of 0.85 (IQR 0.85\u20130.85). Interpretation: The DASHI score allows primary care clinicians to estimate the risk of cardiovascular complications within 28 days in patients with acute respiratory infections. Funding: This research was funded in part by the Wellcome Trust [ 211182/Z/18/Z] and NIHR [ NIHR300738]. For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
\n \n\n \n \nBackground: There has been a drive to increase atrial fibrillation (AF) detection in general practice. However, one-off, opportunistic testing can miss paroxysmal AF and requires significant resource. Paroxysmal AF can be detected through screening that involves repeated ECGs over a period of time, although it is unclear whether screening would need to be led by general practice, and how much support participants require. We aimed to investigate whether AF screening can be delivered remotely by a centralised administration instead of general practice, and to determine the level of support required. Methods: We undertook a controlled comparator study with secondary randomisation in three English general practices. We invited people aged \u2265 70\u00a0years to use a hand-held ECG device four times daily for three weeks. Participants were allocated to practice-led or administrator-led screening, with administrator-led support randomised to three different levels. We compared quantity and quality of ECGs obtained in each arm. The primary outcome was proportion of screened participants who recorded \u2265 56 adequate-quality ECGs (2/3 of possible ECGs). Results: Of 288 screened participants, 59 participants received practice-led screening with a telephone consultation to explain the device. The remainder received administrator-led screening: 81 were automatically given a consultation; 74 were offered a consultation, and 74 were not offered a consultation. Most screened participants (280/288, 97.2%) recorded \u2265 56 adequate-quality ECGs. This proportion did not vary significantly between practice-led and administrator-led screening (100.0% vs. 98.8%), or between support levels (94.6% to 98.8%). Practice-led screening led to slightly more adequate-quality ECGs (mean: 83.9 vs 78.3, p < 0.001). Conclusions: AF screening can be successfully delivered remotely, outside general practice, with minimal support.
\n \n\n \n \nThis perspective provides a critical framework for evaluating the use of Generative AI (GenAI) in healthcare, informed by two roundtable events and a series of semi-structured expert interviews. By outlining key principles and risks\u2014including mapping applications to GenAI strengths, ensuring rigorous evaluation frameworks, and fostering transparency and collaboration\u2014it will support healthcare professionals and policymakers in navigating the ethical and impactful integration of GenAI into healthcare.
\n \n\n \n \nObjectives: Evidence from clinical trials suggests that antihypertensive treatment is associated with an increased risk of common electrolyte abnormalities. We aimed to develop and validate two clinical prediction models to estimate the risk of hyperkalaemia and hyponatraemia, respectively, to facilitate targeted treatment and monitoring strategies for individuals indicated for antihypertensive therapy. Design and methods: Participants aged at least 40 years, registered to an English primary care practice within the Clinical Practice Research Datalink (CPRD), with a systolic blood pressure reading between 130 and 179 mmHg were included the study. The primary outcomes were first hyperkalaemia or hyponatraemia event recorded in primary or secondary care. Model development used a Fine-Gray approach with death from other causes as competing event. Model performance was assessed using C-statistic, D-statistic, and Observed/Expected (O/E) ratio upon external validation. Results: The development cohort included 1 773 224 patients (mean age 59 years, median follow-up 6 years). The hyperkalaemia model contained 23 predictors and the hyponatraemia model contained 29 predictors, with all antihypertensive medications associated with the outcomes. Upon external validation in a cohort of 3 805 366 patients, both models calibrated well (O/E ratio: hyperkalaemia 1.16, 95% CI 1.13-1.19; hyponatraemia 1.00, 95% CI 0.98-1.02) and showed good discrimination at 10 years (C-statistic: 0.69, 95% CI 0.69-0.69; 0.80, 95% CI 0.80-0.80, respectively). Conclusion: Current clinical guidelines recommend monitoring serum electrolytes after initiating antihypertensive treatment. These clinical prediction models predicted individuals' risk of electrolyte abnormalities associated with antihypertensive treatment and could be used to target closer monitoring for individuals at a higher risk, where resources are limited.
