Informing NHS policy in ‘digital-first primary care’: a rapid evidence synthesis

Unveiling the heterogeneous utilisation of the same digital patient management platform: case studies in primary healthcare in Sweden

BACKGROUND

The utilisation of digital technology in primary healthcare, particularly digital patient management platforms, has gained prominence, notably due to the global pandemic. These platforms are positioned as substitutes for face-to-face consultations and telephone triage. They are seen as a potential solution to the escalating costs associated with an aging population, increasing chronic conditions, and a shrinking healthcare workforce. However, a significant knowledge gap exists concerning the practical aspects of their implementation and their effect on the utilisation of digital patient management in primary healthcare.

METHODS

This study addresses this gap by conducting a comprehensive analysis of three case studies involving the implementation of a specific digital patient management platform. Over a period of three years, we examine how the practicalities of implementation shape the adoption and utilisation of a digital patient management platform in three different clinics.

RESULTS

Our findings revealed that differences in implementation strategies directly influenced variations in utilisation. The successful utilisation of the platform was achieved through a bottom-up decision-making process that involved the employees of the primary healthcare clinics. Onsite training, close collaboration with the eHealth provider, and a structured patient onboarding process played crucial roles in this utilisation. In contrast, a top-down approach at two of the primary healthcare clinics led to limited utilisation of the platform into daily workflows. Furthermore, making the platform a part of everyday work meant putting accessibility, by working as a team of physicians, at the forefront of continuity of care, with patients being managed by their designated physician. Additionally, it was observed that digital patient management proved most effective for addressing simple patient issues such as skin rashes, rather than complex cases, and did not reduce the demand for phone triage.

CONCLUSION

Only one of the three clinics studied effectively integrated digital patient management into its daily operations, and did so by aligning objectives among management and all categories of healthcare professionals, employing a bottom-up decision-making process, collaborating with the eHealth service provider for regular platform adjustments to clinic needs, and implementing active patient onboarding. This sociotechnical integration resulted in high platform utilisation. In contrast, the other two clinics faced challenges due to incoherent objectives among diverse healthcare professional employees and top management, a top-down decision-making approach during implementation, limited collaboration with the eHealth service provider, and passive patient onboarding. The findings indicate that these factors negatively affected utilisation and led to low platform adoption as well as disrupted the sociotechnical balance.

The impact of eHealth on relationships and trust in primary care: a review of reviews

BACKGROUND

Given the increasing integration of digital health technologies in team-based primary care, this review aimed at understanding the impact of eHealth on patient-provider and provider-provider relationships.

METHODS

A review of reviews was conducted on three databases to identify papers published in English from 2008 onwards. The impact of different types of eHealth on relationships and trust and the factors influencing the impact were thematically analyzed.

RESULTS

A total of 79 reviews were included. Patient-provider relationships were discussed more frequently as compared to provider-provider relationships. Communication systems like telemedicine were the most discussed type of technology. eHealth was found to have both positive and negative impacts on relationships and/or trust. This impact was influenced by a range of patient-related, provider-related, technology-related, and organizational factors, such as patient sociodemographics, provider communication skills, technology design, and organizational technology implementation, respectively.

CONCLUSIONS

Recommendations are provided for effective and equitable technology selection, application, and training to optimize the impact of eHealth on relationships and trust. The review findings can inform providers' and policymakers' decision-making around the use of eHealth in primary care delivery to facilitate relationship-building.

Personalised management and supporting individuals to live with their asthma in a primary care setting

INTRODUCTION

Complementing recognition of biomedical phenotypes, a primary care approach to asthma care recognizes diversity of disease, health beliefs, and lifestyle at a population and individual level.

AREAS COVERED

We review six aspects of personalized care particularly pertinent to primary care management of asthma: personalizing support for individuals living with asthma; targeting asthma care within populations; managing phenotypes of wheezy pre-school children; personalizing management to the individual; meeting individual preferences for provision of asthma care; optimizing digital approaches to enhance personalized care.

