Marginalisation and distrust in the context of the COVID-19 vaccination programme: experiences of communities in a northern UK city region

BACKGROUND

There are clear inequalities in COVID - 19 vaccination rates amongst marginalised groups, with lower rates for some minoritised ethnic and religious groups, younger people, those living in more deprived areas, and with lower socio-economic status. Existing research focuses on psychological and socio-economic factors that influence vaccine uptake and does not explore broader social and historical contexts. Understanding inequalities in COVID-19 vaccine uptake requires a critical examination of the drivers of, and barriers to, vaccination.

METHODS

We present findings from a co-designed qualitative research study undertaken during the COVID-19 pandemic. Focus groups and interviews were used to examine the context underpinning responses to the COVID-19 vaccination in Greater Manchester, particularly focussing on experiences of marginalisation. Thematic framework analysis was used to analyse the data.

RESULTS

We found that the public's responses to the COVID-19 vaccination programme are intertwined with a longstanding history of institutional distrust and disenfranchisement, resulting from experiences of marginalisation and social inequalities. This was exacerbated further by the disproportionate impacts of the COVID-19 pandemic on minoritised ethnic groups, younger people, and those with existing health conditions.

CONCLUSIONS

Histories of structural inequalities experienced by minoritised groups invoked feelings of suspicion and scepticism at the motivations of the agencies behind the vaccination rollout. This highlights the need for a contextualised analysis of attitudes to vaccines, considering pre-existing inequalities, which may be especially relevant for conceptualising public responses to the vaccination programme. Finally, our study shows the important ways in which public (dis)trust can impact public health policies. We recommend this should be incorporated into responses to future public health crises.

Users' views on the use of a smartwatch app to collect daily symptom data in individuals with multiple long-term conditions (Multimorbidity): A qualitative study

Introduction

Long-term conditions are a major burden on health systems. One way to facilitate more research and better clinical care among patients with long-term conditions is to collect accurate data on their daily symptoms (patient-generated health data) using wearable technologies. Whilst evidence is growing for the use of wearable technologies in single conditions, there is less evidence of the utility of frequent symptom tracking in those who have more than one condition.

Aims

To explore patient views of the acceptability of collecting daily patient-generated health data for three months using a smartwatch app.

Methods

Watch Your Steps was a longitudinal study which recruited 53 patients to track over 20 symptoms per day for a 90-day period using a study app on smartwatches. Semi-structured interviews were conducted with a sub-sample of 20 participants to explore their experience of engaging with the app.

Results

In a population of older people with multimorbidity, patients were willing and able to engage with a patient-generated health data app on a smartwatch. It was suggested that to maintain engagement over a longer period, more 'real-time' feedback from the app should be available. Participants did not seem to consider the management of more than one condition to be a factor in either engagement or use of the app, but the presence of severe or chronic pain was at times a barrier.

Conclusion

This study has provided preliminary evidence that multimorbidity was not a major barrier to engagement with patient-generated health data via a smartwatch symptom tracking app.

Providing care to marginalised communities: a qualitative study of community pharmacy teams

BACKGROUND

Health inequalities in the UK are widening, particularly since the COVID-19 pandemic. Community pharmacies are the most visited healthcare provider in England and are ideally placed to provide and facilitate access to care for those most disadvantaged.

AIM

To explore the experiences and needs of community pharmacy teams in providing care for marginalised groups and how this has changed since the COVID-19 pandemic.

DESIGN AND SETTING

A qualitative study in community pharmacy and across primary care.

METHOD

Semi-structured interviews were undertaken with members of community pharmacy teams, primary care network (PCN) pharmacists, GPs, and nurses in the North of England.

RESULTS

In total, 31 individuals participated in an interview (26 pharmacy staff, three GPs, and two nurses). Most participants acknowledged that their pharmacy had become busier since COVID-19 because of increased footfall compounded by patient difficulties in navigating remote digital systems. Few participants had received any formal training on working with marginalised communities; however, organisational barriers (such as lack of access to translation facilities) combined with interorganisational barriers (such as lack of integrated care) made it more difficult to provide care for some marginalised groups. Despite this, the continuity of care provided by many pharmacies was viewed as an important factor in enabling marginalised groups to access and receive care.

CONCLUSION

There are opportunities to better utilise the skills of community pharmacy teams. Resources, such as access to translation services, and interventions to enable better communication between community pharmacy teams and other primary care services, such as general practice, are essential.

Primary Care Providers Involvement in Caring for Young Adults with Complex Chronic Conditions Exiting Pediatric Care: An Integrative Literature Review

The transition to adulthood is a critical time for everyone to build independence, experience new things, and become self-sufficient. With medical advances, individuals with complex chronic conditions are surviving into adulthood. As such they withstand additional challenges during this stage of their life including; facing a discontinuity of care, loss of prior health-care networks and champions, and a shift toward increased responsibility and self-management of their conditions. Often this shift results in the need for primary care providers to act as care managers, coordinating care and supporting the young adult as they navigate adulthood. In exploring the role of primary care providers with this population we reviewed the literature to identify what strategies primary care providers can use to enhance the transition process for young adults ages 15 to 25 years with complex chronic conditions exiting pediatric services. An integrative literature review approach was used to systematically search the contemporary literature. Applying inclusion criteria and quality assessment of relevant research and gray literature we identified 12 studies that warranted detailed review and analysis. Analysis of the studies highlighted four key themes: relationships, fear and anxiety, preparedness, and communication and collaboration. It was evident that health-care transition for young adults with complex chronic conditions was complicated by their psychosocial development and extensive health and service needs. Health-care transition is a team effort influenced by local contexts, resources, and relational practices. Both groups of primary care providers and young adults must be prepared prior to transition if they are to become immersed and engaged in this work. The population of young adults with complex chronic conditions exiting pediatric care will continue to grow as access to care delivery and medical technology continue to expand. While health-care transition for this population is complicated by extensive needs and psychosocial development, primary care providers can act as key supports in employing strategies to enhance the transition process for these young adults.

Reflections of patient and public involvement from a commissioned research project evaluating a nationally implemented NHS programme focused on diabetes prevention

Patient and Public Involvement and Engagement (PPIE) in research is recognised by the National Institute for Health and Care Research as crucial for high quality research with practical benefit for patients and carers. Patient and public contributors can provide both personal knowledge and lived experiences which complement the perspectives of the academic research team. Nevertheless, effective PPIE must be tailored to the nature of the research, such as the size and scope of the research, whether it is researcher-led or independently commissioned, and whether the research aims to design an intervention or evaluate it. For example, commissioned research evaluations have potential limits on how PPIE can feed into the design of the research and the intervention. Such constraints may require re-orientation of PPIE input to other functions, such as supporting wider engagement and dissemination. In this commentary, we use the 'Guidance for Reporting Involvement of Patients and the Public' (GRIPP2) short form to share our own experiences of facilitating PPIE for a large, commissioned research project evaluating the National Health Service Diabetes Prevention Programme; a behavioural intervention for adults in England who are at high risk of developing type 2 diabetes. The programme was already widely implemented in routine practice when the research project and PPIE group were established. This commentary provides us with a unique opportunity to reflect on experiences of being part of a PPIE group in the context of a longer-term evaluation of a national programme, where the scope for involvement in the intervention design was more constrained, compared to PPIE within researcher-led intervention programmes. We reflect on PPIE in the design, analysis and dissemination of the research, including lessons learned for future PPIE work in large-scale commissioned evaluations of national programmes. Important considerations for this type of PPIE work include: ensuring the role of public contributors is clarified from the outset, the complexities of facilitating PPIE over longer project timeframes, and providing adequate support to public contributors and facilitators (including training, resources and flexible timelines) to ensure an inclusive and considerate approach. These findings can inform future PPIE plans for stakeholders involved in commissioned research.

