The impact and applications of social media platforms for public health responses before and during COVID-19

Background

 Social media platforms have numerous potential benefits and drawbacks on public health, which have been described in the literature. The COVID-19 pandemic has exposed our limited knowledge regarding the potential health impact of these platforms, which have been detrimental to public health responses in many regions.

Objective

This review aims to highlight a brief history of social media in health care and report its potential negative and positive public health impacts, which have been characterized in the literature.

Methods

 We searched electronic bibliographic databases including PubMed, including Medline and Institute of Electrical and Electronics Engineers Xplore, from December 10, 2015, to December 10, 2020. We screened the title and abstracts and selected relevant reports for review of full text and reference lists. These were analyzed thematically and consolidated into applications of social media platforms for public health.

Results

 The positive and negative impact of social media platforms on public health are catalogued on the basis of recent research in this report. These findings are discussed in the context of improving future public health responses and incorporating other emerging digital technology domains such as artificial intelligence. However, there is a need for more research with pragmatic methodology that evaluates the impact of specific digital interventions to inform future health policy.

Conclusions

 Recent research has highlighted the potential negative impact of social media platforms on population health, as well as potentially useful applications for public health communication, monitoring, and predictions. More research is needed to objectively investigate measures to mitigate against its negative impact while harnessing effective applications for the benefit of public health.

Alcohol reduction outcomes following brief counseling among adults with HIV in Zambia: A sequential mixed methods study

Data from sub-Saharan Africa on the impact of alcohol on the HIV epidemic in sub-Saharan Africa is limited. In this region, it is not well understood how people with HIV (PLWHA) respond to alcohol reduction counseling while they are linked to HIV clinical care. We conducted an explanatory sequential mixed-methods study to understand patterns of alcohol use among adults (18+ years) within a prospective HIV cohort at two urban public-sector clinics in Zambia. At antiretroviral therapy (ART) start and one year later, we measured alcohol use with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and those reporting any alcohol use were provided brief counseling. We conducted focus groups at 1 year with participants who had any alcohol use and 20 in-depth interviews among the subgroup with unhealthy use pre-ART and who either reduced or did not reduce their use by 1 year to moderate levels or abstinence. Focus group Discussions (FGDs) (n = 2) were also held with HIV clinic staff. Qualitative data were analyzed using thematic analysis. The data obtained from 693 participants was analyzed (median age 34 years, 45% men), it revealed that unhealthy alcohol use (AUDIT-C >3 for men; >2 for women) was reported among 280 (40.4%) at baseline and 205 (29.6%) at 1 year on ART. Reduction from unhealthy to moderate use or abstinence was more common with older age, female, non-smoking, and at Clinic B (all P<0.05). Qualitative data revealed ineffective alcohol support at clinics, social pressures in the community to consume alcohol, and unaddressed drivers of alcohol use including poverty, poor health status, depression, and HIV stigma. Healthcare workers reported a lack of training in alcohol screening and treatment, which led to mixed messages provided to patients ('reduce to safe levels' versus 'abstain'). In summary, interventions to reduce unhealthy alcohol use are needed within HIV clinics in Zambia as a substantial population have persistent unhealthy use despite current HIV clinical care. A better understanding is needed regarding the implementation challenges related to screening for unhealthy alcohol use integrated with HIV services.

Delivery of TB preventive therapy to incarcerated people living with HIV in southern African correctional facilities

TB preventive treatment (TPT) is recommended for high-risk and hard-to-reach populations such as incarcerated people living with HIV (PLHIV). To assess implementation of TPT delivery in correctional settings, we conducted an exploratory analysis of data from a multisite cohort study in South Africa and Zambia. From 975 participants, 648 were screened for TB, and 409 initiated TPT mostly within a month after initiation of antiretroviral therapy (190/409, 46.5%). We observed a median gap of one month (IQR 0.6-4.7) in TPT delivery to incarcerated PLHIV. Future research should examine standardised quality improvement tools and new strategies such as short-course regimens to improve TPT initiation in this population.

Prioritisation of colonoscopy services in colorectal cancer screening programmes to minimise impact of COVID-19 pandemic on predicted cancer burden: A comparative modelling study

Objectives

Colorectal cancer (CRC) screening with a faecal immunochemical test (FIT) has been disrupted in many countries during the COVID-19 pandemic. Performing catch-up of missed screens while maintaining regular screening services requires additional colonoscopy capacity that may not be available. This study aimed to compare strategies that clear the screening backlog using limited colonoscopy resources.

Methods

A range of strategies were simulated using four country-specific CRC natural-history models: Adenoma and Serrated pathway to Colorectal CAncer (ASCCA) and MIcrosimulation SCreening ANalysis for CRC (MISCAN-Colon) (both in the Netherlands), Policy1-Bowel (Australia) and OncoSim (Canada). Strategies assumed a 3-month screening disruption with varying recovery period lengths (6, 12, and 24 months) and varying FIT thresholds for diagnostic colonoscopy. Increasing the FIT threshold reduces the number of referrals to diagnostic colonoscopy. Outcomes for each strategy were colonoscopy demand and excess CRC-related deaths due to the disruption.

