Search results
Found 20048 matches for
We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Standardisation and its Consequences in Health Care: A Case Study of PRINCE2 Project Management Training
“New models of care”, “care home vanguards” and “innovation test beds”. These are just a few of the initiatives being pursued in England’s National Health Service (NHS). They reflect wider changes in the organisation of the public sector that encourage short-term, focused projects that frequently de-couple the change process from the wider context. The dominant research interest in such projects has been on questions of implementation and outcome (e.g. how are project aims achieved). Far less attention has been given to questions of process and the kind of work that gets done. In this chapter we adopt an interpretive approach to critically examine the significance of project management for public sector health care, drawing on a case study of PRojects IN Controlled Environments (PRINCE2TM) training to examine how the idea of “project management” is constructed, the discourses and categories in play, and the implications for public sector health care. Our findings focus on three areas. Firstly, the principles underpinning PRINCE2TM draw on standardised and linear views of the world with processes leading directly to outputs. This way of conceptualising change presents the work of project management as neat and tidy and distances those involved from the human elements of managing. Secondly, the models, procedures, and techniques underpinning PRINCE2TM are concerned with efficient and cost-effective delivery of projects. This focus on technical responsibility encourages users to focus on the means rather than the end, to substitute moral and ethical concerns with technical procedures and decontextualises projects from the very communities they are (in theory) intended to serve. Finally, language plays a key role in promoting and sustaining ideas of a “market society”. Repeated use of terms such as “business”, “interests”, and “assurance mechanisms” hold potential to translate concerns over sickness or care into market-oriented language that is focused on business cycles and oriented to creating “value”. This jars with values of citizenship or public duty often associated with public welfare. We conclude by reflecting on the consequences of this project management work for health care and other public sector work, paying particular attention to the potential for “moral blindness”.
Could social prescribing contribute to type 2 diabetes prevention in people at high risk? Protocol for a realist, multilevel, mixed methods review and evaluation
Social prescribing is an innovation being widely adopted within the UK National Health Service policy as a way of improving the management of people with long-term conditions, such as type 2 diabetes (T2D). It generally involves linking patients in primary care with non-medical community-based interventions. Despite widespread national support, evidence for the effectiveness of social prescribing is both insufficient and contested. In this study, we will investigate whether social prescribing can contribute to T2D prevention and, if so, when, how and in what circumstances it might best be introduced. We will draw on realist evaluation to investigate the complex interpersonal, organisational, social and policy contexts in which social prescribing relevant to T2D prevention is implemented. We will set up a stakeholder group to advise us throughout the study, which will be conducted over three interconnected stages. In stage 1, we will undertake a realist review to synthesise the current evidence base for social prescribing. In stage 2, we will investigate how social prescribing relevant to people at high risk of T2D ‘works’ in a multiethnic, socioeconomically diverse community and any interactions with existing T2D prevention services using qualitative, quantitative and realist methods. In stage 3 and building on previous stages, we will synthesise a ‘transferable framework’ that will guide implementation and evaluation of social prescribing relevant to T2D prevention at scale. National Health Service ethics approval has been granted (reference 20/LO/0713). This project will potentially inform the adaptation of social prescribing services to better meet the needs of people at high risk of T2D in socioeconomically deprived areas. Findings may also be transferable to other long-term conditions. Dissemination will be undertaken as a continuous process, supported by the stakeholder group. Tailored outputs will target the following audiences: (1) service providers and commissioners; (2) people at high risk of T2D and community stakeholders; and (3) policy and strategic decision makers. CRD42020196259.