EXPERT OPINION

In a primary care setting, personalized management and supporting individuals to live with asthma extend beyond the contemporary concepts of biological phenotypes and pharmacological 'treatable traits' to encompass evidence-based tailored support for self-management, and delivery of patient-centered care including motivational interviewing. It extends to how we organize clinical practiceand the choices provided in mode of consultation. Diagnostic uncertainty due to recognition of phenotypes of pre-school wheeze remains a challenge for primary care. Digital health can support personalized management, but there are concerns about increasing inequities. This broad approach reflects the traditionally holistic ethos of primary care ('knowing their patients and understanding their communities'), but the core concepts resonate with all healthcare.

A rapid mixed-methods evaluation of remote home monitoring models during the COVID-19 pandemic in England

Background

Remote home monitoring services were developed and implemented for patients with COVID-19 during the pandemic. Patients monitored blood oxygen saturation and other readings (e.g. temperature) at home and were escalated as necessary.

Objective

To evaluate effectiveness, costs, implementation, and staff and patient experiences (including disparities and mode) of COVID-19 remote home monitoring services in England during the COVID-19 pandemic (waves 1 and 2).

Methods

A rapid mixed-methods evaluation, conducted in two phases. Phase 1 (July-August 2020) comprised a rapid systematic review, implementation and economic analysis study (in eight sites). Phase 2 (January-June 2021) comprised a large-scale, multisite, mixed-methods study of effectiveness, costs, implementation and patient/staff experience, using national data sets, surveys (28 sites) and interviews (17 sites).

Results

Phase 1 Findings from the review and empirical study indicated that these services have been implemented worldwide and vary substantially. Empirical findings highlighted that communication, appropriate information and multiple modes of monitoring facilitated implementation; barriers included unclear referral processes, workforce availability and lack of administrative support. Phase 2 We received surveys from 292 staff (39% response rate) and 1069 patients/carers (18% response rate). We conducted interviews with 58 staff, 62 patients/carers and 5 national leads. Despite national roll-out, enrolment to services was lower than expected (average enrolment across 37 clinical commissioning groups judged to have completed data was 8.7%). There was large variability in implementation of services, influenced by patient (e.g. local population needs), workforce (e.g. workload), organisational (e.g. collaboration) and resource (e.g. software) factors. We found that for every 10% increase in enrolment to the programme, mortality was reduced by 2% (95% confidence interval: 4% reduction to 1% increase), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1.8% (-1.2% to 4.9%). None of these results are statistically significant. We found slightly longer hospital lengths of stay associated with virtual ward services (adjusted incidence rate ratio 1.05, 95% confidence interval 1.01 to 1.09), and no statistically significant impact on subsequent COVID-19 readmissions (adjusted odds ratio 0.95, 95% confidence interval 0.89 to 1.02). Low patient enrolment rates and incomplete data may have affected chances of detecting possible impact. The mean running cost per patient varied for different types of service and mode; and was driven by the number and grade of staff. Staff, patients and carers generally reported positive experiences of services. Services were easy to deliver but staff needed additional training. Staff knowledge/confidence, NHS resources/workload, dynamics between multidisciplinary team members and patients' engagement with the service (e.g. using the oximeter to record and submit readings) influenced delivery. Patients and carers felt services and human contact received reassured them and were easy to engage with. Engagement was conditional on patient, support, resource and service factors. Many sites designed services to suit the needs of their local population. Despite adaptations, disparities were reported across some patient groups. For example, older adults and patients from ethnic minorities reported more difficulties engaging with the service. Tech-enabled models helped to manage large patient groups but did not completely replace phone calls.

Limitations

Limitations included data completeness, inability to link data on service use to outcomes at a patient level, low survey response rates and under-representation of some patient groups.

Future work

Further research should consider the long-term impact and cost-effectiveness of these services and the appropriateness of different models for different groups of patients.

Conclusions

We were not able to find quantitative evidence that COVID-19 remote home monitoring services have been effective. However, low enrolment rates, incomplete data and varied implementation reduced our chances of detecting any impact that may have existed. While services were viewed positively by staff and patients, barriers to implementation, delivery and engagement should be considered.

Study registration

This study is registered with the ISRCTN (14962466).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (RSET: 16/138/17; BRACE: 16/138/31) and NHSEI and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 13. See the NIHR Journals Library website for further project information. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

A Digital First Healthcare Approach to Managing Pandemics: A Scoping Review of Pandemic Self-Triage Tools

BACKGROUND

During the COVID-19 pandemic, many patient-facing digital self-triage tools were designed and deployed to alleviate demand for pandemic virus triage in hospitals and doctors' offices by providing a way for people to self-assess health status and get advice on whether to seek care. These tools, provided via websites, apps, or patient portals allow people to answer questions, e.g., about symptoms and contact history, and receive guidance to appropriate care, which might be self-care.