Results

Performing catch-up using the regular FIT threshold in 6, 12 and 24 months could prevent most excess CRC-related deaths, but required 50%, 25% and 12.5% additional colonoscopy demand, respectively. Without exceeding usual colonoscopy demand, up to 60% of excess CRC-related deaths can be prevented by increasing the FIT threshold for 12 or 24 months. Large increases in FIT threshold could lead to additional deaths rather than preventing them.

Conclusions

Clearing the screening backlog in 24 months could avert most excess CRC-related deaths due to a 3-month disruption but would require a small increase in colonoscopy demand. Increasing the FIT threshold slightly over 24 months could ease the pressure on colonoscopy resources.

Priorities for family physician and general practitioner recruitment and retention in Singapore: a PRIORITIZE study

Background

A shortage of primary care physicians has been reported in many countries. Primary care systems are diverse and the challenges leading to a decline in workforce are at times context-specific and require tailored solutions. Inviting frontline clinicians to share their insights can help identify optimal strategies for a particular setting. To determine priorities for family physicians’ and general practitioners’ recruitment and retention in Singapore, we invited primary care physicians to rank pertinent strategies using PRIORITIZE, a transparent, systematic priority-setting approach.

Methods

The study advisory board, consisting of representatives of Singapore’s key primary care stakeholders, determined the criteria for prioritising of general practitioners (GPs) and family physicians (FPs) recruitment and retention strategies in Singapore. A comprehensive list of GPs and FPs recruitment and retention strategies was extracted from a recent systematic review of the relevant literature. A questionnaire listing the strategies and the scoring criteria was administered online to doctors practicing in public and private sector in Singapore. Respondents’ scores were combined to create a ranked list of locally most relevant strategies for improving GPs and FPs recruitment and retention.

Results

We recruited a diverse sample of 50 GPs and FPs practicing in a variety of primary care settings, many with a range of additional professional responsibilities. Around 60 and 66% of respondents thought that there was a problem with recruitment and retention of GPs and FPs in Singapore, respectively. Strategies focusing on promoting primary care by emphasizing the advantages and enhancing the status of the profession as well as training-related strategies, such as sub-specialisation and high-quality rotations were considered priorities for improving recruitment. For retention of GPs and FPs, improving working conditions by increasing GPs’ and FPs’ salary and recognition, as well as varying or reducing time commitment, were seen as the most important strategies. The ranking between physicians working in public and private sector was mostly similar, with nine out of the top ten recruitment and retention strategies being the same.

Conclusion

Primary care physicians’ ranking of recruitment and retention strategies for GPs and FPs in Singapore provide important insight into the challenges and the solutions as seen by the members of the profession themselves. This information can guide future policy and decision making in this area.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01570-1.

Whole-genome sequencing and ad hoc shared genome analysis of Staphylococcus aureus isolates from a New Zealand primary school

Epidemiological studies of communicable diseases increasingly use large whole-genome sequencing (WGS) datasets to explore the transmission of pathogens. It is important to obtain an initial overview of datasets and identify closely related isolates, but this can be challenging with large numbers of isolates and imperfect sequencing. We used an ad hoc whole-genome multi locus sequence typing method to summarise data from a longitudinal study of Staphylococcus aureus in a primary school in New Zealand. Each pair of isolates was compared and the number of genes where alleles differed between isolates was tallied to produce a matrix of "allelic differences". We plotted histograms of the number of allelic differences between isolates for: all isolate pairs; pairs of isolates from different individuals; and pairs of isolates from the same individual. 340 sequenced isolates were included, and the ad hoc shared genome contained 445 genes. There were between 0 and 420 allelic differences between isolate pairs and the majority of pairs had more than 260 allelic differences. We found many genetically closely related S. aureus isolates from single individuals and a smaller number of closely-related isolates from separate individuals. Multiple S. aureus isolates from the same individual were usually very closely related or identical over the ad hoc shared genome. Siblings carried genetically similar, but not identical isolates. An ad hoc shared genome approach to WGS analysis can accommodate imperfect sequencing of the included isolates, and can provide insights into relationships between isolates in epidemiological studies with large WGS datasets containing diverse isolates.

477 Surgical Solutions and Problems in An Adult Patient with VACTERL Association

Background

We report an adult patient with features of VACTERL - oesophageal and anal atresia, with cardiac malformation. In infancy he underwent colonic interposition for oesophageal atresia using the transverse colon as a conduit. As a teenager he underwent formation of a Koch continent ileostomy after previous stoma formation for anal atresia. Eventual failure of the Koch pouch nipple valve necessitated a laparotomy for attempted refashioning. Unfortunately, this operation was beset by life-threatening complications and a protracted post-operative course. He presented to our hospital with a laparostomy, high output enterocutaneous fistulae (ECF) necessitating home total parenteral nutrition (TPN), severe cachexia and deconditioning.

