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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.
Utilising primary care electronic health records to deliver the ALABAMA randomised controlled trial of penicillin allergy assessment
Background: Use of electronic health records (EHR) to provide real-world data for research is established, but using EHR to deliver randomised controlled trials (RCTs) more efficiently is less developed. The Allergy AntiBiotics And Microbial resistAnce (ALABAMA) RCT evaluated a penicillin allergy assessment pathway versus usual clinical care in a UK primary care setting. The aim of this paper is to describe how EHRs were used to facilitate efficient delivery of a large-scale randomised trial of a complex intervention embracing efficient participant identification, supporting minimising GP workload, providing accurate post-intervention EHR updates of allergy status, and facilitating participant follow up and outcome data collection. The generalisability of the EHR approach and health economic implications of EHR in clinical trials will be reported in the main ALABAMA trial cost-effectiveness analysis. Methods: A descriptive account of the adaptation of functionality within SystmOne used to deliver/facilitate multiple trial processes from participant identification to outcome data collection. Results: An ALABAMA organisation group within SystmOne was established which allowed sharing of trial functions/materials developed centrally by the research team. The ‘ALABAMA unit’ within SystmOne was also created and provided a secure efficient environment to access participants’ EHR data. Processes of referring consented participants, allocating them to a trial arm, and assigning specific functions to the intervention arm were developed by adapting tools such as templates, reports, and protocols which were already available in SystmOne as well as pathways to facilitate allergy de-labelling processes and data retrieval for trial outcome analysis. Conclusions: ALABAMA is one of the first RCTs to utilise SystmOne EHR functionality and data across the RCT delivery, demonstrating feasibility and applicability to other primary care RCTs. Trial registration: ClinicalTrials.gov: NCT04108637, registered 05/03/2019. ISRCTN: ISRCTN20579216.
Stigma relating to tuberculosis infection prevention and control implementation in rural health facilities in South Africa — a qualitative study outlining opportunities for mitigation
Background: Tuberculosis (TB) is a stigmatised disease with intersectional associations with poverty, HIV, transmission risk and mortality. The use of visible TB infection prevention and control (IPC) measures, such as masks or isolation, can contribute to stigma. Methods: To explore stigma in this condition, we conducted in-depth individual interviews with 18 health workers and 15 patients in the rural Eastern Cape of South Africa using a semi-structured interview guide and narrative approach. We used reflexive thematic analysis guided by line-by-line coding. We then interpreted these key findings using Link and Phelan’s theoretical model of stigma, related this to stigma mitigation recommendations from participants and identified levels of intervention with the Health Stigma and Discrimination Framework. Results: Participants shared narratives of how TB IPC measures can contribute to stigma, with some describing feeling ‘less than human’. We found TB IPC measures sometimes exacerbated stigma, for example through introducing physical isolation that became prolonged or through a mask marking the person out as being ill with TB. In this context, stigma emerged from the narrow definition of what mask-wearing symbolises, in contrast with broader uses of masks as a preventative measure. Patient and health workers had contrasting perspectives on the implications of TB IPC-related stigma, with patients focussing on communal benefit, while health workers focussed on the negative impact on the health worker-patient relationship. Participant recommendations to mitigate TB IPC-related stigma included comprehensive information on TB IPC measures, respectful communication between health workers and patients, shifting the focus of TB IPC messages to communal safety (which could draw on ubuntu, a humanist framework) and using universal IPC precautions instead of measures targeted at someone with infectious TB. Conclusions: Health facilities may unwittingly perpetuate stigma through TB IPC implementation, but they also have the potential to reduce it. Evoking ‘ubuntu’ as an African humanist conceptual framework could provide a novel perspective to guide future TB IPC stigma mitigation interventions, including policy changes to universal IPC precautions.