OBJECTIVE

The purpose of this scoping review was to explore the state of literature on digital self-triage tools that direct or advise care for adults during a pandemic, and to explore what has been learned about intended purpose, use, and quality of guidance, tool usability, impact on providers, and ability to forecast health outcomes or care demand.

METHODS

A literature search was conducted in July 2021 using MEDLINE, Embase, Scopus, PsycINFO, CINAHL and Cochrane databases. Using Covidence, 1227 titles and abstracts were screened by two researchers, with 83 reviewed via full text screening. 22 articles met inclusion criteria: they allowed adults to self-assess for pandemic virus and directed to care. Using Microsoft Excel, we extracted and charted the following data: authors, publication year and country, country the tool was used in, whether the tool was integrated into a healthcare system, research question/purpose, direction of care provided, and key findings.

RESULTS

All but two studies reported on tools developed since early 2020 during the COVID-19 pandemic. Studies reported on tools were developed in 17 countries. Direction of care advice included directing to an ER, seek urgent care, contact/see a doctor, be tested, or to stay at home/self-isolate. Only two studies evaluated tool usability. One used 52 use-cases to evaluate quality of advice by tools in four countries, finding advice varied, e.g., tools in the US and UK often advising staying home when clinical assessment was warranted, while tools in Japan and Singapore advised seeking care. No study demonstrated that the tools reduce demand on the health care system, although at least one suggests data can predict demand for care and data allows monitoring public health.

CONCLUSIONS

While self-triage tools developed and used around the world have similarities in directing to care (ER, physician, self-care), they also differ in important ways. Some collect data to predict healthcare demand. Some are for use when concerned about health status; others are intended to be used repeatedly by users to monitor public health. Quality of triage may vary. The high use of such tools during the COVID-19 pandemic suggests research is needed to assess and ensure quality of advice given by self-triage tools, and to assess intended or unintended consequences on public health and health care systems.

CLINICALTRIAL

Workload effects of online consultation implementation from a Job-Characteristics Model perspective: a qualitative study

BACKGROUND

Online consultation (OC) was previously promoted by the NHS to solve primary care workload challenges. Its implementation was sped up during the COVID-19 pandemic. Workload effects are widely debated. Using a job design perspective may enhance understandings of workload effect.

AIM

To qualitatively interrogate the workload experiences of primary care staff involved in OC implementation, using the Job Characteristics Model (JCM) to enable the following: a clearer understanding of the primary care staff psychological experiences; and recommendations informing the design of digital implementations and continued use.

DESIGN & SETTING

A qualitative interview study of GP practices using OC within South West England.

METHOD

Thirteen participants representing seven practices completed JCM-based semi-structured telephone interviews. An abductive theoretically driven thematic analysis was completed.

RESULTS

Participants experienced different tasks pre- and post-implementation of OC, and adapted differently to them. Differences included the following: contact modality change, some administrative staff felt removed from patient contact; and in perceived autonomy, some GPs valued increased workload control. Variation in workload experience was affected by job role and practice context, and the form of and rationale for implementation. Use of a psychological model (the JCM) allowed clearer consideration of the effects of change, as well as OC on workload.

CONCLUSION

Psychological theory may be helpful in interpreting workload effects of technology implementation such as OC. Designing change to include consideration of technology effects, psychological experiences, differences across roles, and individual and practice contexts may be important for technology implementation and evaluation of its workload effects.

Protocol: Remote care as the 'new normal'? Multi-site case study in UK general practice

Background

Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices' varied experiences over time as they seek to establish remote forms of accessing and delivering care.

Methods

This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups).

Results anticipated

We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint).

Conclusion

By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.

User initiated symptom assessment with an electronic symptom checker. Study protocol for mixed-methods validation. (Preprint)

BACKGROUND

The national Omaolo digital social welfare and health care service of Finland provides a symptom checker, Omaolo, which is a medical device (based on Duodecim Clinical Decision Support EBMEDS software) with a CE marking (risk class IIa), manufactured by the government-owned DigiFinland Oy. Users of this service can perform their triage by using the questions in the symptom checker. By completing the symptom checker, the user receives a recommendation for action and a service assessment with appropriate guidance regarding their health problems on the basis of a selected specific symptom in the symptom checker. This allows users to be provided with appropriate health care services, regardless of time and place.