Method

Conservative therapy was utilised to improve the nutritional and physiological status of the patient. Simultaneously, attempts were made to define the anatomy of his abdomen in relation to previous surgery. However, operation notes for the original procedures (oesophageal reconstruction and Koch pouch formation) were lost due to closure of the hospital which he attended at the time.

A laparotomy was subsequently performed to manage the ECFs. Most of the small intestine was unsalvageable due to multiple fistulae and adhesions, leaving 35cm of small bowel terminating in an end ileostomy. A cholecystectomy was performed to mitigate gallstone formation.

Conclusions

Efficient communication is imperative in the management of complex patients. The loss of original operation notes made interpretation of subsequent imaging and planning of surgery troublesome. In contrast, efficient communication between teams involved in his peri-operative care, particularly the respiratory and intensive care teams facilitated a smooth post-operative course and successful discharge from hospital.

The expression and activity of Toll-like receptors in the preimplantation human embryo suggest a new role for innate immunity

STUDY QUESTION

Is the innate immunity system active in early human embryo development?

SUMMARY ANSWER

The pattern recognition receptors and innate immunity Toll-like receptor (TLR) genes are widely expressed in preimplantation human embryos and the pathway appears to be active in response to TLR ligands.

WHAT IS KNOWN ALREADY

Early human embryos are highly sensitive to their local environment, however relatively little is known about how embryos detect and respond to specific environmental cues. While the maternal immune response is known to be key to the establishment of pregnancy at implantation, the ability of human embryos to detect and signal the presence of pathogens is unknown.

STUDY DESIGN, SIZE, DURATION

Expression of TLR family and related genes in human embryos was assessed by analysis of published transcriptome data (n = 40). Day 5 (D-5) human embryos (n = 25) were cultured in the presence of known TLR ligands and gene expression and cytokine production measured compared to controls.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Human embryos surplus to treatment requirements were donated with informed consent from several ART centres. Embryos were cultured to Day 6 (D-6) in the presence of the TLR3 and TLR5 ligands Poly (I: C) and flagellin, with gene expression measured by quantitative PCR and cytokine release into medium measured using cytometric bead arrays.

MAIN RESULTS AND THE ROLE OF CHANCE

TLR and related genes, including downstream signalling molecules, were expressed variably at all human embryo developmental stages. Results showed the strongest expression in the blastocyst for TLRs 9 and 5, and throughout development for TLRs 9, 5, 2, 6 and 7. Stimulation of Day 5 blastocysts with TLR3 and TLR5 ligands Poly (I: C) and flagellin produced changes in mRNA expression levels of TLR genes, including the hyaluronan-mediated motility receptor (HMMR), TLR5, TLR7, nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and monocyte chemoattractant Protein-1 (MCP-1) (P < 0.05, P < 0.001 compared to unstimulated controls), and release into culture medium of cytokines and chemokines, notably IL8 (P = 0.00005 and 0.01277 for flagellin and Poly (I: C), respectively).

LIMITATIONS, REASONS FOR CAUTION

This was a descriptive and experimental study which suggests that the TLR system is active in human embryos and capable of function, but does not confirm any particular role. Although we identified embryonic transcripts for a range of TLR genes, the expression patterns were not always consistent across published studies and expression levels of some genes were low, leaving open the possibility that these were expressed from the maternal rather than embryonic genome.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first report of the expression and activity of a number of components of the innate immunity TLR system in human embryos. Understanding the role of TLRs during preimplantation human development may be important to reveal immunological mechanisms and potential clinical markers of embryo quality and pregnancy initiation during natural conception and in ART.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the Ministry of Higher Education, The State of Libya, the UK Medical Research Council, and the NIHR Local Comprehensive Research Network and NIHR Manchester Clinical Research Facility and the European Union's Horizon 2020 Research and Innovation Programmes under the Marie Skłodowska-Curie Grant Agreement No. 812660 (DohART-NET). In accordance with H2020 rules, no new human embryos were sacrificed for research activities performed from the EU funding, which concerned only in silico analyses of recorded time-lapse and transcriptomics datasets. None of the authors has any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

n/a.

How practice setting affects family physicians' views on genetic screening: a qualitative study

BACKGROUND

Genetic screening (GS), defined as the clinical testing of a population to identify asymptomatic individuals with the aim of providing those identified as high risk with prevention, early treatment, or reproductive options. Genetic screening (GS) improves patient outcomes and is accessible to the community. Family physicians (FPs) are ideally placed to offer GS. There is a need for FPs to adopt GS to address anticipated genetic specialist shortages.

OBJECTIVE

To explore FP attitudes, perceived roles, motivators and barriers, towards GS; and explore similarities and differences between private and public sector FPs.