Informal care, older people, and COVID-19: Evidence from the UK
The negative health effects and mortality caused by the COVID-19 pandemic disproportionately fell upon older and disabled people. Protecting these vulnerable groups has been a key policy priority throughout the pandemic and related vaccination campaigns. Using data from the latest survey of the UK Household Longitudinal Study on COVID-19 we found that people who receive informal care have higher probability of being infected when compared to those not receiving informal care. Further, we found that care recipients who are in the lowest income groups have a higher probability of catching the virus when compared to those in the highest income groups. We also estimated the likelihood of being infected for informal carers versus those who did not provide any care during the pandemic and found no significant differences between these two groups. Our empirical findings suggest that the standard measures introduced with the aim of protecting vulnerable groups, such as closing care homes or prioritising the vaccination of their staff, were not sufficient to avoid the spread of the virus amongst disabled and older people. Informal carers play an important role in the social care sector. As such, protecting vulnerable people by investing in the informal care sector should be a priority for future health policy.
Addressing fiscal uncertainty: Proposing policy pathways for enhancing economic growth and fertility rates in South Korea
This study investigates the critical role of fiscal uncertainty in driving economic growth in South Korea and explores the potential implications for the nation's long-standing low fertility challenge. Utilizing country-year data and advanced measures disaggregating economic policy uncertainty into dimensions like fiscal, monetary, and trade uncertainty, the analysis reveals a strong negative association between fiscal uncertainty and GDP growth rates over the past three decades. Periods of heightened fiscal volatility, characterized by unpredictable government spending, tax policies, and overall economic instability, consistently preceded declines in economic growth. Moreover, the findings indicate that fiscal uncertainty moderates the relationship between economic expansion and fertility rates. While GDP growth generally improves conditions favorable for childbearing by raising living standards, the positive impact on fertility diminishes as fiscal uncertainty increases. Strikingly, at sufficiently high levels of uncertainty, economic growth fails to boost fertility rates, underscoring the crucial role of fiscal stability in reaping the full benefits of growth. These insights highlight the importance of reducing fiscal uncertainty through strategies like implementing tax and spending "calendarization" systems and adopting long-term policy planning horizons. By promoting fiscal predictability and fostering an environment conducive to sustained economic expansion, policymakers can indirectly create conditions that support higher fertility rates by alleviating household aversion to uncertainty. While focused on economic factors, this research acknowledges the multifaceted nature of fertility decisions and calls for a holistic policy approach combined with further causal investigations using micro-level data and experimental designs. Ultimately, prioritizing fiscal stability and addressing fiscal uncertainty present a critical pathway towards stimulating economic growth and potentially revitalizing fertility rates in South Korea and similar developed nations confronting demographic challenges.
Periodontal diseases and cardiovascular diseases, diabetes, and respiratory diseases: Summary of the consensus report by the European Federation of Periodontology and WONCA Europe
Background: Periodontitis is a chronic inflammatory non-communicable disease (NCD) characterised by the destruction of the tooth-supporting apparatus (periodontium), including alveolar bone, the presence of periodontal pockets, and bleeding on probing. Objectives: To outline, for family doctors, the implications of the association between periodontal and systemic diseases; to explore the role of family doctors in managing periodontitis as an ubiquitous non-communicable disease (NCD). Methods: The consensus reports of previous focused collaborative workshops between WONCA Europe and the European Federation of Periodontology (using previously undertaken systematic reviews), and a specifically commissioned systematic review formed the technical papers to underpin discussions. Working groups prepared proposals independently, and the proposals were subsequently discussed and approved at plenary meetings. Results: Periodontitis is independently associated with cardiovascular diseases, diabetes, chronic obstructive pulmonary disease, obstructive sleep apnoea, and COVID-19 complications. Treatment of periodontitis has been associated with improvements in systemic health outcomes. The article also presents evidence gaps. Oral health care professionals (OHPs) and family doctors should collaborate in managing these conditions, including implementing strategies for early case detection of periodontitis in primary medical care centres and of systemic NCDs in oral/dental care settings. There is a need to raise awareness of periodontal diseases, their consequences, and the associated risk factors amongst family doctors. Conclusion: Closer collaboration between OHPs and family doctors is important in the early case detection and management of NCDs like cardiovascular diseases, diabetes mellitus, and respiratory diseases. Strategies for early case detection/prevention of NCDs, including periodontitis, should be developed for family doctors, other health professionals (OHPs), and healthcare funders. Evidence-based information on the reported associations between periodontitis and other NCDs should be made available to family doctors, OHPs, healthcare funders, patients, and the general population.