"Take a walk in someone else's shoes": the role of participatory arts for health research development and training

Participatory arts are increasingly recognised as a valuable and accessible mechanism for giving a voice to the experiences of individuals' health and healthcare. In recent years, there has been a move towards embedding participatory arts-based models into public engagement processes. Here, we contribute to the existing literature on the use of participatory arts-based approaches and their role in health research and healthcare practise, focusing on two interlinked approaches, the creation of personas and storytelling. We draw on two recent projects which have utilised these approaches to inform subsequent healthcare research and as a professional training tool to improve patient experience in a healthcare setting. We add to emerging literature to outline the benefits of these approaches in supporting research and training in healthcare settings, with a focus towards the co-produced foundations of these approaches. We demonstrate how such approaches can be utilised to capture different forms of voices, experiences and perspectives to help inform healthcare research and training, rooted in the lived experience of individuals who are directly involved in the creative process of developing personas via storytelling. These approaches challenge the listener to "walk in someone else's shoes", using their own homes and lives as a theatrical set in which to envisage someone else's story, involving the listener in the creative process through (re)imagining the stories and experiences of the characters. Greater use of immersive, co-produced participatory art-based approaches should be used in PPIE to inform research and training in healthcare settings as a means of centring those with lived experience through co-production. Involving those with lived experience, particularly from groups who are traditionally excluded from research, via a process which is based on co-creation and co-production, reorientates the researcher-participant dynamic to fully centre those involved in the research at the heart of the tools used to guide health and healthcare research. In this way, it may also aid in trust and relationship building between institutions and communities in a way which is focused around positive, creative methods to aid health research and healthcare processes. Such approaches may help to break down barriers between academic institutions, healthcare sites and communities.

A study to explore the usefulness of a mobile health application to support people with mild cognitive and/or communication impairment due to dementia and their carers

Background

Mobile apps for health (mHealth) have the potential to support people living with dementia. However, dementia is a complex and progressive condition that imposes specific constraints on the introduction/use of mhealth. Few studies have explored mHealth adoption and use within the complexity of everyday domestic settings. This study used an existing App co-designed with people living with mild cognitive and communication impairment (PWMCCI) due to learning disabilities and examined the usefulness for PWMICCI due to dementia and their carers.

Methods

A qualitative study of people with dementia and their carers. Data were collected in a phased approach to identify the potential need for, as well as the usability and utility of the app. Analysis employed the Domestication of Technology Model (DTM) to explore, in a novel way mHealth, in this user group(s).

Results

Most participants did not adopt the mHealth during the study period but some (n  =  2) did routinely as it fulfilled a unique, unmet need. The use of DTM highlighted the complexities of dementia, pressure on carers and duplication of effort created barriers to app adoption and use in the long term.

Conclusions

The ability of mHealth to support PWMCCI due to dementia and/or their carers may have potential. Users were motivated to try the technology but for any potential to be fully realised, the interplay between complexity of the condition including its progressive nature, demand on carers and nature of the technology needs to be more fully understood. Such issues place unique constraints around the size and window of opportunities for mHealth in this user group.

Does the process of developing products for knowledge mobilisation from healthcare research influence their uptake? A comparative case study

Background

Getting knowledge from healthcare research into practice (knowledge mobilisation) remains a global challenge. One way in which researchers may attempt to do this is to develop products (such as toolkits, actionable tools, dashboards, guidance, audit tools, protocols and clinical decision aids) in addition to journal papers. Despite their increasing ubiquity, the development of such products remains under-explored in the academic literature. This study aimed to further this understanding by exploring the development of products from healthcare research and how the process of their development might influence their potential application.

Methods

This study compared the data generated from a prospective, longitudinal, comparative case study of four research projects which aimed to develop products from healthcare research. Qualitative methods included thematic analysis of data generated from semi-structured interviews (38), meeting observations (83 h) and project documents (300+). Cases were studied for an average of 11.5 months (range 8–19 months).

Results

Case comparison resulted in the identification of three main themes with the potential to affect the use of products in practice. First, aspects of the product, including the perceived need for the specific product being identified, the clarity of product aim and clarity and range of end-users. Second, aspects of development, whereby different types of stakeholder engagement appear to influence potential product application, which either needs to be ‘meaningful’, or delivered through the implicit understanding of users’ needs by the developing team. The third, overarching theme, relates to the academic context in which products are developed, highlighting how the academic context perpetuates the development of products, which may not always be useful in practice.

Conclusions

This study showed that aspects of products from healthcare research (need/aim/end-user) and aspects of their development (stakeholder engagement/implicit understanding of end-users) influence their potential application. It explored the motivation for product development and identifies the influence of the current academic context on product development. It shows that there is a tension between ideal ‘systems approaches’ to knowledge mobilisation and ‘linear approaches’, which appear to be more pervasive in practice currently. The development of fewer, high-quality products which fulfil the needs of specified end-users might act to counter the current cynicism felt by many stakeholders in regard to products from healthcare research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00360-9.

Radiation Therapy Decision Making Process and Operations for COVID-19 Positive Patients

Purpose/Objective(s)

A challenging clinical dilemma during the COVID-19 pandemic is management of cancer patients who test positive for COVID. Given the need to balance the risk of disease progression with the risk of transmission to other patients and staff, radiation therapy for these patients requires careful consideration and modification of standard workflows. It is also critical to develop processes to mitigate radiation treatment interruption, which can affect patient outcomes. The objective of this study was to report the clinical operations and outcomes for COVID positive patients receiving radiation therapy during the pandemic at a tertiary cancer center including 2 network locations.

Materials/Methods

During March 2020 to March 2022, the Radiation Oncology COVID committee (RO COVID) developed an integrated process to triage patients, provide treatment recommendations, and implement infection control procedures to safely deliver radiation therapy to COVID positive patients. Policies were created for each center with multidisciplinary input from infectious disease, radiation oncology, radiation therapy, and nursing. All COVID positive patients were presented to the RO COVID group and evaluated for clinical urgency, benefit with radiation, and life expectancy. If deemed necessary, a limited planned break or hypofractionated regimen was recommended to minimize staff exposure. We conducted a retrospective review of COVID positive patients with different primary malignancies treated through the COVID positive pathway.

Results

A total of 68 COVID positive patients were treated with the COVID positive pathway (HN 15, Breast 9, CNS 8, GU 8, GYN, 7, Thoracic 6, GI 5, HEME 5, PED 3, SARC 2). The median age was 57.1 years (IQR 45.8-63.4) and 47% were female. There were 39 patients (57%) who were asymptomatic and were tested for routine pre-radiation screening or due to concerns of COVID exposure. Twenty-three (34%) patients were treated with palliative intent and 8 (12%) were treated for an emergent indication (i.e., spinal cord compression, bleeding). Thirteen (19%) patients were receiving radiation treatment, had a treatment break (7-21 days), and then resumed their radiation course. All treatments were successfully completed without known nosocomial spread of COVID to staff or other patients. Among this heterogenous group of patients, 58 (85%) were alive with a median follow up of 2 months (IQR 0.5-7.5). COVID infection may have contributed to 3 out of 10 deaths (4% of total cohort). The remaining deaths were due to progression of disease or other non-COVID causes.