METHODS

We developed a semi-structured interview guide using existing literature. We interviewed private and public sector FPs recruited by purposive, convenience and snowballing strategies, by telephone or video to theme saturation. All sessions were audio-recorded, transcribed and coded for themes by two independent researchers with an adjudicator.

RESULTS

Thirty FPs were interviewed (15 private, 15 public). Theme saturation was reached for each group. A total of 12 themes (6 common, 3 from private-practice participants, 3 public-employed participants) emerged. Six common major themes emerged: personal lack of training and experience, roles and relevance of GS to family medicine, reluctance and resistance to adding GS to practice, FP motivations for adoption, patient factors as barrier, and potential solutions. Three themes (all facilitators) were unique to the private group: strong rapport with patients, high practice autonomy, and high patient literacy. Three themes (all barriers) were unique to the public group: lack of control, patients' lower socioeconomic status, and rigid administrative infrastructure.

CONCLUSION

FPs are motivated to incorporate GS but need support for implementation. Policy-makers should consider the practice setting when introducing new screening functions. Strategies to change FP behaviours should be sensitive to their sense of autonomy, and the external factors (either as facilitators or as barriers) shaping FP practices in a given clinical setting.

Cost-effectiveness of specialist eating disorders services for children and adolescents with anorexia nervosa: a national surveillance study

BACKGROUND

Evidence suggests specialist eating disorders services for children and adolescents with anorexia nervosa have the potential to improve outcomes and reduce costs through reduced hospital admissions. This study aimed to evaluate the cost-effectiveness of assessment and diagnosis in community-based specialist child and adolescent mental health services (CAMHS) compared to generic CAMHS for children and adolescents with anorexia nervosa.

METHOD

Observational, surveillance study of children and adolescents aged 8 to 17, in contact with community-based CAMHS in the UK or Republic of Ireland for a first episode of anorexia nervosa. Data were reported by clinicians at baseline, 6 and 12-months follow-up. Outcomes included the Children's Global Assessment Scale (CGAS) and percentage of median expected body mass for age and sex (%mBMI). Service use data included paediatric and psychiatric inpatient admissions, outpatient and day-patient attendances. A joint distribution of incremental mean costs and effects for each group was generated using bootstrapping to explore the probability that each service is the optimal choice, subject to a range of values a decision-maker might be willing to pay for outcome improvements. Uncertainty was explored using cost-effectiveness acceptability curves.

RESULTS

Two hundred ninety-eight children and adolescents met inclusion criteria. At 12-month follow-up, there were no significant differences in total costs or outcomes between specialist eating disorders services and generic CAMHS. However, adjustment for pre-specified baseline covariates resulted in observed differences favouring specialist services, due to significantly poorer clinical status of the specialist group at baseline. Cost-effectiveness analysis using CGAS suggests that the probability of assessment in a specialist service being cost-effective compared to generic CAMHS ranges from 90 to 50%, dependent on willingness to pay for improvements in outcome.

CONCLUSIONS

Assessment in a specialist eating disorders service for children and adolescents with anorexia nervosa may have a higher probability of being cost-effective than assessment in generic CAMHS.

TRIAL REGISTRATION

ISRCTN12676087 . Date of registration 07/01/2014.

Principles for pandemics: COVID-19 and professional ethical guidance in England and Wales

BACKGROUND

During the arrival of the COVID-19 pandemic, various professional ethical guidance was issued to (and for) health and social care professionals in England and Wales. Guidance can help to inform and support such professionals and their patients, clients and service users, but a plethora of guidance risked information overload, confusion, and inconsistency.

METHODS

During the early months of the pandemic, we undertook a rapid review, asking: what are the principles adopted by professional ethical guidance in England and Wales for dealing with COVID-19? We undertook thematic content analysis of the 29 documents that met our inclusion criteria.

RESULTS

The 29 documents captured 13 overlapping principles: respect, fairness, minimising harm, reciprocity, proportionality, flexibility, working together, inclusiveness, communication, transparency, reasonableness, responsibility, and accountability.

CONCLUSIONS

We intend this attempt to collate and outline the prominent principles to be helpful, particularly, for healthcare practice during the COVID-19 pandemic and, hopefully, for future pandemic planning. We also offer some reflections on the guidance and the principles therein. After describing the principles, we reflect on some of the similarities and differences in the guidance, and the challenges associated not only with the specific guidance reviewed, but also with the nature and import of "professional ethical guidance".

Understanding the decision-making of critical care nurses when restraining a patient with psychomotor agitation secondary to hyperactive delirium: A 'Think Aloud' study

AIMS & OBJECTIVES

This study aimed to explore the decision-making processes undertaken by critical care nurses when considering restraint to manage a patient with psychomotor agitation secondary to hyperactive delirium.