OBJECTIVE

This study describes the protocol for the mixed methods validation process of the symptom checker available in Omaolo digital services.

METHODS

This is a mixed methods study using quantitative and qualitative methods, which will be part of the clinical validation process that takes place in primary health care centers in Finland. Each organization provides a space where the study and the nurse triage can be done in order to include an unscreened target population of users. The primary health care units provide walk-in model services, where no prior phone call or contact is required. For the validation of the Omaolo symptom checker, case vignettes will be incorporated to supplement the triage accuracy of rare and acute cases that cannot be tested extensively in real-life settings. Vignettes are produced from a variety of clinical sources, and they test the symptom checker in different triage levels by using 1 standardized patient case example.

RESULTS

This study plan underwent an ethics review by the regional permission, which was requested from each organization participating in the research, and an ethics committee statement was requested and granted from Pirkanmaa hospital district's ethics committee, which is in accordance with the University of Tampere's regulations. Of 964 clinical user-filled symptom checker assessments, 877 cases were fully completed with a triage result, and therefore, they met the requirements for clinical validation studies. The goal for sufficient data has been reached for most of the chief symptoms. Data collection was completed in September 2019, and the first feasibility and patient experience results were published by the end of 2020. Case vignettes have been identified and are to be completed before further testing the symptom checker. The analysis and reporting are estimated to be finalized in 2024.

CONCLUSIONS

The primary goals of this multimethod electronic symptom checker study are to assess safety and to provide crucial information regarding the accuracy and usability of the Omaolo electronic symptom checker. To our knowledge, this will be the first study to include real-life clinical cases along with case vignettes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41423.

Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review

BACKGROUND

The use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation-referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services-may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear.

OBJECTIVE

This study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation.

METHODS

Adopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach.

RESULTS

A total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients' trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation.

CONCLUSIONS

Digital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019.

Subjective experiences of the first response to mental health crises in the community: a qualitative systematic review

OBJECTIVE

To review and synthesise qualitative studies that have explored subjective experiences of people with lived experience of mental health-related illness/crisis (MHC), their families and first responders.

DESIGN

A systematic review of qualitative evidence was conducted. English-language articles exploring the content of interactions and participants' experiences were included.

DATA SOURCES

MEDLINE, PsycINFO, EMBASE, CINAHL; Google Scholar, SAGE journals, Science Direct and PubMed.

DATA EXTRACTION AND SYNTHESIS

Two reviewers read and systematically extracted data from the included papers. Papers were appraised for methodological rigour using the Critical Appraisal Skills Programme Qualitative Checklist. Data were thematically analysed.

RESULTS

We identified 3483 unique records, 404 full-texts were assessed against the inclusion criteria and 79 studies were included in the qualitative synthesis. First responders (FRs) identified in studies were police and ambulance staff. Main factors influencing response are persistent stigmatised attitudes among FRs, arbitrary training and the triadic interactions between FRs, people with mental illness and third parties present at the crisis. In addition, FR personal experience of mental illness and focused training can help create a more empathetic response, however lack of resources in mental health services continues to be a barrier where 'frequent attenders' are repeatedly let down by mental health services.

CONCLUSION

Lack of resources in mental healthcare and rise in mental illness suggest that FR response to MHC is inevitable. Inconsistent training, complexity of procedures and persistent stigmatisation make this a very challenging task. Improving communication with family carers and colleagues could make a difference. Broader issues of legitimacy and procedural barriers should be considered in order to reduce criminalisation and ensure an empathetic response.

Patient and clinician experiences of remote consultation during the SARS-CoV-2 pandemic: A service evaluation

Objectives

During the SARS-CoV-2 pandemic, clinicians were instructed to move all but emergency consultations to remote means to reduce the spread of the virus. The aim of this study was to evaluate patients’ and clinicians’ experiences of moving to remote means of consultation with their health care professionals during the SARS-CoV-2 pandemic.