Conclusion

In this study, COVID positive patients were safely treated with radiation therapy through a comprehensive decision making and clinical operations pathway taking into account evolving COVID guidelines for three different variant surges. Although limited in follow up, patient outcomes are promising with few COVID-related deaths and low overall mortality rates, even with hypofractionated regimens.

Weaving a new blanket together: lessons on compassionate leadership and engagement from a virtual regional summit on early childhood wellness in northern communities of British Columbia, Canada

BACKGROUND

Early childhood is a critical period of development for infants, young children, and their families. An array of services, programs, and interventions exist to support families during this life stage, often delivered by a diverse range of professionals. Overlap in early years services exists between healthcare, social care, childcare, education, and not-for-profit organizations. Such diversity in services has the potential to add a rich experience to early childhood development, or without collaboration, widen service gaps, risking providers' ability to meet the needs of families.

METHODS

In northern British Columbia (BC), Canada, a group of individuals came together to approach building relationships and engagement across sectors in early years services using compassionate systems leadership (CSL). A virtual summit was hosted with early childhood service providers including peer support workers and parents/caregivers using a hybrid model of pre-recorded asynchronous sessions combined with a live workshop. The purpose of the event was to find common ground, celebrate local success, and build understanding of how to work collaboratively across the region to identify and address early years priorities.

RESULTS

The event was successful in engaging 121 providers across early years services from a broad geographic region. Applying CSL principles for engagement allowed the team to examine how all partners could address silos in early years services across northern BC. Using a reflexive thematic approach, four key themes were identified at the Summit: (1) early years services are a patchwork but there are dreams of weaving a new blanket together, (2) an ideal model of service is family-centred and inclusive, (3) all sectors are needed at the table, and (4) compassion is the thread that weaves this work together.

CONCLUSIONS

The application of CSL principles can be used to guide engagement and develop supportive spaces for open conversation about creating systems change. In facilitating a space that allowed for vulnerability and relational ways of engaging across sectors we discovered commitment and a willingness for those present to consider new ideas and partnerships that would allow for greater integration of early years services in northern BC.

Impact of Charles Bonnet Syndrome on visually impaired older adults’ ability to engage in physical activity: A scoping review

Charles Bonnet syndrome (CBS) is a condition associated with sight loss, characterised by vivid, spontaneous visual hallucinations. Currently, it is unclear whether CBS presents challenges to participation in physical activities, in addition to barriers attributed to sight loss alone. The purpose of this scoping review was to establish the extent of the literature, and gaps in the knowledge base, concerning the impact of CBS on older adults’ engagement in physical activities. Review conduct was informed by Arksey and O’Malley and Levac et al.’s scoping review methodologies. Six academic databases were searched during May 2021, yielding 2709 results: eight articles met eligibility criteria. Two additional sources were located via a reference check of included papers and stakeholder consultation. Quantitative cross-sectional studies ( n = 3) indicate that CBS may interfere with the ability to move around, while qualitative sources (case report/series n = 6; autobiography n = 1) show that sudden presentation of hallucinations in a person’s pathway, or threatening content, may jeopardise safety while walking. Moving to avoid a hallucination could present a fall risk if attention is diverted from environmental hazards. One case report stated that CBS did not affect personal care activities. Due to a limited evidence base, further empirical research is needed to achieve a comprehensive understanding about how CBS affects older adults’ participation in physical activities.

Listening to individuals with differences in sex development or intersex and their families: 'not doing surgery doesn't mean doing nothing'

Informed decision-making and considerations of the child's best interest offer a starting place for building informed and lifelong discussions that promote the long-term interests and the wellbeing of individuals experiencing differences in sex development (DSD) or intersex traits. Parents require sufficient information and support to understand what 'doing something and doing nothing' really means when learning about non-surgical options. This may take the form of health literacy support, asking how parents are given access to meaningful and understandable information, as well as psychosocial support and psychological care. Timely psychological assessment and interventions that support informed decision-making actions are an essential aspect of holistic care with children and youth with DSD and their parents. Without actionable tools or approaches parents cannot make informed decisions about their child's health and, as such, health literacy is a key attribute to aid decision making for both parents and children. As individuals with DSD become increasingly adept at building resourcefulness, gathering and applying knowledge about their bodies, limiting irreversible surgeries in childhood can afford wider life choices. To this end an educated and informed comprehensive and helpful multidisciplinary group understands and embodies, as a whole team, the need for compassionate, emotionally supportive, and validating care in all interactions with parents of children and individuals with DSD. The paper draws on the primary author's experiences working with the charity, dsdfamilies, concluding with actionable approaches that include supporting personal knowledge through health literacy, examining team based psychological care, and psychosocial approaches across the lifespan.

Pediatric practicums in undergraduate nursing programs: an integrative review

BACKGROUND

Practicum Placements are the signature andragogy used in undergraduate nursing programs to bring about knowledge consolidation. Little is known, however, about the types of pediatric practicum placements utilized by nursing programs to provide practical learning opportunities in child health to their students. The purpose of this integrative review is to identify and appraise existing literature on practical pediatric practices in undergraduate nursing education.

METHOD

Searches were conducted using the main relevant databases and search engines. Of the numerous articles retrieved, screened, and reviewed, 15 met the inclusion and exclusion criteria. Results were then analyzed using thematic analysis.

RESULTS

Two overarching themes were identified: (1) Adaptation, and (2) Learning.

CONCLUSION

Findings revealed that most nursing programs utilize alternative placement sites to meet the learning need of their students. These sites provided students with the opportunities to care for children and adolescents, and engage in a variety of health promotion and teaching activities.

P066 COVID Voices: co-produced research to explore the shielding experiences of people with inflammatory musculoskeletal disease

Background/Aims

Up to one-third of people living with inflammatory arthritis or auto-immune disease may have been classified as ‘clinically extremely vulnerable’ (CEV) to COVID-19 and required to ‘shield’. Communication regarding shielding notification and details of how to shield were unclear, causing confusion and uncertainty. Most research into the impact of shielding on people living with musculoskeletal disease has involved either quantitative or survey-based data, with little patient involvement. This project aims to capture patient “stories” to understand and explore the experiences of people with inflammatory musculoskeletal conditions who shielded, using co-produced, qualitative methodology.

Methods

The Centre for Epidemiology Versus Arthritis (CfE) is committed to involving patients and the public, convening a COVID-19 Patient and Public Involvement (PPI) group early in the pandemic. Two PPI group members developed the research idea and collaborated with a clinical academic to co-produce a successful grant application to the Versus Arthritis “New opportunities” fund. The research aims to capture experiences and opinions on the processes for determining and communicating who is identified as CEV, and the impact of shielding upon individuals’ lives. We will develop recommendations to improve the process for subsequent pandemics. People who shielded due to inflammatory arthritis / auto-immune disease are invited to discuss their experiences of shielding in semi-structured interviews (n = 30) or focus groups (n = 12). Up to 50 participants may submit creative materials (artwork, poetry, photographs or written word), to include those unable, or unwilling, to speak about their experiences. A framework approach to thematic analysis of data generated from interviews and focus groups will be employed. Creative materials will be used to illustrate these themes. In addition to the core team, an experienced Patient Advisory Group will contribute to the analysis. Full ethical approval was awarded by the University of Manchester Research Ethics Committee. The ‘core team’ (two patient/public contributors and a clinical academic) are committed to ‘co-production’: working together in equal partnership, driven by values such as transparency, sharing power and inclusivity, which we anticipate will improve the relevance and quality of this work.