BACKGROUND

Psychomotor agitation is frequently cited as clinical rationale for initiating chemical or physical restraint. Despite the presence of clinical guidance for restraint in critical care, wide variations in nursing and prescribing practice are evident. Nurses are the primary decision makers when initiating restraint, but little is known about this process and influencing factors.

DESIGN

A pragmatic qualitative approach was used to explore critical care nurses' decision-making processes.

METHODS

A 'think aloud' approach was undertaken. Audio-visual vignettes featuring simulated patients were used as stimulus to elicit decision-making processes from thirty critical care nurses and practitioners. The COREQ checklist was followed.

RESULTS

Five themes relating to restraint were identified: Intrinsic beliefs and aptitudes; Handover and labelling; Failure to maintain a consistent approach; Restraint might be used to replace vigilance; The tyranny of the now.

CONCLUSIONS

Restraint was more frequent when staffing ratios were reduced below 1:1 and opportunities for vigilance reduced. Participants described physical and psychological exhaustion when caring for a patient with delirium and how this might lead to restraint to create 'space' for respite. Variations in practice were evident and restraint use appears rooted in custom and culture rather than objective assessment.

RELEVANCE TO CLINICAL PRACTICE

The lack of pre-emptive management for hyperactive delirium and reduced staffing ratios lead to the decision to restrain to preserve safety in acute agitation. The struggle to manage agitated behaviour is associated with nurse burnout and reduced engagement with therapeutic management methods, suggesting the need for psychological and educational support for clinical staff. Delirium is an important and debilitating form of organ dysfunction which should be collaboratively managed by the multi-disciplinary team.

Vaccine acceptability, uptake and completion amongst men who have sex with men: A systematic review, meta-analysis and theoretical framework

BACKGROUND

Due to an increased risk of sexually transmitted infections (STIs), gay, bisexual and other men who have sex with men (MSM) have been recommended to receive vaccinations against human papillomavirus, meningitis C and hepatitis A/B. This review aimed to compare the rates of vaccine acceptability, uptake and completion, and to identify determinants of vaccine outcomes specific to MSM to inform a theoretical framework.

METHODS

In January 2020 four databases were explored to identify vaccination behaviours and associated factors among MSM. A narrative systematic review and meta-analysis were performed. Data were synthesised for theoretical modelling.

RESULTS

Seventy-eight studies, mostly from the USA, were included. The average vaccine acceptability was 63% (median = 72%, range: 30%-97%), vaccine uptake 45% (median = 42%, range: 5%-100%) and vaccine completion 47% (median = 45%, range: 12%-89%). Six categories of factors associated with vaccination acceptability, uptake and completion were conceptualised: Individual (e.g., demographic and psychosocial); Interpersonal (e.g., peer education); Healthcare provider (e.g., vaccine recommendation); Organisational and practice setting (e.g., routine collection of patient sexual orientation information that is integrated into a clinical decision support system); Community environment (e.g., targeted health promotion campaigns); and National, state and local policy environment (e.g., public health guidelines targeting MSM).

CONCLUSION

Despite overall high levels of acceptability, uptake and completion rates were below targets predicted by cost-effectiveness modelling across all recommended vaccines. These parameters may need to be adjusted for more precise estimations of cost-effectiveness. Addressing the multiple levels of determinants, as outlined in our theoretical framework, will help guide interventions to increase vaccine completion among MSM.

Using audiovisual vignettes to collect data remotely on complex clinical care: a practical insight

BACKGROUND

Vignettes are regularly used in nursing research and education to explore complex clinical situations. However, paper-based vignettes lack clinical realism and do not fully recreate the pressures, sights and sounds of clinical settings, limiting their usefulness when studying complex decision-making processes.

AIM

To discuss the approach taken by the authors in developing and implementing audiovisual vignettes to collect data remotely in a qualitative study.

DISCUSSION

The authors describe how they created audiovisual vignettes for a qualitative 'Think Aloud' study exploring how critical care nurses decide whether to restrain agitated patients with varying degrees of psychomotor agitation. They discuss the practicalities of filming, editing and hosting, as well as the theoretical and clinical background that informed the creation of the vignettes.

CONCLUSION

Audiovisual vignettes are a cost- and time-effective way of remotely exploring decision-making in challenging environments. This innovative method assists in studying decision-making under simulated clinical pressures and captures data about how people make complex decisions.

IMPLICATIONS FOR PRACTICE

Audiovisual vignettes are an innovative tool for collecting data and could also be used in educational settings and offer the opportunity to explore complex clinical decision making remotely. Clinical accuracy is essential for immersing participants and simulating an environment and its pressures. The method could be further enhanced by making vignettes responsive to participants' decisions.

Usability and acceptability of a multimodal respiratory rate and pulse oximeter device in case management of children with symptoms of pneumonia: A cross-sectional study in Ethiopia

Aim

Pneumonia is the leading infectious cause of death among children under five globally. Many pneumonia deaths result from inappropriate treatment due to misdiagnosis of signs and symptoms. This study aims to identify whether health extension workers (HEWs) in Ethiopia, using an automated multimodal device (Masimo Rad‐G), adhere to required guidelines while assessing and classifying under five children with cough or difficulty breathing and to understand device acceptability.