Persistent symptoms after Covid-19: qualitative study of 114 “long Covid” patients and draft quality principles for services
Background: Approximately 10% of patients with Covid-19 experience symptoms beyond 3–4 weeks. Patients call this “long Covid”. We sought to document such patients’ lived experience, including accessing and receiving healthcare and ideas for improving services. Methods: We held 55 individual interviews and 8 focus groups (n = 59) with people recruited from UK-based long Covid patient support groups, social media and snowballing. We restricted some focus groups to health professionals since they had already self-organised into online communities. Participants were invited to tell their stories and comment on others’ stories. Data were audiotaped, transcribed, anonymised and coded using NVIVO. Analysis incorporated sociological theories of illness, healing, peer support, clinical relationships, access, and service redesign. Results: Of 114 participants aged 27–73 years, 80 were female. Eighty-four were White British, 13 Asian, 8 White Other, 5 Black, and 4 mixed ethnicity. Thirty-two were doctors and 19 other health professionals. Thirty-one had attended hospital, of whom 8 had been admitted. Analysis revealed a confusing illness with many, varied and often relapsing-remitting symptoms and uncertain prognosis; a heavy sense of loss and stigma; difficulty accessing and navigating services; difficulty being taken seriously and achieving a diagnosis; disjointed and siloed care (including inability to access specialist services); variation in standards (e.g. inconsistent criteria for seeing, investigating and referring patients); variable quality of the therapeutic relationship (some participants felt well supported while others felt “fobbed off”); and possible critical events (e.g. deterioration after being unable to access services). Emotionally significant aspects of participants’ experiences informed ideas for improving services. Conclusion: Suggested quality principles for a long Covid service include ensuring access to care, reducing burden of illness, taking clinical responsibility and providing continuity of care, multi-disciplinary rehabilitation, evidence-based investigation and management, and further development of the knowledge base and clinical services. Trial registration: NCT04435041.
Masks and face coverings for the lay public a narrative update
Whether and when to mandate the wearing of facemasks in the community to prevent the spread of coronavirus disease 2019 remains controversial. Published literature across disciplines about the role of masks in mitigating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission is summarized. Growing evidence that SARS-CoV-2 is airborne indicates that infection control interventions must go beyond contact and droplet measures (such as handwashing and cleaning surfaces) and attend to masking and ventilation. Observational evidence suggests that masks work mainly by source control (preventing infected persons from transmitting the virus to others), but laboratory studies of mask filtration properties suggest that they could also provide some protection to wearers (protective effect). Even small reductions in individual transmission could lead to substantial reductions in population spread. To date, only 1 randomized controlled trial has examined a community mask recommendation. This trial did not identify a significant protective effect and was not designed to evaluate source control. Filtration properties and comfort vary widely across mask types. Masks may cause discomfort and communication difficulties. However, there is no evidence that masks result in significant physiologic decompensation or that risk compensation and fomite transmission are associated with mask wearing. The psychological effects of masks are culturally shaped; they may include threats to autonomy, social relatedness, and competence. Evidence suggests that the potential benefits of wearing masks likely outweigh the potential harms when SARS-CoV-2 is spreading in a community. However, mask mandates involve a tradeoff with personal freedom, so such policies should be pursued only if the threat is substantial and mitigation of spread cannot be achieved through other means.