Results

Recruitment to interview and focus groups was exceeded within 10 days. Half the creative materials participants were recruited within a month, and recruitment remains open. The team have given invited talks at several national and regional events, discussing the research and methodological approach, demonstrating the significant interest generated by this work.

Conclusion

Although most funders now mandate some form of PPI in grant applications, research ideas conceived and genuinely co-produced by patient partners are rare. The CfE’s commitment to PPI enabled conversations and collaboration, which built on existing relationships, and led to successful grant funding. We look forward to further highlighting and sharing both the model of our collaboration, and the qualitative research findings.

Disclosure

J. Fox: None. L. Laidlaw: None. W.G. Dixon: Consultancies; WGD has received consultancy fees from Abbvie and Google, unrelated to this work. C. Sanders: None. C.A. Sharp: None.

Challenges and adaptations to public involvement with marginalised groups during the COVID-19 pandemic: commentary with illustrative case studies in the context of patient safety research

Patient and public involvement (PPI) is integral to research on patient safety in the NIHR Greater Manchester Patient Safety Translational Research Centre (NIHR GMPSTRC), and is central to our patient safety research within our theme focusing on people in marginalised groups. Due to the impact of COVID-19, researchers had to adapt how they do PPI. For marginalised groups, remote working and digital adaptations (the key adaptations made in accessing and utilising health services in the United Kingdom during COVID-19) can potentially lead to further marginalisation of people already marginalised and provide new barriers to others. This editorial showcases three case examples of PPI with marginalised groups during COVID-19, these are with: (1) adults with vision impairments, (2) adults and carers with lived experience of self-harm and/ or suicide and (3) adults with lived experience of homelessness. In these case examples, we focus on challenges relating to key aspects of PPI during the pandemic. First, setting up a PPI advisory group and secondly maintaining relationships and effective PPI with a pre-existing advisory group. We contrast these examples using more traditional ways of 'doing PPI' i.e. involving public contributors in various stages of the research cycle, with a more fully 'co-produced' approach to research when developing a new patient safety intervention. Important considerations for PPI with marginalised groups during COVID-19 include: how to avoid exacerbating the digital divide when using video conferencing for PPI, the need for enhanced awareness around flexibility and resources, and the value of working closely with specialist charities to enable adaptations that are sensitive to the changed circumstances and needs of PPI contributors.

Lifespan healthcare transitions among individuals with intersex traits in Canada: a mixed-methods and qualitative study

OBJECTIVES

To: (1) complete an integrative literature review of transition studies that focus on individuals with intersex traits; (2) conduct an environmental scan of the current resources (practice guidelines, policies and procedures) used by healthcare providers working with Canadians with intersex traits; (3) investigate the experiences of Canadians with intersex traits in their healthcare transitions across the lifespan and (4) assess the understanding of healthcare providers about these transitions.

DESIGN

A qualitative prospective community participation study was conducted. It used mixed methods including an environmental scan and semistructured engagement sessions.

SETTING

The environmental scan examined resources available throughout Canada. The engagement sessions took place in British Columbia and Ontario, Canada.

PARTICIPANTS

Sixteen participants were recruited. These included 13 individuals with intersex traits (a heterogeneous group of congenital conditions affecting the development of sex characteristics) and three caregivers.

METHODS

Mixed methods included an integrated literature review, environmental scan and qualitative approaches developed in collaboration with community partners.

RESULTS

The literature review identified gaps in transition care for individuals with intersex traits. The environmental scan uncovered no specific resources used by healthcare providers working with patients with intersex traits, though several general guidelines were used. Engaging providers in the study was problematic. Thematic analysis generated three main themes that emerged from the engagement sessions: (1) transition is a lifespan activity; (2) building personal agency is valuable and (3) well-being promotion is an application of health literacy.

CONCLUSIONS

Transition resources for individuals living in Canada with intersex are scarce. Transitions happen across the lifespan with ownership of thought and actions seen as acts of personal agency. Health literacy skills and knowledge change with increased age, yet the primary source of knowledge often remained important in the individual's autobiographical self.

Correction: Ethnic inequalities in COVID-19 vaccine uptake and comparison to seasonal influenza vaccine uptake in Greater Manchester, UK: A cohort study

[This corrects the article DOI: 10.1371/journal.pmed.1003932.].

Using patient-generated health data in clinical practice: How timing influences its function in rheumatology outpatient consultations

OBJECTIVE

Utilizing patient-generated health data (PGHD) in clinical consultations and informing clinical and shared decision-making processes has the potential to improve clinical practice but has proven challenging to implement. Looking at consultations between people with rheumatoid arthritis (RA) and rheumatologists, this study examines when and how daily PGHD was discussed in outpatient consultations.

METHODS

We conducted a secondary qualitative analysis of 17 audio-recorded research outpatient consultations using thematic and interactional approaches.

RESULTS

Clinicians decided when to look at the PGHD and what symptoms to prioritise during the consultation. When PGHD was introduced early in consultations, it was usually used to invite patients to collaborate (elicit new information). When introduced later, PGHD was used to corroborate patient accounts and to convince the patient about proposed actions and treatments. Clinicians occasionally disregarded PGHD if it did not fit into their clinical assessment.

CONCLUSION

The time that PGHD is introduced may influence how PGHD is used in consultations. Further research is needed to understand how best to empower patients to discuss PGHD.

PRACTICE IMPLICATIONS

Educating patients and clinicians about the importance of timing and strategies when using PGHD in consultations may help promote shared decision-making.

The Emirates Mars Mission

The Emirates Mars Mission (EMM) was launched to Mars in the summer of 2020, and is the first interplanetary spacecraft mission undertaken by the United Arab Emirates (UAE). The mission has multiple programmatic and scientific objectives, including the return of scientifically useful information about Mars. Three science instruments on the mission's Hope Probe will make global remote sensing measurements of the Martian atmosphere from a large low-inclination orbit that will advance our understanding of atmospheric variability on daily and seasonal timescales, as well as vertical atmospheric transport and escape. The mission was conceived and developed rapidly starting in 2014, and had aggressive schedule and cost constraints that drove the design and implementation of a new spacecraft bus. A team of Emirati and American engineers worked across two continents to complete a fully functional and tested spacecraft and bring it to the launchpad in the middle of a global pandemic. EMM is being operated from the UAE and the United States (U.S.), and will make its data freely available.

Understanding the implementation, impact and sustainable use of an electronic pharmacy referral service at hospital discharge: A qualitative evaluation from a sociotechnical perspective

Introduction

The transition of patients across care settings is associated with a high risk of errors and preventable medication-related harm. Ensuring effective communication of information between health professionals is considered important for improving patient safety. A National Health Service(NHS) organisation in the North West of England introduced an electronic transfer of care around medicines (TCAM) system which enabled hospital pharmacists to send information about patient’s medications to their nominated community pharmacy. We aimed to understand the adoption, and the implications for sustainable use in practice of the TCAM service

Methods

We evaluated the TCAM service in a Clinical Commissioning Group (CCG) and NHS Foundation Trust in Salford, United Kingdom (UK). Participants were opportunistically recruited to take part in qualitative interviews through stakeholder networks and during hospital admission, and included hospital pharmacists, hospital pharmacy technicians, community pharmacists, general practice-based pharmacists, patients and their carers. A thematic analysis, that was iterative and concurrent with data collection, was undertaken using a template approach. The interpretation of the data was informed by broad sociotechnical theory.