Methods

A cross‐sectional study was conducted in three districts of Southern Nations, Nationalities, and Peoples' Region, Ethiopia. Between September and December 2018, 133 HEWs were directly observed using Rad‐G while conducting 599 sick child consultations. Usability was measured as adherence to the World Health Organization requirements to assess fast breathing and device manufacturer instructions for use. Acceptability was assessed using semi‐structured interviews with HEWs, first‐level health facility workers and caregivers.

Results

Adherence using the Rad‐G routinely for 2 months was 85.3% (95% CI 80.2, 89.3). Health workers and caregivers stated a preference for Rad‐G. Users highlighted a number of device design issues.

Conclusion

While demonstrating high levels of acceptability and usability, the device modifications to consider include better probe fit, improved user interface with exclusive age categories and simplified classification outcomes.

Identifying behaviour change techniques to support medicines management for older people at care transitions

Introduction

Older patients are at significant risk of medicines-related harm following a hospital to home transition [1]. Strategies, such as information transfer and medicines reconciliation, have been suggested to promote successful transitions through better medicines management [2]. These interventions, however, are not often underpinned by patient experience or grounded in theory, and therefore have variable effects in real-world contexts.

Aim

To identify which behaviour change techniques (BCTs) could be combined within a complex intervention to support post-discharge medicines management.

Methods

Barriers and facilitators to post-discharge medicines management behaviours were identified from an analysis of interviews with twenty-seven older people (aged 75 years plus) and mapped to the Theoretical Domains Framework (TDF). These participants were recruited during a stay in two large hospitals in the North of England. All potential BCTs targeting the identified TDF domains were found using validated mapping exercises and refined by panel consensus. The panel consisted of two pharmacists, two health services researchers, a social work academic and a patient representative. Next, a convenience sample of key stakeholders (n=40; patients and family carers, healthcare professionals and researchers) were invited to take part in an online survey to prioritise remaining techniques. A total score for each BCT was calculated based on its potential i) effectiveness, ii) acceptability and iii) ability to cause unintended consequences. The BCTs were ranked from lowest to highest scores. As validation, the final selection of BCTs was assessed using the APEASE criteria and mapped back to the behavioural determinants to check the components would enhance facilitators and overcome barriers (Figure 1).

Results

Forty-six behavioural determinants were identified within interviews and classified as barriers (n=19), facilitators (n=10), or both (n=17). These were deductively mapped onto 11 domains of the TDF. Following the mapping, 50 discrete BCTs were identified, which were reduced to 35 after subsequent consensus discussions between panel members to remove any deemed inappropriate. The survey resulted in 25 responses (62.5% response rate). Following visual inspection of the ranking, a natural cut-off was identified by panel consensus at 88% of the total score. This, and further assessment using the APEASE criteria, prioritised eight BCTs that were highly rated to be effective in promoting post-discharge medicines management when combined within a complex intervention. These were: practical social support, goal/ target specified, prompts, triggers or cues, social processes of encouragement, motivational interviewing, rehearsal, review goals, and comparative imagining of future outcomes.

Conclusion

This study has identified eight BCTs that could be valuable when combined within a complex intervention to support post-discharge medicines management for older people. Consensus allowed prioritisation of BCTs that were likely to be effective, acceptable to older people, practical and cost-effective to deliver within current healthcare organisations. Limitations included challenges of coding complex behavioural determinants to the TDF, defining the BCTs within the medicines management context and modest survey sample size. To overcome these limitations, input was sought from a health psychologist with expertise and consensus involved all relevant stakeholders.

References

1. Parekh, N., Ali, K., Stevenson, J. M., et al. Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK. British journal of clinical pharmacology 2018;84(8):1789–1797.

2. Tomlinson, J., Cheong, V., Fylan, B., et al. Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity. Age and Ageing 2020;00:1–12.

22 Coping with Medicines After Hospital Discharge; the Invisible Work of Older Patients and Their Care-Givers

Introduction

Older patients often experience medication-related problems following discharge from hospital. These can be categorised as issues with obtaining medication, taking medication, medication effects or problems with communication or care co-ordination (Nicosia et al., Journal of General Internal Medicine, 2019, https://doi.org/10.1007/s11606-019-05463-z). The aim of this study was to explore older adults’ experiences of post-discharge medicines management, including the strategies they use to safely manage their changed medicines.

Methods

Following ethical approval, patients aged 75 and above, with a change in their long term medicines, were recruited during admission to one of two hospitals in Yorkshire. Semi-structured interviews took place with the participants in their own homes, approximately two weeks after discharge. Interviews were audio recorded and transcribed. Data were analysed using the Framework method.