Prevention of cardiometabolic diseases through dietary modifications
Purpose of review Cardiometabolic diseases (CMDs) increasingly contribute to the cumulative burden of morbidity and mortality worldwide. Here, we reviewed intervention studies using a randomized controlled trial (RCT) design as well as meta-analyses of RCTs aimed at testing the effectiveness of different dietary approaches for CMD prevention. Recent findings Recent studies testing dietary approaches for CMD prevention were summarized narratively, with a focus on interventions based on caloric restriction and fasting, healthy dietary patterns and food-based dietary modifications. Evidence supports intermittent fasting, Mediterranean, Nordic, DASH, low-carbohydrate/ketogenic and plant-based diets as effective strategies for improving cardiometabolic health. However, the benefits observed with some of these dietary patterns are linked to energy restriction, and the independent effects beyond weight loss remain unclear. The effectiveness of some strategies may also depend on the overall dietary quality and adherence to the programme. Summary Recent findings highlight the importance of focusing on overall dietary patterns, rather than isolated nutrients, for preventing CMD. Future research should prioritize long-term intervention studies to assess the sustained effects of these dietary patterns on CMD outcomes.
Oro-faecal transmission of SARS-CoV-2: A systematic review of studies employing viral culture from gastrointestinal and other potential oro-faecal sources and evidence for transmission to humans
The extent to which the oro-faecal route contributes to the transmission of SARS-CoV-2 is not established. We systematically reviewed the evidence on the presence of infectious SARS-CoV-2 in faeces and other gastrointestinal sources by examining studies that used viral culture to investigate the presence of replication-competent virus in these samples. We conducted searches in the WHO COVID-19 Database, LitCovid, medRxiv, and Google Scholar for SARS-CoV-2 using keywords and associated synonyms, with a search date up to 28 November 2023. We included 13 studies involving 229 COVID-19 subjects-providing 308 faecal or rectal swab SARS-CoV2 reverse transcription-polymerase chain reaction (RT-PCR)-positive samples tested with viral culture. The methods used for viral culture across the studies were heterogeneous. Three studies (two cohorts and one case series) reported observing replication-competent SARS-CoV-2 confirmed by quantitative RT-PCR (qPCR) and whole-genome sequencing, and qPCR including appropriate cycle threshold changes. Overall, six (1.9%) of 308 faecal samples subjected to cell culture showed replication-competent virus. One study found replication-competent samples from one immunocompromised patient. No studies were identified demonstrating direct evidence of oro-faecal transmission to humans. Our review found a relatively low frequency of replication-competent SARS-CoV-2 in faecal and other gastrointestinal sources. Although it is biologically plausible, more research is needed using standardized cell culture methods, control groups, adequate follow-up, and robust epidemiologic methods, including whether secondary infections occurred, to determine the role of the oro-faecal route in the transmission of SARS-CoV-2.