Results

Twenty-three interviews were conducted with health care professionals patients and carers. The ways in which the newly implemented TCAM intervention was adopted and used in practice and the perceptions of it from different stakeholders were conceptualised into four main thematic areas: The nature of the network and how it contributed to implementation, use and sustainability; The material properties of the system; How work practices for medicines safety were adapted and evolved; and The enhancement of medication safety activities. The TCAM intervention was perceived as effective in providing community pharmacists with timely, more accurate and enhanced information upon discharge. This allowed for pharmacists to enhance clinical services designed to ensure that accurate medication reconciliation was completed, and the correct medication was dispensed for the patient.

Conclusions

By providing pharmacy teams with accurate and enhanced information the TCAM intervention supported healthcare professionals to establish and/or strengthen interprofessional networks in order to provide clinical services designed to ensure that accurate medication reconciliation and dispensing activities were completed. However, the intervention was implemented into a complex and at times fragmented network, and we recommend opportunities be explored to fully integrate this network to involve patients/carers, general practice pharmacists and two-way communication between primary and secondary care to further enhance the reach and impact of the TCAM service.

Co-designing an Adaption of a Mobile App to Enhance Communication, Safety, and Well-being Among People Living at Home With Early-Stage Dementia: Protocol for an Exploratory Multiple Case Study

Background

There is a growing interest in using mobile apps to support communication, safety, and well-being. Evidence directly from people with dementia regarding the usability, usefulness, and relevance of mobile apps is limited.

Objective

This paper describes the protocol of a study that will evaluate an app designed for supporting communication, safety, and well-being among people living with dementia. The study aims to understand if the app can enhance safety through improved communication among users.

Methods

The study will use participatory qualitative methods over 3 cycles of evaluation with co-designers (service users, their families, and care practitioners). The study will be developed in partnership with a specialist home care service in England. Purposive case selection will be performed to ensure that the cases exemplify differences in experiences. The app will be evaluated in a walk-through workshop by people living with early-stage dementia and then trialed at home by up to 12 families in a try-out cycle. An amended version will be evaluated in a final walk-through workshop during cycle 3. Data will be collected from at least 4 data sources during the try-out phase and analyzed thematically. An explanatory multiple case study design will be used to synthesize and present the evidence from the three cycles, drawing on the Normalization Process Theory to support the interpretation of the findings.

Results

The study is ready to be implemented, but it was paused to protect vulnerable individuals during the COVID-19 pandemic in 2020. The findings will be particularly relevant for understanding how to support vulnerable people living in the community during social distancing and the period following the pandemic as well as for providing insight into the challenges of social isolation that arise from living with dementia.

Conclusions

Evaluating a mobile app for enhancing communication, safety, and well-being among people living with dementia contributes to the key ambitions enshrined in policy and practice—championing the use of digital technology and supporting people with dementia to live safely in their own homes. The study will involve co-designers living with dementia, so that the voices of service users can be used to highlight the benefits and challenges of assistive technology and shape the future development of apps that enhance safety by improving communication.

International Registered Report Identifier (IRRID)

PRR1-10.2196/19543

Reflection on the proposed changes to dose quantities-an industrial perspective

In 2021, the ICRP initiated the revision of the general recommendations of the system of radiation protection, and part of it will focus on dose quantities. The recently published ICRP Publication 147 and ICRU Report 95 have described the extent of the proposed modifications and paved the way for the strategy to be adopted. These revisions would seek to simplify, improve the accuracy and extend the field of use of dose quantities. While the Radiological Protection Working Group of the World Nuclear Association recognises the notable improvement in the estimation of the protection quantities and the usefulness of such changes for the medical and research sector, the benefits of the proposed new system seem very limited for the nuclear industry and industries involving naturally occurring radioactive materials. The complexity associated with changing a long-standing and robust system and the risk incurred by the human factor seem unjustified, bearing in mind the likely cost.

Co-designing new tools for collecting, analysing and presenting patient experience data in NHS services: working in partnership with patients and carers

BACKGROUND

The way we collect and use patient experience data is vital to optimise the quality and safety of health services. Yet, some patients and carers do not give feedback because of the limited ways data is collected, analysed and presented. In this study, we worked together with researchers, staff, patient and carer participants, and patient and public involvement and engagement (PPIE) contributors, to co-design new tools for the collection and use of patient experience data in multiple health settings. This paper outlines how the range of PPIE and research activities enabled the co-design of new tools to collect patient experience data.

METHODS

Eight public contributors represented a range of relevant patient and carer experiences in specialist services with varied levels of PPIE experience, and eleven members of Patient and Participation Groups (PPGs) from two general practices formed our PPIE group at the start of the study. Slide sets were used to trigger co-design discussions with staff, patient and carer research participants, and PPIE contributors. Feedback from PPIE contributors alongside verbatim quotes from staff, patient and carer research participants is presented in relation to the themes from the research data.

RESULTS

PPIE insights from four themes: capturing experience data; adopting digital or non-digital tools; ensuring privacy and confidentiality; and co-design of a suite of new tools with guidance, informed joint decisions on the shaping of the tools and how these were implemented. Our PPIE contributors took different roles during co-design and testing of the new tools, which supported co-production of the study.

CONCLUSIONS

Our experiences of developing multiple components of PPIE work for this complex study demonstrates the importance of tailoring PPIE to suit different settings, and to maximise individual strengths and capacity. Our study shows the value of bringing diverse experiences together, putting patients and carers at the heart of improving NHS services, and a shared approach to managing involvement in co-design, with the effects shown through the research process, outcomes and the partnership. We reflect on how we worked together to create a supportive environment when unforeseen challenges emerged (such as, sudden bereavement).

Reflections on low-dose radiation, the misconceptions, reality and moving forward

Low dose radiation has been widely accepted by the radiation protection community as presenting a very low risk to human health, if any. Over-conservatism in optimisation principles and regulations have resulted in a disproportionate fear of radiation amongst the general public and government authorities alike, overlooking the great benefits nuclear science and techniques have brought to society as a whole. As such, the World Nuclear Association advocates for a recontextualisation of the radiation hazards with regards to low dose radiation, and a greater awareness as to the absence of any discernible effects associated with it.

Visual impairment and medication safety: a protocol for a scoping review

BACKGROUND

The number of individuals with a visual impairment in the UK was estimated a few years ago to be around 1.8 million. People can be visually impaired from birth, childhood, early adulthood or later in life. Those with visual impairment are subject to health inequities and increased risk for patient safety incidents in comparison to the general population. They are also known to be at an increased risk of experiencing medication errors compared to those without visual impairment. In view of this, this review aims to understand the issues of medication safety for VI people.

METHODS/DESIGN

Four electronic bibliographic databases will be searched: MEDLINE, Embase, PsycInfo and CINAHL. Our search strategy will include search combinations of two key blocks of terms. Studies will not be excluded based on design. Included studies will be empirical studies. They will include studies that relate to both medication safety and visual impairment. Two reviewers (SG and LR) will screen all the titles and abstracts. SG, LR, RM, SCS and PL will perform study selection and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected will include study characteristics (year, objective, research method, setting, country), participant characteristics (number, age, gender, diagnoses), medication safety incident type and characteristics.