Results

Twenty-seven patients (mean age 85 years; 6 males) consented to be interviewed. They described multiple self-management and safety strategies used to support medicines management in the early post-discharge phase. The work done included adaptations (to routines, the home environment and action plans), scaffolding (where patients and their care-givers support the primary care system by providing additional documentation or prompts to ensure medicines were supplied on time and were correct) and error avoidance (seeking information, performing checks and balances).

Conclusion

Older patients experience gaps in their post-discharge medicines-related care which they had to bridge through implementing their own strategies or by enlisting support from others. This study shines a spotlight on to the invisible work that patients have to do in order to make post-discharge medicines management fit for purpose. Further work should consider those patients who are not able to carry out these tasks or who do not have any care-givers available for support and how this potential gap in care can be addressed.

Characteristics of Patients Seeking and Proceeding with Non-Surgical Facial Aesthetic Procedures

Purpose

Identifying predictors for patients' readiness to receive non-surgical facial aesthetic treatments facilitates the physician's understanding of the patient's goals and expectations. This paper aims to identify clinical and demographic characteristics of patients who proceed with non-surgical facial aesthetic procedures in Singapore.

Patients and Methods

Using data from electronic patient health records, authors examined clinical and demographic characteristics of 624 Asian and Caucasian patients who sought treatment in a 12-month period and who had minimum follow-up of 1 year. Variables examined included age, race/ethnicity, gender, prior treatment, and attitudes and motivation for seeking treatment. Univariate and multivariate analyses of factors associated with proceeding with the treatment plan were evaluated using chi-square and logistic regression analyses.

Results

Approximately 88% of patients who sought consultation proceeded with treatment. The majority were older than 40 years of age, were female and received prior treatments. Notable is the high frequency of rejuvenation rather than correction as the clinical outcome goal. There were slightly more Caucasians than Chinese patients but the racial distribution allowed the identification of differences between the two groups. Chinese patients were younger and more likely to seek correction or more obvious changes as compared to Caucasian patients. On multivariate analyses, powerful predictors for proceeding with non-invasive facial treatments included a treatment goal of rejuvenation rather than correction, an expectation of an immediate result, and prior aesthetic treatments.

Conclusion

This study is the first to compare race/ethnic differences in factors that influence treatment with non-invasive aesthetic procedures. This is also the first to identify demographic, clinical and motivational characteristics associated with actual treatment with non-invasive facial procedures. Further research on a systematic approach to defining a patient's motivation for receiving treatment, as well as research identifying which patients are more likely to have positive clinical outcomes are warranted.

Asthma prescribing according to Arg16Gly beta-2 genotype: a randomised trial in adolescents

INTRODUCTION

The A allele of rs1042713 (Arg16 amino acid) in the beta-2 (β2) adrenoreceptor is associated with poor response to long-acting β2-agonist (LABA) in young people with asthma. Our aim was to assess whether the prescribing of second line controller with LABA or a leukotriene receptor antagonist (LTRA) according to Arg16Gly genotype would result in improvements in pediatric asthma-related quality of life questionnaire (PAQLQ).

METHODS

We performed a pragmatic randomised controlled trial (RCT) via a primary care clinical research network covering England and Scotland. We enrolled participants aged 12-18 years with asthma taking inhaled corticosteroids. A total of 241 participants (mean (sd) age 14.7 years (1.91)) were randomised (1:1) to receive personalised care (genotype directed prescribing) or standard guideline care. Following 4-week run-in participants were followed for 12-months. The primary outcome measure was change in PAQLQ. Asthma control, asthma exacerbation frequency and healthcare utilisation were secondary outcomes.

RESULTS

Genotype directed prescribing resulted in an improvement in PAQLQ compared to standard care 0.16, (95%CI 0.00-0.31; p=0.049), although this improvement was below the pre-determined clinical threshold of 0.25. The AA genotype was associated with a larger improvement in PAQLQ with personalised versus standard care 0.42, (95%CI 0.02-0.81; p=0.041).

CONCLUSION

This is the first RCT demonstrating that genotype driven asthma prescribing is associated with a significant improvement in a clinical outcome compared to standard care. Adolescents with the AA homozygous genotype benefited most. The potential role of such β2-adrenoceptor genotype directed therapy in younger and more severe childhood asthma warrants further exploration.

Long-term Impact of Pneumococcal Conjugate Vaccines on Invasive Disease and Pneumonia Hospitalizations in Indigenous and Non-Indigenous Australians

BACKGROUND

Universal pneumococcal conjugate vaccine (PCV) programs began in Indigenous Australian children in 2001 and all children in 2005, changing to 13-valent PCV (PCV13) in 2011. We used laboratory data for invasive pneumococcal disease (IPD) and coded hospitalizations for noninvasive pneumococcal community-acquired pneumonia (PnCAP) to evaluate long-term impact.