Technology-Enhanced Consultations in Diabetes, Cancer, and Heart Failure: Protocol for the Qualitative Analysis of Remote Consultations (QuARC) Project (Preprint)
BACKGROUND Remote videoconsulting is promoted by policy makers as a way of delivering health care efficiently to an aging population with rising rates of chronic illness. As a radically new service model, it brings operational and interactional challenges in using digital technologies. In-depth research on this dynamic is needed before remote consultations are introduced more widely. OBJECTIVE The objective of this study will be to identify and analyze the communication strategies through which remote consultations are accomplished and to guide patients and clinicians to improve the communicative quality of remote consultations. METHODS In previous research, we collected and analyzed two separate datasets of remote consultations in a National Institute for Health Research–funded study of clinics in East London using Skype and a Wellcome Trust–funded study of specialist community heart failure teams in Oxford using Skype or FaceTime. The Qualitative Analysis of Remote Consultations (QuARC) study will combine datasets and undertake detailed interactional microanalysis of up to 40 remote consultations undertaken by senior and junior doctors and nurse specialists, including consultations with adults with diabetes, women who have diabetes during pregnancy, people consulting for postoperative cancer surgery and community-based patients having routine heart failure reviews along with up to 25 comparable face-to-face consultations. Drawing on established techniques (eg, conversation analysis), analysis will examine the contextual features in remote consultations (eg, restricted visual field) combined with close analysis of different modes of communication (eg, speech, gesture, and gaze). RESULTS Our findings will address the current gap in knowledge about how technology shapes the fine detail of communication in remote consultations. Alongside academic outputs, findings will inform the coproduction of information and guidance about communication strategies to support successful remote consultations. CONCLUSIONS Identifying the communication strategies through which remote consultations are accomplished and producing guidance for patients and clinicians about how to use this kind of technology successfully in consultations is an important and timely goal because roll out of remote consultations is planned across the National Health Service. REGISTERED REPORT IDENTIFIER RR1-10.2196/10913
The effects of the London 2012 Olympics and related urban regeneration on physical and mental health: the ORiEL mixed-methods evaluation of a natural experiment
BackgroundThere is limited evidence for public health policy-makers on the health impacts of urban regeneration programmes.ObjectivesTo assess whether or not the London 2012 Olympic and Paralympic Games, and related urban regeneration, were associated with an increase in physical activity and mental health and well-being; to assess whether or not any benefits were sustained over time; and to capture the experiences of residents of the Olympic host boroughs.DesignQuasi-experimental prospective cohort study of adolescents and their parents/carers, with a nested qualitative longitudinal study of families.SettingLondon boroughs of Newham, Barking and Dagenham, Tower Hamlets and Hackney.ParticipantsA cohort of 2254 adolescents in 25 schools; a repeat cross-sectional study of parents/carers and a sample of 20 families for the qualitative study.InterventionThe London 2012 Olympic and Paralympic Games, and urban regeneration primarily associated with the redevelopment of the Olympic Park for legacy use.Primary outcome measuresChange in the proportion of respondents meeting physical activity recommendations (using self-reported physical activity); change in the proportion of respondents reporting depression and anxiety and change in well-being score.Main resultsAt 6 months, adolescents who became inactive were less likely to come from the intervention borough (Newham) than from comparison boroughs [risk ratio (RR) = 0.69, 95% confidence interval (CI) 0.51 to 0.93]. At 18 months, there were no statistically significant differences between intervention and comparison boroughs for all adolescent physical activity and screen-time transitions. Those who visited the Olympic Park more than once a month were the least likely to remain inactive (RR 0.11, 95% CI 0.02 to 0.48) and the least likely to become inactive (RR 0.38, 95% CI 0.24 to 0.60) compared with those who were active at baseline and at the 18-month follow-up. No impacts on parental/carer physical activity were observed. Adolescents who were ‘no longer depressed’ (RR 1.53, 95% CI 1.07 to 2.20) or ‘remained depressed’ (RR 1.78, 95% CI 1.12 to 2.83) at 6 months were more likely to be from the intervention borough. For well-being, there was no association between boroughs and change in well-being between baseline and the 6-month follow-up. At 18 months’ follow-up, adolescents who ‘remained depressed’ (RR 1.93, 95% CI 1.01 to 3.70) were more likely to be from the intervention borough than from comparison boroughs. No associations were observed for well-being at 18 months. There was limited evidence of change for parental mental health and well-being. The qualitative study found that residents generally welcomed the unexpected chance to live in a cleaner, safer and more unified environment. The findings suggested that the Games temporarily alleviated certain stressors in the social and physical environment. Overall, the Games lessened participants’ sense of social exclusion and appeared to generate a sense of inclusion and respite, even if this was only temporary. Study limitations include the potential for adolescents to not be assigned the correct level of exposure to urban regeneration and the effect of reductions in central and local public budgets owing to the UK Government’s deficit reduction programme.ConclusionsThis study provided the highest quality data to date on the short- and medium-term social and health impacts of sporting mega-events. We found limited evidence that the London 2012 Olympic and Paralympic Games had a positive effect on adolescent or parental physical activity, mental health or well-being.FundingThe National Institute for Health Research Public Health Research programme.