DISCUSSION

The review will summarise the literature relating to medication safety and visual impairment.

Comparative 4-year risk and type of hospital admission among homeless and housed emergency department attendees: longitudinal study of hospital records in England 2013-2018

OBJECTIVES

People experiencing homelessness are frequent users of secondary care. Currently, there is no study of potentially preventable admissions for homeless patients in England. We aim to estimate the number of potentially preventable hospital admissions for homeless patients and compare to housed patients with similar characteristics.

DESIGN

Retrospective matched cohort study.

SETTING

Hospitals in England.

PARTICIPANTS

16 161 homeless patients and 74 780 housed patients aged 16-75 years who attended an emergency department (ED) in England in 2013/2014, matched on the basis of age, sex, ED attended and primary diagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual counts of admissions, emergency admissions, ambulatory care-sensitive (ACS) emergency admissions, acute ACS emergency admissions and chronic ACS emergency admissions over the following 4 years (2014/2015-2017/2018). We additionally compare the prevalence of specific ACS conditions for homeless and housed patients.

RESULTS

Mean admissions per 1000 patients per year were 470 for homeless patients and 230 for housed patients. Adjusted for confounders, annual admissions were 1.79 times higher (incident rate ratio (IRR)=1.79; 95% CI 1.69 to 1.90), emergency admissions 2.08 times higher (IRR=2.08; 95% CI 1.95 to 2.21) and ACS admissions 1.65 times higher (IRR=1.65; 95% CI 1.51 to 1.80), compared with housed patients. The effect was greater for acute (IRR=1.78; 95% CI 1.64 to 1.93) than chronic (IRR=1.45; 95% CI 1.27 to 1.66) ACS conditions. ACS conditions that were relatively more common for homeless patients were cellulitis, convulsions/epilepsy and chronic angina.

CONCLUSIONS

Homeless patients use hospital services at higher rates than housed patients, particularly emergency admissions. ACS admissions of homeless patients are higher which suggests some admissions may be potentially preventable with improved access to primary care. However, these admissions comprise a small share of total admissions.

Exploring engagement with digital screens for collecting patient feedback in clinical waiting rooms: The role of touch and place

Health service settings are increasingly installing digital devices to enable people to engage digitally with multiple processes, including automated 'check-in', as well as collecting feedback on experiences of care. In addition, policy is increasingly driving digital agendas to promote patient engagement with online services, management of health records and routine monitoring. While this tendency towards widespread digital diffusion has been viewed as a means of enabling greater empowerment of patients and improved responsiveness of services to 'patient voice', social scientists have provided critical insights on the use of digital technologies in practice. However, there remains limited understanding of the mechanisms and contexts for digital engagement. In particular, there is a need for further research on the sensory and spatial aspects of engagement that are integral to everyday use (or non-use) of technology in practice. This article reports new insights from detailed qualitative case studies utilising in-depth interviews with patients, carers and staff, in addition to ethnographic observations of different digital modalities and their usage in specific health care contexts. A sociomaterial approach and concepts of affective atmosphere and technogeography are drawn upon to analyse the role of touch and place in the collection of digital feedback in multiple waiting room settings for people with physical and mental health long-term conditions. The findings highlight how barriers to engagement varied by context such as particular concerns about privacy for those with mental health problems and physical and sensory barriers for those with physical impairments. The findings demonstrate how digital inequalities can play out in practice and have implications for the design and development of digital innovations and tackling inequalities that may be associated with implementation of new digital technologies in healthcare.

Managing returns to prison from medium-secure services: qualitative study

BACKGROUND

Little is known about factors that influence discharge decision-making for people admitted to medium-secure services from prison, particularly for those who are returned to prison following treatment.

AIMS

To explore the organisational influences on care pathways through medium-secure services for those admitted from prison.

METHOD

We recruited 24 clinicians via purposive and snowball sampling; 13 shared their experiences via a focus group, and 11 shared their experiences via individual semi-structured interviews. A thematic analysis was conducted, producing three overarching themes: maintenance of throughput and service provision, class of two systems, and desirable and undesirable patients.

RESULTS

Data indicated external factors that direct and, at times, limit clinicians' pathway decisions, including commissioning criteria and legal status under the Mental Health Act 1983 and within the criminal courts system (i.e. whether on remand or sentenced). These factors also influence how clinicians view the role and function of medium-secure services within the wider forensic mental health system, and therefore the types of patients that are deemed 'appropriate' for continued treatment when making discretionary pathway decisions.

CONCLUSIONS

There remains a deficit in adequate resources to meet the mental health needs of prisoners who are admitted to medium-secure services. To meet the clinical need of all admissions, criteria for prolonged treatment in medium-secure services needs to be reconsidered, and it is likely that provision for the medium-secure hospital estate will need to increase substantially if effective rehabilitation of those who transfer from prison is to take place.

Children's Independent Mobility and Physical Activity during the COVID-19 Pandemic: A Qualitative Study with Families

Children's independent mobility (CIM) is the freedom of children to move around their neighbourhood without adult supervision and is closely related to overall physical activity participation. The COVID-19 pandemic has impacted movement behaviours for children, with evidence indicating a decrease in physical activity. The aim of this study was to explore experiences of CIM and physical activity during the COVID-19 pandemic from the perspectives of children and their parents. We completed 21 family (at least one parent and one child aged 7-12) semi-structured interviews with 45 participants living in small urban and rural areas of British Columbia, Canada. Three themes were identified through a reflexive thematic analysis: (1) keeping everyone safe from COVID-19; (2) change in pattern and types of activity; (3) social impacts with family, friends, and community. Participants expressed a perceived increase in unstructured activity and a decrease in structured physical activity during the pandemic, which many parents viewed as a positive change. Parents and children indicated negative feelings due to spending less time with peers and reflected positively about spending more time with family. Parents and children expressed fear and anxiety in trying to keep their families safe from virus spread and creativity in adapting play behaviours. Findings highlight the impact of the pandemic on social friendship networks for families and a shift in activity patterns for children toward unstructured play.

A qualitative exploration of patients' experiences, needs and expectations regarding online access to their primary care record

OBJECTIVES

Primary care records have traditionally served the needs and demands of clinicians rather than those of the patient. In England, general practices must promote and offer registered patients online access to their primary care record, and research has shown benefits to both patients and clinicians of doing so. Despite this, we know little about patients' needs and expectations regarding online access to their record. This study explored what patients and carers want from online access to their electronic primary care health record, their experiences of using it, how they would like to interact with their record and what support they may need.

DESIGN

Focus groups and semistructured interviews using purposive sampling to achieve a good sociodemographic spread. Interviews were digitally audiorecorded, transcribed and coded using an established thematic approach.

SETTING

Focus groups and interviews were conducted in community settings in the UK.

PARTICIPANTS

Fifty-four individuals who were either eligible for the National Health Service Health Check, living with more than one long-term condition or caring for someone else.