Ethnic differences in meat consumption attitudes, norms and behaviors: A survey of White, South Asian and Black ethnic groups in the UK
A reduction in meat consumption is necessary to mitigate negative impacts of climate change and adverse health outcomes. The UK has an increasingly multi-ethnic population, yet there is little research on meat consumption habits and attitudes among ethnic groups in the UK. We ran a survey (N = 1014) with quota samples for ethnic groups and analyzed attitudes, behaviors and norm perceptions of White, South Asian and Black British respondents. Most respondents believe overconsumption of red and processed meat has negative impacts on health (73.3%) and the environment (64.3%).South Asian respondents were statistically significantly less likely to be meat eaters than White respondents (OR = 0.44, 95% CIs: 0.30-0.65, t = −4.15, p = 0.000), while there was no significant difference between White and Black respondents (OR = 1.06, 95% CIs: 0.63–1.76, t = 0.21, p = 0.834). Both South Asian (OR = 2.76, 95% CIs: 1.89–4.03 t = 5.25, p = 0.000) and Black respondents (OR = 2.09, 95% CIs: 0.1.30–3.35, t = 3.06, p = 0.002) were significantly more likely to express being influenced by friends and family in their food choices than White respondents. South Asian (OR = 3.24,95% CIs: 2.17–4.84, t = 5.74, p = 0.000) and Black (OR = 2.02,95% CIs: 1.21–3.39, t = 2.69, p = 0.007) respondents were also both significantly more likely to report they would want to eat similarly to their friends and family than White respondents. Statistical analyses suggested some gender and socioeconomic differences across and among ethnic groups, which are reported and discussed. The differences in meat consumption behaviors and norm conformity between ethnic groups raises the prospect that interventions that leverage social norms may be more effective in South Asian groups than Black and White groups in the UK.
Rapid implementation of blood pressure self-monitoring in pregnancy at a UK NHS Trust during the COVID-19 pandemic: A quality improvement evaluation
Background This service evaluation describes the rapid implementation of self-monitoring of blood pressure (SMBP) into maternity care at a tertiary referral centre during the COVID-19 pandemic. It summarises findings, identifies knowledge gaps and provides recommendations for further research and practice. Intervention Pregnant and postpartum women monitored their blood pressure (BP) at home, with instructions on actions to take if their BP exceeded pre-determined thresholds. Some also conducted proteinuria self-testing. Data collection and analysis Maternity records, app data and staff feedback were used in interim evaluations to assess process effectiveness and guide adjustments, employing a Plan-Do-Study-Act and root cause analysis approach. Results Between March 2020 and August 2021, a total of 605 women agreed to self-monitor their BP, including 10 women with limited English. 491 registered for telemonitoring (81.2%). 21 (3.5%) took part in urine self-testing. Engagement was high and increased over time with no safety issues. Biggest concerns related to monitor supply and postnatal monitoring. In December 2020, SMBP was integrated into the standard maternity care pathway. Conclusions This project demonstrated successful integration of SMBP into maternity care. Early stakeholder engagement and clear guidance were crucial and community midwifery support essential. Supplying BP monitors throughout pregnancy and post partum could improve the service and fully digitised maternity records would aid data collection. More research is needed on SMBP in the postnatal period and among non-English speakers. These findings support efforts to implement app-supported self-monitoring and guide future research.
Frameworks for modelling the potential longer-term costs and consequences of self-monitoring of blood pressure (SMBP) during pregnancy
Aims To develop model frameworks to be able to explore the potential long-term costs and effects of future interventions that may combine self-monitoring of blood pressure (SMBP) with targeted blood pressure (BP) management policies for the prevention of hypertension-related complications during pregnancy. Methods Two model frameworks were constructed; the first focussed upon women at risk of developing pregnancy hypertension, and the second upon women with existing pregnancy hypertension. The model structures were developed using expert clinical opinion and the published literature. Modelled pregnancy pathways included the complications of pregnancy hypertension (for example pre-eclampsia and stroke). The longer-term risks of developing chronic hypertension and cardiovascular disease following pregnancy hypertension and pre-eclampsia were simulated using a Markov model over a 10-year period. Health care costs were modelled and health outcomes were expressed as quality-adjusted life years (QALYs). Event probabilities, costs and utility scores were informed by two randomised trials conducted during the same programme of work and the published literature, and were entered as distributions to enable probabilistic sensitivity analysis. The model was run for a range of different hypothesised intervention effect sizes and implemented so as to be able to simulate results for different cohorts of women with varying risk factors. Results We present no definitive cost-effectiveness results, instead running a series of hypothetical scenarios to illustrate the capabilities of the models. For example, simulating a hypothetical scenario in which a new SMBP-guided intervention could reduce the risk of a pregnant women developing pre-eclampsia by 10%, the modelling suggested that long-term cost-effectiveness could potentially vary between hypertensive pregnant women and women at risk of pregnancy hypertension. This is because hypertensive women face a greater likelihood of developing associated complications both during and following pregnancy, in turn suggesting a greater absolute level of benefit from a 10% reduction in complications via the mechanism of better BP control. Such hypotheses would of course require empirical testing in practice. The model frameworks developed permit the exploration of cost-effectiveness results for cohorts of women with different risk factors and potential interventions of varying levels of effectiveness, and can be adapted and further developed by researchers for use within their own settings. Conclusions: Model frameworks have been developed that can be used to begin to explore the potential long-term cost-effectiveness of adding novel targeted blood pressure management policies to SMBP during pregnancy.