Using Complexity Assessment to Inform the Development and Deployment of a Digital Dashboard for Schizophrenia Care: Case Study (Preprint)
BACKGROUND Health care is becoming more complex. For an increasing number of individuals, interacting with health care means addressing more than just one illness or disorder, engaging in more than one treatment, and interacting with more than one care provider. Individuals with severe mental illnesses such as schizophrenia are disproportionately affected by this complexity. Characteristic symptoms can make it harder to establish and maintain relationships. Treatment failure is common even where there is access to effective treatments, increasing suicide risk. Knowledge of complex adaptive systems has been increasingly recognized as useful in understanding and developing health care. A complex adaptive system is a collection of interconnected agents with the freedom to act based on their own internalized rules, affecting each other. In a complex health care system, relevant feedback is crucial in enabling continuous learning and improvement on all levels. New technology has potential, but the failure rate of technology projects in health care is high, arguably due to complexity. The Nonadoption, Abandonment, and challenges to Scale-up, Spread, and Sustainability (NASSS) framework and complexity assessment tool (NASSS-CAT) have been developed specifically to help identify and manage complexity in technology-related development projects in health care. OBJECTIVE This study aimed to use a pilot version of the NASSS-CAT instrument to inform the development and deployment of a point-of-care dashboard supporting schizophrenia care in west Sweden. Specifically, we report on the complexity profile of the project, stakeholders’ experiences with using NASSS-CAT, and practical implications. METHODS We used complexity assessment to structure data collection and feedback sessions with stakeholders, thereby informing an emergent approach to the development and deployment of the point-of-care dashboard. We also performed a thematic analysis, drawing on observations and documents related to stakeholders' use of the NASSS-CAT to describe their views on its usefulness. RESULTS Application of the NASSS framework revealed different types of complexity across multiple domains, including the condition, technology, value proposition, organizational tasks and pathways, and wider system. Stakeholders perceived the NASSS-CAT tool as useful in gaining perspective and new insights, covering areas that might otherwise have been neglected. Practical implications derived from feedback sessions with managers and developers are described. CONCLUSIONS This case study shows how stakeholders can identify and plan to address complexities during the introduction of a technological solution. Our findings suggest that NASSS-CAT can bring participants a greater understanding of complexities in digitalization projects in general.
Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study (Preprint)
BACKGROUND There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings. OBJECTIVE The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model. METHODS A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system). RESULTS When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive. CONCLUSIONS Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity.