RESULTS

Participants views regarding online access were categorised into four main themes: awareness, capabilities, consequences and inevitability. Participants felt online access should be better promoted, and suggested a number of additional functions, such as better integration with other parts of the healthcare system. It was felt that online access could improve quality of care (eg, through increased transparency) but also have potential negative consequences (eg, by replacing face to face contact). A move towards more online records access was considered inevitable, but participants noted a need for additional support and training in using the online record, especially to ensure that health inequalities are not exacerbated.

CONCLUSIONS

Discussions with patients and carers about their views of accessing online records have provided useful insights into future directions and potential improvements for this service.

Public Perspectives of Using Social Media Data to Improve Adverse Drug Reaction Reporting: A Mixed-Methods Study

Introduction

Information on suspected adverse drug reactions (ADRs) voluntarily submitted by patients can be a valuable source of information for improving drug safety; however, public awareness of reporting mechanisms remains low. Whilst methods to automatically detect ADR mentions from social media posts using text mining techniques have been proposed to improve reporting rates, it is unclear how acceptable these would be to social media users.

Objective

The objective of this study was to explore public opinion about using automated methods to detect and report mentions of ADRs on social media to enhance pharmacovigilance efforts.

Methods

Users of the online health discussion forum HealthUnlocked participated in an online survey (N = 1359) about experiences with ADRs, knowledge of pharmacovigilance methods, and opinions about using automated data mining methods to detect and report ADRs. To further explore responses, five qualitative focus groups were conducted with 20 social media users with long-term health conditions.

Results

Participant responses indicated a low awareness of pharmacovigilance methods and ADR reporting. They showed a strong willingness to share health-related social media data about ADRs with researchers and regulators, but were cautious about automated text mining methods of detecting and reporting ADRs.

Conclusions

Social media users value public-facing pharmacovigilance schemes, even if they do not understand the current framework of pharmacovigilance within the UK. Ongoing engagement with users is essential to understand views, share knowledge and respect users’ privacy expectations to optimise future ADR reporting from online health communities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-021-01042-6.

Protocol for a non-randomised feasibility study evaluating a codesigned patient safety guide in primary care

INTRODUCTION

Patients and carers should be active partners in patient safety with healthcare professionals and be empowered to use personalised approaches to identify safety concerns and work together to prevent them. This protocol paper details a study to examine the feasibility of a multicomponent intervention to involve patients and/or carers in patient safety in primary care in the UK.

METHODS AND ANALYSIS

This is a two-phase, non-randomised feasibility mixed methods pragmatic study of a patient safety guide for primary care (PSG-PC). 8 general practices will recruit 120 patient and/or carer participants. All patient and/or carer participants will receive the PSG-PC. It will examine the feasibility and acceptability of the PSG-PC in primary care settings in patients aged 18 years or older who attend appointments at general practice with health professionals four or more times per year as either patients or carers. It will identify secondary outcomes for improving patient safety, health status and patient empowerment, and reducing health service utilisation over 6 months between baseline and 6-month follow-ups. The findings will inform whether a main effectiveness trial is feasible and, if so, how it should be designed, and how many patients and practices will be needed. The study will be undertaken between January 2020 and September 2021.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the National Health Service London-West London and Gene Therapy Advisory Committee Research Ethics Committee (reference: 19/LO/1289). Research findings will be disseminated with participating general practices and shared in a range of different ways to engage different audiences, including presenting at international and national conferences, publishing in open-access, peer-reviewed journals and facilitating dissemination workshops within local communities with patients, carers and healthcare professionals.

TRIAL REGISTRATION NUMBER

ISRCTN90222092.

Exploring the experiences of changes to support access to primary health care services and the impact on the quality and safety of care for homeless people during the COVID-19 pandemic: a study protocol for a qualitative mixed methods approach

Background

Despite high level of health care need amongst people experiencing homelessness, poor access is a major concern. This is sometimes due to organisational and bureaucratic barriers, but also because they often feel stigmatised and treated badly when they do seek health care. The COVID-19 pandemic and the required social distancing measures have caused unprecedented disruption and change for the organisation of primary care, particularly for people experiencing homelessness. Against this backdrop there are many questions to address regarding whether the recent changes required to deliver services to people experiencing homelessness in the context of COVID-19 will help to address or compound problems in accessing care and inequalities in health outcomes.

Methods

An action led and participatory research methodology will be employed to address the study objectives. Interviews with people experiencing homelessness were will be conducted by a researcher with lived experience of homelessness. Researchers with lived experience are able to engage with vulnerable communities in an empathetic, non-judgemental way as their shared experience promotes a sense of trust and integrity, which in turn encourages participation in research and may help people speak more openly about their experience. The experiences of health professionals and stakeholders delivering and facilitating care for people experiencing homelessness during the pandemic will also be explored.

Discussion

It is important to explore whether recent changes to the delivery of primary care in response to the COVID-19 pandemic compromise the safety of people experiencing homelessness and exacerbate health inequalities. This could have implications for how primary healthcare is delivered to those experiencing homelessness not only for the duration of the pandemic but in the future.

Implementing disruptive technological change in UK healthcare: exploring development of a smart phone app for remote patient monitoring as a boundary object using qualitative methods

PURPOSE

Developing technological innovations in healthcare is made complex and difficult due to effects upon the practices of professional, managerial and other stakeholders. Drawing upon the concept of boundary object, this paper explores the challenges of achieving effective collaboration in the development and use of a novel healthcare innovation in the English healthcare system.

DESIGN/METHODOLOGY/APPROACH

A case study is presented of the development and implementation of a smart phone application (app) for use by rheumatoid arthritis patients. Over a two-year period (2015-2017), qualitative data from recorded clinical consultations (n = 17), semi-structured interviews (n = 63) and two focus groups (n = 13) were obtained from participants involved in the app's development and use (clinicians, patients, researchers, practitioners, IT specialists and managers).

FINDINGS

The case focuses on the use of the app and its outputs as a system of inter-connected boundary objects. The analysis highlights the challenges overcome in the innovation's development and how knowledge sharing between patients and clinicians was enhanced, altering the nature of the clinical consultation. It also shows how conditions surrounding the innovation both enabled its development and inhibited its wider scale-up.

ORIGINALITY/VALUE

By recognizing that technological artefacts can simultaneously enable and inhibit collaboration, this paper highlights the need to overcome tensions between the transformative capability of such healthcare innovations and the inhibiting effects simultaneously created on change at a wider system level.

Smartphone-Enhanced Symptom Management In Psychosis: Open, Randomized Controlled Trial

Background

Improving recovery from acute symptoms and preventing relapse are two significant challenges in severe mental illness. We developed a personalized smartphone-based app to monitor symptoms in real time and validated its acceptance, reliability, and validity.

Objective

To assess (i) acceptability of continuous monitoring to SMI patients and health professionals over 3 months; (ii) impact of active self-monitoring on positive psychotic symptoms assessed at 6 and 12 weeks; and (iii) the feasibility of detecting early warning signs of relapse.

Methods

The active symptom monitoring smartphone app was built into an end-to-end system in two NHS Trusts to enable real-time symptom self-monitoring and detection by the clinical team of early signs of relapse in people with severe mental illness. We conducted an open randomized controlled trial of active symptom monitoring compared to usual management to assess: (i) acceptability and safety of continuous monitoring over 3 months; (ii) impact of active self-monitoring on positive psychotic symptoms assessed at 6 and 12 weeks; (iii) feasibility of detecting early warning signs of relapse communicated to the healthcare staff via an app streaming data to the electronic health record. Eligible participants with a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnosis of schizophrenia and related disorders, and a history of relapse within the previous two years were enrolled from an early intervention team and a community mental health team.