Methods

The study design was a qualitative service evaluation. Twenty-six clinicians and forty-eight patients who met the inclusion criteria consented to be interviewed. Clinician participants were from either medical, nursing, or allied health professional backgrounds. Patients were recruited from diabetes, acute care, and haematology and cancer areas. Data analysis was conducted using a thematic analysis framework.

Results

Following coding and thematic analysis of the data collected from clinicians, five themes were identified: personal and professional well-being; providing a safe and high-quality experience; adapting to a new way of working; making remote consultations fit for purpose and an awareness of altered dynamics during consultation. Patient data was coded into 3 themes: remote consultation adds value; remote consultation brings challenges and concerns about remote consultation.

Conclusions

Clinician and patient experiences reported here are reflected in the literature. The study indicates that remote consultation is not suitable for all patients and in all contexts. Whilst maintaining the benefits to patients, remote means of consultation needs organisational support and preparation. A way forward that maintains the benefits whilst addressing concerns seems urgent.

Online and telephone access to general practice: a cross-sectional patient survey

Background

Improving access to primary health care in the UK has focused on the use of telephone and online access, but little is known about how awareness of and use varies between different patient groups.

Aim

To determine how patients are interacting with telephone and online channels for accessing general practice services and information, and to analyse how this varies according to patient characteristics and health status.

Design & setting

A cross-sectional self-administered survey of adult patients in general practices across the West Midlands, UK.

Method

Descriptive statistics were used to show participants’ awareness of and interaction with online information sources and remote access. Multivariable logistic regression was used to model the relationships between demographic and health characteristics, and awareness and use of online services and alternatives to face-to-face consultations (for example, telephone).

Results

A total of 2789 patients (19.0% response rate) from 43 general practices participated. The study found 60.8% (n = 1651/2715) of participants were aware of online services and 30.3% (n = 811/2674) reported having used one. Daily internet usage and frequently visiting the GP showed the strongest associations with knowledge and use of online services.

Conclusion

The study shows that there is the potential for inequitable awareness and use of telephone and online services in general practice populations. Given that their use has greatly increased owing to the COVID-19 pandemic, future service design will need to ensure equity is taken into account.

Synthesis for health services and policy: case studies in the scoping of reviews

Background

For systematic reviews to be rigorous, deliverable and useful, they need a well-defined review question. Scoping for a review also requires the specification of clear inclusion criteria and planned synthesis methods. Guidance is lacking on how to develop these, especially in the context of undertaking rapid and responsive systematic reviews to inform health services and health policy.

Objective

This report describes and discusses the experiences of review scoping of three commissioned research centres that conducted evidence syntheses to inform health and social care organisation, delivery and policy in the UK, between 2017 and 2020.

Data sources

Sources included researcher recollection, project meeting minutes, e-mail correspondence with stakeholders and scoping searches, from allocation of a review topic through to review protocol agreement.

Methods

We produced eight descriptive case studies of selected reviews from the three teams. From case studies, we identified key issues that shape the processes of scoping and question formulation for evidence synthesis. The issues were then discussed and lessons drawn.

Findings

Across the eight diverse case studies, we identified 14 recurrent issues that were important in shaping the scoping processes and formulating a review’s questions. There were ‘consultative issues’ that related to securing input from review commissioners, policy customers, experts, patients and other stakeholders. These included managing and deciding priorities, reconciling different priorities/perspectives, achieving buy-in and engagement, educating the end-user about synthesis processes and products, and managing stakeholder expectations. There were ‘interface issues’ that related to the interaction between the review team and potential review users. These included identifying the niche/gap and optimising value, assuring and balancing rigour/reliability/relevance, and assuring the transferability/applicability of study evidence to specific policy/service user contexts. There were also ‘technical issues’ that were associated with the methods and conduct of the review. These were choosing the method(s) of synthesis, balancing fixed and fluid review questions/components/definitions, taking stock of what research already exists, mapping versus scoping versus reviewing, scoping/relevance as a continuous process and not just an initial stage, and calibrating general compared with specific and broad compared with deep coverage of topics.

Limitations

As a retrospective joint reflection by review teams on their experiences of scoping processes, this report is not based on prospectively collected research data. In addition, our evaluations were not externally validated by, for example, policy and service evidence users or patients and the public.