METHODS

Annual incidence (per 100 000 population) was calculated for age-specific total IPD, PCV13 non-7-valent PCV (PCV7) serotypes, and PnCAP by Indigenous status. Incidence in the pre-universal PCV7 (2002-2004), early PCV7 (2005-2007), pre-PCV13 (2008 to mid-2011), and post-PCV13 (mid-2011 to 2016) periods was used to calculate incidence rate ratios (IRRs).

RESULTS

In the total population, all-age incidence of IPD declined from 11.8 pre-PCV7 to 7.1 post-PCV13 (IRR, 0.61 [95% confidence interval {CI}, .59-.63]) but for PnCAP declined among ages <1 year (IRR, 0.34 [95% CI, .25-.45]) and 1-4 years (IRR, 0.50 [95% CI, .43-.57]) but increased significantly among age ≥5 years (IRRs, 1.08-1.14). In Indigenous people, baseline PCV13 non-PCV7 IPD incidence was 3-fold higher, amplified by a serotype 1 epidemic in 2011. By 2015-2016, although incidence of IPD and PnCAP in children aged <5 years decreased by 38%, neither decreased in people aged ≥5 years.

CONCLUSIONS

Fifteen years post-PCV and 5 years post-PCV13, direct and indirect impact on IPD and PnCAP differed by age and between Indigenous and non-Indigenous people, with potential implications for long-term PCV impact in comparable settings.Fifteen years after pneumococcal conjugate vaccine (PCV) introduction and 5 years post-PCV13, direct and indirect impact on invasive pneumococcal disease and pneumococcal community-acquired pneumonia differed by age and between Indigenous and non-Indigenous people, with potential implications for long-term PCV impact in comparable settings.

Stillbirths During the COVID-19 Pandemic in England, April-June 2020

This study uses National Health Service data to compare the stillbirth rate overall and regionally during the initial April-June 2020 coronavirus lockdown vs the same period in 2019.

The hallmarks of childhood abuse and neglect: A systematic review

BACKGROUND

Studies on the impacts of child maltreatment (CM) have been conducted in diverse areas. Mechanistic understanding of the complex interplay between factors is lacking. Hallmarking is an approach which identifies common factors across studies and highlights the most robust findings.

OBJECTIVES

In a review of systematic reviews and meta-analyses, we addressed the following questions: 1) What are the hallmarks associated with exposure to CM across the bio-ecological spectrum? 2) What is the strength of evidence to support each hallmark? 3) What are the gaps that future research should address?

METHODS

A comprehensive literature search was carried out to find relevant systematic reviews or meta-analyses. 269 articles were read in full and 178 articles, encompassing more than 6000 original papers, were included in the final synthesis. All reviews were independently rated for quality by at least 2 reviewers using AMSTAR-2.

RESULTS

Of 178 review articles, 6 were rated as high quality (all meta-analyses) and 46 were rated as medium quality. Most were from high income countries.

CONCLUSIONS

Based on the most commonly reported high-quality research findings we propose that the hallmarks of exposure to child maltreatment are: Increased risk of psychopathology; Increased risk of obesity; Increased risk of high- risk sexual behaviours, Increased risk of smoking; and Increased risk of child maltreatment in children with disabilities. Research gaps include a lack of focus on complexity and resilience. Little can be concluded about directions of causality or mechanisms. Adequately powered prospective studies are required to move the field forward.

COVID-19 Contact-Tracing Apps: Analysis of the Readability of Privacy Policies

Apps that enable contact-tracing are instrumental in mitigating the transmission of COVID-19, but there have been concerns among users about the data collected by these apps and their management. Contact tracing is of paramount importance when dealing with a pandemic, as it allows for rapid identification of cases based on the information collected from infected individuals about other individuals they may have had recent contact with. Advances in digital technology have enabled devices such as mobile phones to be used in the contract-tracing process. However, there is a potential risk of users’ personal information and sensitive data being stolen should hackers be in the near vicinity of these devices. Thus, there is a need to develop privacy-preserving apps. Meanwhile, privacy policies that outline the risk associated with the use of contact-tracing apps are needed, in formats that are easily readable and comprehensible by the public. To our knowledge, no previous study has examined the readability of privacy policies of contact-tracings apps. Therefore, we performed a readability analysis to evaluate the comprehensibility of privacy policies of 7 contact-tracing apps currently in use. The contents of the privacy policies of these apps were assessed for readability using Readability Test Tool, a free web-based reliability calculator, which computes scores based on a number of statistics (ie, word count and the number of complex words) and indices (ie, Flesch Reading Ease, Flesch-Kincaid Reading Grade Level, Gunning Fog Index, and Simplified Measure of Gobbledygook index). Our analysis revealed that explanations used in the privacy policies of these apps require a reading grade between 7 and 14, which is considerably higher than the reading ability of the average individual. We believe that improving the readability of privacy policies of apps could be potentially reassuring for users and may help facilitate the increased use of such apps.