Infrastructure Revisited: An Ethnographic Case Study of how Health Information Infrastructure Shapes and Constrains Technological Innovation (Preprint)
BACKGROUND Star defined infrastructure as something other things “run on”; it consists mainly of “boring things.” Building on her classic 1999 paper, and acknowledging contemporary developments in technologies, services, and systems, we developed a new theorization of health information infrastructure with five defining characteristics: (1) a material scaffolding, backgrounded when working and foregrounded upon breakdown; (2) embedded, relational, and emergent; (3) collectively learned, known, and practiced (through technologically-supported cooperative work and organizational routines); (4) patchworked (incrementally built and fixed) and path-dependent (influenced by technical and socio-cultural legacies); and (5) institutionally supported and sustained (eg, embodying standards negotiated and overseen by regulatory and professional bodies). OBJECTIVE Our theoretical objective was, in a health care context, to explore what information infrastructure is and how it shapes, supports, and constrains technological innovation. Our empirical objective was to examine the challenges of implementing and scaling up video consultation services. METHODS In this naturalistic case study, we collected a total of 450 hours of ethnographic observations, over 100 interviews, and about 100 local and national documents over 54 months. Sensitized by the characteristics of infrastructure, we sought examples of infrastructural challenges that had slowed implementation and scale-up. We arranged data thematically to gain familiarity before undertaking an analysis informed by strong structuration, neo-institutional, and social practice theories, together with elements taken from the actor-network theory. RESULTS We documented scale-up challenges at three different sites in our original case study, all of which relate to “boring things”: the selection of a platform to support video-mediated consultations, the replacement of desktop computers with virtual desktop infrastructure profiles, and problems with call quality. In a fourth subcase, configuration issues with licensed video-conferencing software limited the spread of the innovation to another UK site. In all four subcases, several features of infrastructure were evident, including: (1) intricacy and lack of dependability of the installed base; (2) interdependencies of technologies, processes, and routines, such that a fix for one problem generated problems elsewhere in the system; (3) the inertia of established routines; (4) the constraining (and, occasionally, enabling) effect of legacy systems; and (5) delays and conflicts relating to clinical quality and safety standards. CONCLUSIONS Innovators and change agents who wish to introduce new technologies in health services and systems should: (1) attend to materiality (eg, expect bugs and breakdowns, and prioritize basic dependability over advanced functionality); (2) take a systemic and relational view of technologies (versus as an isolated tool or function); (3) remember that technology-supported work is cooperative and embedded in organizational routines, which are further embedded in other routines; (4) innovate incrementally, taking account of technological and socio-cultural legacies; (5) consider standards but also where these standards come from and what priorities and interests they represent; and (6) seek to create leeway for these standards to be adapted to different local conditions.
Case study research for better evaluations of complex interventions: rationale and challenges
Background: The need for better methods for evaluation in health research has been widely recognised. The ‘complexity turn’ has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. We argue that case study research—currently denigrated as poor evidence—is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear. Main body: Case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings. Empirical case studies typically enable dynamic understanding of complex challenges and provide evidence about causal mechanisms and the necessary and sufficient conditions (contexts) for intervention implementation and effects. This is essential evidence not just for researchers concerned about internal and external validity, but also research users in policy and practice who need to know what the likely effects of complex programmes or interventions will be in their settings. The health sciences have much to learn from scholarship on case study methodology in the social sciences. However, there are multiple challenges in fully exploiting the potential learning from case study research. First are misconceptions that case study research can only provide exploratory or descriptive evidence. Second, there is little consensus about what a case study is, and considerable diversity in how empirical case studies are conducted and reported. Finally, as case study researchers typically (and appropriately) focus on thick description (that captures contextual detail), it can be challenging to identify the key messages related to intervention evaluation from case study reports. Conclusion: Whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences.
Expanding video consultation services at pace and scale in scotland during the covid-19 pandemic: national mixed methods case study
Background: Scotland-a country of 5.5 million people-has a rugged geography with many outlying islands, creating access challenges for many citizens. The government has long sought to mitigate these through a range of measures including an ambitious technology-enabled care program. A strategy to develop a nationwide video consultation service began in 2017. Our mixed methods evaluation was commissioned in mid-2019 and extended to cover the pandemic response in 2020. Objective: To draw lessons from a national evaluation of the introduction, spread, and scale-up of Scotland's video consultation services both before and during the pandemic. Methods: Data sources comprised 223 interviews (with patients, staff, technology providers, and policymakers), 60 hours of ethnographic observation (including in-person visits to remote settings), patient and staff satisfaction surveys (n=20,349), professional and public engagement questionnaires (n=5400), uptake statistics, and local and national documents. Fieldwork during the pandemic was of necessity conducted remotely. Data were analyzed thematically and theorized using the Planning and Evaluating Remote Consultation Services (PERCS) framework which considers multiple influences interacting dynamically and unfolding over time. Results: By the time the pandemic hit, there had been considerable investment in material and technological infrastructure, staff training, and professional and public engagement. Scotland was thus uniquely well placed to expand its video consultation services at pace and scale. Within 4 months (March-June 2020), the number of video consultations increased from about 330 to 17,000 per week nationally. While not everything went smoothly, video was used for a much wider range of clinical problems, vastly extending the prepandemic focus on outpatient monitoring of chronic stable conditions. The technology was generally considered dependable and easy to use. In most cases (14,677/18,817, 78%), patients reported no technical problems during their postconsultation survey. Health care organizations' general innovativeness and digital maturity had a strong bearing on their ability to introduce, routinize, and expand video consultation services. Conclusions: The national-level groundwork before the pandemic allowed many services to rapidly extend the use of video consultations during the pandemic, supported by a strong strategic vision, a well-resourced quality improvement model, dependable technology, and multiple opportunities for staff to try out the video option. Scotland provides an important national case study from which other countries may learn.