\n \n\n \n \nBACKGROUND: In the United Kingdom, pregnant women are offered two scans: at 11-14 and 18-20 weeks' gestation. Current guidance supports fetal anatomical screening at the second scan, but evidence suggests earlier detection is possible. OBJECTIVES: To determine clinical and cost-effectiveness of a detailed two-dimensional ultrasound scan in the first trimester for detection of fetal anomalies, in addition to usual practice. DESIGN: Systematic review and meta-analysis. Nationwide survey. Analysis of National Congenital Anomaly Disease Registry data. Consensus procedure. Prospective survey of parental opinions. Probabilistic decision-analytic model for cost-effectiveness. Value-of-information analysis. SETTING: United Kingdom National Health Service. PARTICIPANTS: Pregnant women and partners. INTERVENTIONS: Detailed anomaly ultrasound at 11-14 weeks' gestation, in addition to usual practice. MAIN OUTCOME MEASURES: Diagnostic accuracy, protocol development, health economic modelling and value-of-information analysis. DATA SOURCES: MEDLINE (OvidSP), EMBASE (OvidSP), Science Citation Index and Conference Proceedings Citation Index-Science (Web of Science Core Collection); National Congenital Anomaly Disease Registry; European Congenital Anomalies Registry; Surveys of National Health Service Trusts; screening sonographers, midwives and doctors; and parents; National Schedule of National Health Service Costs (2019-20). REVIEW METHODS: Systematic review and meta-analysis for diagnostic accuracy. RESULTS: First-trimester ultrasound detects 93.3% (95% confidence interval 90.4% to 95.7%) of a pre-selected group of eight major anomalies with specificity of 99.99% (95% confidence interval 99.98% to 99.99%) and positive predictive value of 96.5% (95% confidence interval 93.3 to 98.8, 416,877 fetuses, 40 studies). For major cardiac anomalies, the respective data are 55.8% (95% confidence interval 45.9% to 65.5%), 99.98% (95% confidence interval 99.97% to 99.99%) and 94.85% (95% confidence interval 91.63% to 97.32%, 306,872 fetuses, 45 studies). Of NHS trusts surveyed, 77% currently perform first-trimester anatomy assessment, with evidence of inequity of care; earlier screening resulted in more diagnoses before 16 weeks' gestation. A consensus procedure (n\u2005=\u2005172) developed an anatomical protocol and minimum targets for diagnosis. Parental survey (n\u2005=\u20051374) indicated that over 90% would opt for such screening. Modelling of singleton pregnancies undergoing earlier anomaly screening using two-dimensional ultrasound was associated with increased mean healthcare costs per woman (\u00a311, 95% confidence interval \u00a31 to \u00a329) and maternal quality-adjusted life-years (0.002065, 95% confidence interval 0.000565 to 0.00358), an incremental cost per quality-adjusted life-year of \u00a35270, with likelihood of being cost-effective at \u00a320,000 per quality-adjusted life-year of over 95%. Additional modelling predicted reductions in infant healthcare costs and quality-adjusted life-years. Decision uncertainty was low. Value-of-information analysis of cost-effectiveness results showed no groups of parameters for which further research to reduce uncertainty would likely prove cost-effective. LIMITATIONS: Study heterogeneity; the lack of a universal reference standard; simplifying assumptions relating to economic model structure; and estimation of some parameters are documented and justified. The rarity of the conditions made estimation of longer-term maternal and infant costs and quality-adjusted life-years challenging, resulting in likely under-estimation of healthcare costs. CONCLUSIONS: With standardisation and training, first-trimester ultrasound screening for fetal anomalies is clinically effective with over 90% detection for eight major conditions and low false-positive rates. Decision uncertainty around implementation is low and a prospective study would not be an efficient investment. Adding first-trimester anomaly screening to the current screening likely represents a cost-effective use of resources and is acceptable to parents. FUTURE WORK: Focus on developing an implementation framework to modify the current United Kingdom Fetal Anomaly Screening Programme. STUDY REGISTRATION: This study is registered as PROSPERO CRD42018111781 and CRD42018112434. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/19/10) and is published in full in Health Technology Assessment; Vol. 29, No. 22. See the NIHR Funding and Awards website for further award information.
\n \n\n \n \nBACKGROUND: Social prescribing is increasingly used to support well-being through non-clinical, community-based interventions. However, there is limited understanding of how cultural activities can be tailored for older people from global majority groups. The TOUS study (Tailoring cultural Offers with and for diverse older Users of Social prescribing) explores how cultural offers can be adapted to meet the needs of these communities. AIM: This study aims to understand how storytelling can be used within a realist evaluation to explore the role of cultural activities in enhancing well-being among older adults from global majority groups. METHOD: Storytelling was used as a key method of data collection in two case studies. This approach involves four open-ended questions that allow participants to share experiences in their own words. Each transcript is condensed into a two-page narrative, approved by the participant, and used in collaborative discussions with stakeholders. This method aligns with the patient-centred ethos of social prescribing and complements realist evaluation by highlighting mechanisms of change and barriers to participation. RESULTS: Preliminary findings suggest cultural institutions can foster inclusion, connection, and identity among participants. Storytelling revealed the importance of culturally relevant, welcoming spaces and captured the nuanced experiences of individuals often overlooked in traditional research. CONCLUSION: Storytelling enriches realist evaluation by offering a participant-led, less extractive method of data collection. It bridges individual experiences with broader programme outcomes and provides a valuable approach for researchers aiming to centre voices from underrepresented communities in primary care research.
\n \n\n \n \nOBJECTIVES: The postdischarge period is crucial for vulnerable newborns at risk of morbidity, readmission and mortality in low- and middle-income countries (LMICs). Addressing gaps in care during this period could improve outcomes. This review consolidates evidence on caregiver information needs and relevant information tools used in postdischarge care for vulnerable newborns in LMICs. DESIGN: Scoping review using the methodological framework developed by Arksey and O'Malley. DATA SOURCES: We searched six databases for relevant articles published in English between 2001 and 2021. Additional articles were identified through citation and reference checking. ELIGIBILITY CRITERIA: Articles on postdischarge care for newborns in LMICs, excluding economic and technical development studies, discharge to other healthcare facilities (rather than to home) and maternal-focused studies. DATA EXTRACTION AND SYNTHESIS: Data extraction followed Arksey and O'Malley's data charting method. Using a descriptive synthesis approach, heterogeneous data were collated in narrative format. RESULTS: From 5190 articles, 22 were included. Only a small number of articles discussed caregiver challenges, like receiving insufficient information at discharge which led to uncertainty in caring for vulnerable newborns. Caregivers had a number of needs in relation to maternal and newborn care, including in terms of coordination of follow-up care. Although a number of tools have been used to support relevant needs (for postnatal care in general rather than specifically for postdischarge care of vulnerable newborns), these have shown mixed effectiveness due to challenges with completeness, lack of training and support, supply chain issues and cultural barriers to adoption, such as preference for alternative providers. CONCLUSION: Our understanding of postdischarge information needs for those looking after vulnerable newborns in LMICs remains limited. More effective use of information tools could help address some of these needs and contribute towards reducing neonatal mortality rates.
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