Participatory Surveillance and Candidacy: A Discourse Analysis of Views on Self-Testing for Proteinuria in Pregnancy
Actively involving people in self-monitoring and management during their pregnancy is an emerging clinical and social practice. Self-monitoring of blood pressure and self-testing for proteinuria, key diagnostic tests for pre-eclampsia, are becoming commonplace in hypertensive pregnancies. While evidence exists on the acceptability and feasibility of self-monitoring blood pressure, evidence for self-testing for proteinuria in pregnancy is thin, with little knowledge of how it might affect the traditional structures of maternity care. As part of a diagnostic accuracy study on self-testing for proteinuria, pregnant people and healthcare professionals were recruited to a qualitative study to understand their experiences of, and attitudes to, self-testing. Multiple qualitative methods were used, including interviews, focus groups, and free text postcards. A discourse analysis was conducted to understand how self-testing might inform and reshape routine antenatal care. Analysis revealed a tension between the empowering concept of participatory surveillance, which pregnant people and healthcare professionals were broadly positive about, and the adjudications made by healthcare professionals about the candidacy, or suitability, of certain pregnant people to self-test. Candidacy is a framework for understanding what influences access to healthcare for socially disadvantaged groups, including professional judgments that impact access to interventions. While participatory surveillance was felt to have the potential to empower pregnant people in antenatal care, the loss of the traditional clinical gaze was disquieting for some, and pregnant people and healthcare professionals were reluctant to cede professional responsibility.
Ethical issues in vaccine trial participation by adolescents: qualitative insights on family decision making from a human papillomavirus vaccine trial in Tanzania.
BACKGROUND: Research in children is essential for them to benefit from the outcomes of research but involvement must be weighed against potential harms. In many countries and circumstances, medical research legally requires parental consent until the age of 18 years, with poorly defined recommendations for assent prior to this. However, there is little research exploring how these decisions are made by families and the ethical implications of this. AIM: To explore key ethical debates in decision-making for participation of children and adolescents in a human papillomavirus (HPV) vaccine trial. METHODS: Semi-structured interviews were undertaken with Tanzanian girls (aged 9-16 years) who had participated in an HPV vaccine trial (n = 13), their parents or guardians (n = 12), and girls together with their parents (in paired parent-child interviews) (n = 6). The interviews were analysed using thematic analysis. Interview data came from a qualitative acceptability study undertaken as part of the Dose Reduction Immunobridging and Safety Study of Two Human Papillomavirus (HPV) Vaccines in Tanzanian Girls (DoRIS) trial. RESULTS: Girls and parents desired collaborative decision-making, with parents ultimately making the decision to consent. However, girls wanted a larger part in decision-making. Decisions to consent involved many people, including extended social networks, the trial team, media outlets and healthcare professionals and this resulted in conflicts to be negotiated. Deciding where to place trust was central in participants and parents considering decisions to consent and overcoming rumours about trial involvement. CONCLUSIONS: Existing models of decision-making help to understand dynamics between parents, adolescents and researchers but neglect the important wider social impacts and the fundamental nature of trust. Children's roles in discussions can be evaluated using the principles of consent: autonomy, freedom and information. Concepts such as relational autonomy help to explain mechanisms families use to negotiate complex consent decisions. Whilst interviewees supported the maintenance of legal parental consent, researchers must design consent processes centring the child to ensure that whole family decision-making processes are supported.