Conclusions

We have summarised our reflections on scoping from this programme of reviews as 14 common issues and 28 practical ‘lessons learned’. Effective scoping of rapid, responsive reviews extends beyond information exchange and technical procedures for specifying a ‘gap’ in the evidence. These considerations work alongside social processes, in particular the building of relationships and shared understanding between reviewers, research commissioners and potential review users that may be reflective of consultancy, negotiation and co-production models of research and information use.

Funding

This report has been based on work commissioned by the National Institute for Health Research (NIHR) Health Services and Delivery Research (HSDR) programme as three university-based evidence synthesis centres to inform the organisation, delivery and commissioning of health and social care; at the University of Exeter (NIHR 16/47/22), the University of Sheffield (NIHR 16/47/17) and the University of York (NIHR 16/47/11). This report was commissioned by the NIHR HSDR programme as a review project (NIHR132708) within the NIHR HSDR programme. This project was funded by the NIHR HSDR programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 15. See the NIHR Journals Library website for further project information.

Decision-making for the infant sleep environment among families with children considered to be at risk of sudden unexpected death in infancy: a systematic review and qualitative metasynthesis

BACKGROUND

Advice to families to sleep infants on their backs, avoid smoke exposure, reduce excess bedcovering and avoid specific risks associated with cosleeping has greatly reduced sudden unexpected death in infancy (SUDI) rates worldwide. The fall in rates has not been equal across all groups, and this advice has been less effective for more socially deprived families. Understanding decision-making processes of families with infants at risk would support the development of more effective interventions.

AIM

To synthesise the qualitative evidence on parental decision-making for the infant sleep environment among families with children considered to be at increased risk of SUDI.

METHODS

This study was one of three related reviews of the literature for the Child Safeguarding Practice Review Panel's National Review in England into SUDI in families where the children are considered at risk of harm. A systematic search of eight online databases was carried out in December 2019. Metasynthesis was conducted, with themes extracted from each paper, starting with the earliest publication first.

RESULTS

The wider review returned 3367 papers, with 16 papers (across 13 studies) specifically referring to parental decision-making. Six overall themes were identified from the synthesis: (1) knowledge as different from action; (2) external advice must be credible; (3) comfort, convenience and disruption to the routine; (4) plausibility and mechanisms of protection; (5) meanings of safety and risk mitigation using alternative strategies; and (6) parents' own expertise, experience and instincts.

CONCLUSION

Interventions that are intended to improve the uptake of safer sleep advice in families with infants at risk of sleep-related SUDI need to be based on credible advice with mechanisms of protection that are understandable, consistent with other sources, widened to all carers of the infant and fit within the complex practice of caring for infants.

How do users of a 'digital-only' contraceptive service provide biometric measurements and what does this teach us about safe and effective online care? A qualitative interview study

OBJECTIVES

To describe user experience of obtaining and uploading biometric measurements to a 'digital-only' contraceptive service prior to a prescription for the combined oral contraceptive (COC). To analyse this experience to inform the design of safe and acceptable 'digital-only' online contraceptive services.

SETTING

An online contraceptive service available free of charge to women in South East London, UK.

PARTICIPANTS

Twenty participants who had ordered the combined oral contraceptive (COC) online. Our purposive sampling strategy ensured that we included participants from a wide range of ages and those who were and were not prescribed the COC.

INTERVENTION

A 'digital-only' contraceptive service that prescribes the COCafter an online medical history and self-reported height, weight and blood pressure (BP) with pills prescribed by a GMC registered doctor, dispensed by an online pharmacy and posted to the user.

DESIGN

Semistructured interviews with a purposive sample of 20 participants who were already enrolled in a larger study of this service.

ANALYSIS

Inductive, thematic analysis of the interviews assisted by NVivo qualitative analysis software.

RESULTS

Users valued the convenience of 'digital-only care' but experienced measuring BP but not height or weight as a significant barrier to service use. They actively engaged in work to understand and measure BP through a combination of recent/past measurements, borrowed machines, health service visits and online research. They negotiated tensions around maintaining a trusting relationship with the service, meeting its demands for accurate information while also obtaining the contraception that they needed.

CONCLUSION

Digital strategies to build trusting clinical relationships despite a lack of face-to-face contact are needed in 'digital-only' health services. This includes acknowledgement of work required, evidence of credible human support and a digital interface that communicates the health benefits of collaborating with an engaged clinical team.