Orthodoxy, illusio, and playing the scientific game: a Bourdieusian analysis of infection control science in the COVID-19 pandemic
Background: Scientific and policy bodies’ failure to acknowledge and act on the evidence base for airborne transmission of SARS-CoV-2 in a timely way is both a mystery and a scandal. In this study, we applied theories from Bourdieu to address the question, “How was a partial and partisan scientific account of SARS-CoV-2 transmission constructed and maintained, leading to widespread imposition of infection control policies which de-emphasised airborne transmission?”. Methods: : From one international case study (the World Health Organisation) and three national ones (UK, Canada and Japan), we selected a purposive sample of publicly available texts including scientific evidence summaries, guidelines, policy documents, public announcements, and social media postings. To analyse these, we applied Bourdieusian concepts of field, doxa , scientific capital, illusio, and game-playing. We explored in particular the links between scientific capital, vested interests, and policy influence. Results: : Three fields—political, state (policy and regulatory), and scientific—were particularly relevant to our analysis. Political and policy actors at international, national, and regional level aligned—predominantly though not invariably—with medical scientific orthodoxy which promoted the droplet theory of transmission and considered aerosol transmission unproven or of doubtful relevance. This dominant scientific sub-field centred around the clinical discipline of infectious disease control, in which leading actors were hospital clinicians aligned with the evidence-based medicine movement. Aerosol scientists—typically, chemists, and engineers—representing the heterodoxy were systematically excluded from key decision-making networks and committees. Dominant discourses defined these scientists’ ideas and methodologies as weak, their empirical findings as untrustworthy or insignificant, and their contributions to debate as unhelpful. Conclusion: The hegemonic grip of medical infection control discourse remains strong. Exit from the pandemic depends on science and policy finding a way to renegotiate what Bourdieu called the ‘rules of the scientific game’—what counts as evidence, quality, and rigour.
Rapid evidence review to inform safe return to campus in the context of coronavirus disease 2019 (COVID-19)
Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted predominantly through the air in crowded and unventilated indoor spaces among unvaccinated people. Universities and colleges are potential settings for its spread. Methods: An interdisciplinary team from public health, virology, and biology used narrative methods to summarise and synthesise evidence on key control measures, taking account of mode of transmission. Results: Evidence from a wide range of primary studies supports six measures. Vaccinate (aim for > 90% coverage and make it easy to get a jab). Require masks indoors, especially in crowded settings. If everyone wears well-fitting cloth masks, source control will be high, but for maximum self-protection, respirator masks should be worn. Masks should not be removed for speaking or singing. Space people out by physical distancing (but there is no 'safe' distance because transmission risk varies with factors such as ventilation, activity levels and crowding), reducing class size (including offering blended learning), and cohorting (students remain in small groups with no cross-mixing). Clean indoor air using engineering controls ventilation (while monitoring CO 2 levels), inbuilt filtration systems, or portable air cleaners fitted with high efficiency particulate air [HEPA] filters). Test asymptomatic staff and students using lateral flow tests, with tracing and isolating infectious cases when incidence of coronavirus disease 2019 (COVID-19) is high. Support clinically vulnerable people to work remotely. There is no direct evidence to support hand sanitising, fomite controls or temperature-taking. There is evidence that freestanding plastic screens, face visors and electronic air-cleaning systems are ineffective. Conclusions: The above six evidence-based measures should be combined into a multi-faceted strategy to maximise both student safety and the continuation of in-person and online education provision. Staff and students seeking to negotiate a safe working and learning environment should collect data (e.g. CO 2 levels, room occupancy) to inform conversations.