'Online boundary-work': How people with diabetes negotiate what counts as legitimate knowledge in Facebook peer support groups.
People with chronic conditions such as diabetes use social media to interact with peers. While these online interactions allow them to exchange advice and gain insight into how others cope with their condition, concerns about 'misinformation' being shared are persistently raised, especially among medical professionals. Rather than assessing whether information shared on social media is 'correct' from a clinical perspective, we explore how people with diabetes negotiate what counts as legitimate knowledge as they interact in Facebook groups. Empirically, we draw on a six-month observation of interactions in two Danish Facebook groups for people with type 1 and 2 diabetes, including a data sample of 300 posts and 7797 comments. Observations were carried out in 2021. Guided by the concept of boundary-work (Gieryn, 1983), we analyse how members of the Facebook groups demarcate legitimate knowledge from what they deem illegitimate, enacted as they scrutinise peer advice and knowledge claims. We refer to this ongoing process as 'online boundary-work' and draw out three distinct negotiations, specifying how group members (a) recognise sharing of personal experiences as useful but do not necessarily accept them as valid forms of self-management advice, (b) support each other in evaluating medical issues but delegate certain treatment decisions and responsibility to professionals and (c) do not necessarily agree on the most accurate answer but mobilise scientific or professionally managed sources to legitimise or question claims. Our work contributes to the science and technology studies (STS) literature on how social media facilitates a collective space for people with chronic conditions to 'diagnose' issues in daily self-management and reflect on solutions, especially through sharing personal experiences. By demonstrating how these activities involve an ongoing, collective task of negotiating what counts as legitimate knowledge, we elucidate the effort people with diabetes put into upholding peer support groups as digital spaces for solidarity and knowledge useful to daily self-management. However, as we highlight, online boundary-work does not necessarily result in consensus, prevent certain types of advice from being shared or guarantee that answers are considered useful to members or 'correct' from a clinical perspective.
Cost-effectiveness of a novel AI technology to quantify coronary inflammation and cardiovascular risk in patients undergoing routine Coronary Computed Tomography Angiography.
AIMS: Coronary Computed Tomography Angiography (CCTA) is a first line investigation for chest pain in patients with suspected obstructive coronary artery disease (CAD). However, many acute cardiac events occur in the absence of obstructive CAD. We assessed the lifetime cost-effectiveness of integrating a novel artificial intelligence-enhanced image analysis algorithm (AI-Risk) that stratifies the risk of cardiac events by quantifying coronary inflammation, combined with the extent of coronary artery plaque and clinical risk factors, by analysing images from routine CCTA. METHODS AND RESULTS: A hybrid decision-tree with population cohort Markov model was developed from 3,393 consecutive patients who underwent routine CCTA for suspected obstructive CAD and followed up for major adverse cardiac events over a median(IQR) of 7.7(6.4-9.1) years. In a prospective real-world evaluation survey of 744 consecutive patients undergoing CCTA for chest pain investigation, the availability of AI-Risk assessment led to treatment initiation or intensification in 45% of patients. In a further prospective study of 1,214 consecutive patients with extensive guideline recommended cardiovascular risk profiling, AI-Risk stratification led to treatment initiation or intensification in 39% of patients beyond the current clinical guideline recommendations. Treatment guided by AI-Risk modelled over a lifetime horizon could lead to fewer cardiac events (relative reductions of 4%, 4%, 11%, and 12% for myocardial infarction, ischaemic stroke, heart failure and cardiac death, respectively). Implementing AI-Risk classification in routine interpretation of CCTA is highly likely to be cost-effective (Incremental cost-effectiveness ratio £1,371-3,244), both in scenarios of current guideline compliance or when applied only to patients without obstructive CAD. CONCLUSIONS: Compared with standard care, the addition of AI-Risk assessment in routine CCTA interpretation is cost effective, by refining risk guided medical management.