Miasmas, mental models and preventive public health: Some philosophical reflections on science in the COVID-19 pandemic
When the history of the COVID-19 pandemic is written, it is likely to show that the mental models held by scientists sometimes facilitated their thinking, thereby leading to lives saved, and at other times constrained their thinking, thereby leading to lives lost. This paper explores some competing mental models of how infectious diseases spread and shows how these models influenced the scientific process and the kinds of facts that were generated, legitimized and used to support policy. A central theme in the paper is the relative weight given by dominant scientific voices to probabilistic arguments based on experimental measurements versus mechanistic arguments based on theory. Two examples are explored: the cholera epidemic in nineteenth century London - in which the story of John Snow and the Broad Street pump is retold - and the unfolding of the COVID-19 pandemic in 2020 and early 2021 - in which the evidence-based medicine movement and its hierarchy of evidence features prominently. In each case, it is shown that prevailing mental models - which were assumed by some to transcend theory but were actually heavily theory-laden - powerfully shaped both science and policy, with fatal consequences for some.
An early warning risk prediction tool (recap-v1) for patients diagnosed with covid-19: Protocol for a statistical analysis plan
Background: Since the start of the COVID-19 pandemic, efforts have been made to develop early warning risk scores to help clinicians decide which patient is likely to deteriorate and require hospitalization. The RECAP (Remote COVID-19 Assessment in Primary Care) study investigates the predictive risk of hospitalization, deterioration, and death of patients with confirmed COVID-19, based on a set of parameters chosen through a Delphi process performed by clinicians. We aim to use rich data collected remotely through the use of electronic data templates integrated in the electronic health systems of several general practices across the United Kingdom to construct accurate predictive models. The models will be based on preexisting conditions and monitoring data of a patient's clinical parameters (eg, blood oxygen saturation) to make reliable predictions as to the patient's risk of hospital admission, deterioration, and death. Objective: This statistical analysis plan outlines the statistical methods to build the prediction model to be used in the prioritization of patients in the primary care setting. The statistical analysis plan for the RECAP study includes the development and validation of the RECAP-V1 prediction model as a primary outcome. This prediction model will be adapted as a three-category risk score split into red (high risk), amber (medium risk), and green (low risk) for any patient with suspected COVID-19. The model will predict the risk of deterioration and hospitalization. Methods: After the data have been collected, we will assess the degree of missingness and use a combination of traditional data imputation using multiple imputation by chained equations, as well as more novel machine-learning approaches to impute the missing data for the final analysis. For predictive model development, we will use multiple logistic regression analyses to construct the model. We aim to recruit a minimum of 1317 patients for model development and validation. We will then externally validate the model on an independent dataset of 1400 patients. The model will also be applied for multiple different datasets to assess both its performance in different patient groups and its applicability for different methods of data collection. Results: As of May 10, 2021, we have recruited 3732 patients. A further 2088 patients have been recruited through the National Health Service Clinical Assessment Service, and approximately 5000 patients have been recruited through the DoctalyHealth platform. Conclusions: The methodology for the development of the RECAP-V1 prediction model as well as the risk score will provide clinicians with a statistically robust tool to help prioritize COVID-19 patients.