Results

Of 181 eligible patients, 81 (45%) consented and were randomized to either active symptom monitoring or management as usual. At 12 weeks, 90% (33/36) of those in the active monitoring group continued to use the system and exhibited an adherence rate (defined as responding to >33% of alerts) of 84% (30/36}. Active symptom monitoring was associated with no difference on the empowerment scale in comparison to the usual management group at 12 weeks. The pre-planned intent-to-treat analysis of the primary outcome, a positive score on the Positive and Negative Syndrome Scale (PANSS) scale, showed a significant reduction in the active symptom monitoring group over 12 weeks in the early intervention center. Alerts for personalized early warning signs of relapse were built into the workflows of both NHS Trusts, and 100% of health professional staff used the system in a new digital workflow. Qualitative analyses supported the acceptability of the system to participants and staff.

Conclusions

The active smartphone monitoring system is feasible and was accepted by users in a 3-month study of people with severe mental illness, with surprisingly high levels of adherence. App use was associated with psychotic symptom improvement in recent-onset participants, but not those with longstanding illness, supporting the notion of improved self-management. When built into clinical management workflows to enable personalized alerts of symptom deterioration, the app has demonstrated utility in promoting earlier intervention for relapse.

Trial Registration

ISRCTN Registry ISRCTN88145142; http://www.isrctn.com/ISRCTN88145142

Providing 'the bigger picture': benefits and feasibility of integrating remote monitoring from smartphones into the electronic health record

Objectives

To establish the acceptability and feasibility of collecting daily patient-generated health data (PGHD) using smartphones and integrating PGHD into the electronic health record, using the example of RA.

Methods

The Remote Monitoring of RA smartphone app was co-designed with patients, clinicians and researchers using qualitative semi-structured interviews and focus groups, including selection of question sets for symptoms and disease impact. PGHD were integrated into the electronic health record of one hospital and available in graphical form during consultations. Acceptability and feasibility were assessed with 20 RA patients and two clinicians over 3 months. A qualitative evaluation included semi-structured interviews with patients and clinicians before and after using the app, and audio-recordings of consultations to explore impact on the consultation. PGHD completeness was summarized descriptively, and qualitative data were analysed thematically.

Results

Patients submitted data on a median of 91% days over 3 months. Qualitative analysis generated three themes: RA as an invisible disease; providing the bigger picture of RA; and enabling person-centred consultations. The themes demonstrated that the system helped render patients’ RA more visible by providing the ‘bigger picture’, identifying real-time changes in disease activity and capturing symptoms that would otherwise have been missed. Graphical summaries during consultations enabled a more person-centred approach whereby patients felt better able to participate in consultations and treatment plans.

Conclusion

Remote Monitoring of RA has uniquely integrated daily PGHD from smartphones into the electronic health record. It has delivered proof-of-concept that such integrated remote monitoring systems are feasible and can transform consultations for clinician and patient benefit.

Digital methods to enhance the usefulness of patient experience data in services for long-term conditions: the DEPEND mixed-methods study

Background

Collecting NHS patient experience data is critical to ensure the delivery of high-quality services. Data are obtained from multiple sources, including service-specific surveys and widely used generic surveys. There are concerns about the timeliness of feedback, that some groups of patients and carers do not give feedback and that free-text feedback may be useful but is difficult to analyse.

Objective

To understand how to improve the collection and usefulness of patient experience data in services for people with long-term conditions using digital data capture and improved analysis of comments.

Design

The DEPEND study is a mixed-methods study with four parts: qualitative research to explore the perspectives of patients, carers and staff; use of computer science text-analytics methods to analyse comments; co-design of new tools to improve data collection and usefulness; and implementation and process evaluation to assess use of the tools and any impacts.

Setting

Services for people with severe mental illness and musculoskeletal conditions at four sites as exemplars to reflect both mental health and physical long-terms conditions: an acute trust (site A), a mental health trust (site B) and two general practices (sites C1 and C2).

Participants

A total of 100 staff members with diverse roles in patient experience management, clinical practice and information technology; 59 patients and 21 carers participated in the qualitative research components.

Interventions

The tools comprised a digital survey completed using a tablet device (kiosk) or a pen and paper/online version; guidance and information for patients, carers and staff; text-mining programs; reporting templates; and a process for eliciting and recording verbal feedback in community mental health services.

Results

We found a lack of understanding and experience of the process of giving feedback. People wanted more meaningful and informal feedback to suit local contexts. Text mining enabled systematic analysis, although challenges remained, and qualitative analysis provided additional insights. All sites managed to collect feedback digitally; however, there was a perceived need for additional resources, and engagement varied. Observation indicated that patients were apprehensive about using kiosks but often would participate with support. The process for collecting and recording verbal feedback in mental health services made sense to participants, but was not successfully adopted, with staff workload and technical problems often highlighted as barriers. Staff thought that new methods were insightful, but observation did not reveal changes in services during the testing period.

Conclusions

The use of digital methods can produce some improvements in the collection and usefulness of feedback. Context and flexibility are important, and digital methods need to be complemented with alternative methods. Text mining can provide useful analysis for reporting on large data sets within large organisations, but qualitative analysis may be more useful for small data sets and in small organisations.

Limitations

New practices need time and support to be adopted and this study had limited resources and a limited testing time.

Future work

Further research is needed to improve text-analysis methods for routine use in services and to evaluate the impact of methods (digital and non-digital) on service improvement in varied contexts and among diverse patients and carers.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 28. See the NIHR Journals Library website for further project information.

Dementia and mild cognitive impairment in prisoners aged over 50 years in England and Wales: a mixed-methods study

Background

People aged ≥ 50 years constitute the fastest-growing group in the prison population of England and Wales. This population has complex health and social care needs. There is currently no national strategy to guide the development of the many-faceted services required for this vulnerable population; therefore, prisons are responding to the issue with a range of local initiatives that are untested and often susceptible to failure if they are not fully embedded in and securely funded as part of commissioned services.

Objectives

The objectives were to establish the prevalence of dementia and mild cognitive impairment in prisoners in England and Wales and their health and social care needs; validate the six-item cognitive impairment test for routine use in prisons to aid early and consistent identification of older prisoners with possible dementia or mild cognitive impairment; identify gaps in current service provision; understand the first-hand experiences of prisoners living with dementia and mild cognitive impairment; develop a care pathway for prisoners with dementia and mild cognitive impairment; develop dementia and mild cognitive impairment training packages for staff and prisoners; and produce health economic costings for the care pathway and training packages.

Design

This was a mixed-methods study.

Setting

The study setting was prisons in England and Wales.

Participants

Prisoners aged ≥ 50 years and multiagency staff working in prison discipline and health and social care services took part.

Results

Quantitative research estimated that the prevalence rate of suspected dementia and mild cognitive impairment in the prison population of England and Wales is 8%. This equates to 1090 individuals. Only two people (3%) in our sample had a relevant diagnosis in their health-care notes, suggesting current under-recognition of these conditions. The prevalence rate in prisons was approximately two times higher among individuals aged 60–69 years and four times higher among those aged ≥ 70 years than among those in the same age groups living in the community. The Montreal Cognitive Assessment screening test was found to be more effective than the six-item cognitive impairment test assessment in the older prisoner population. Qualitative research determined that staff and prisoners lacked training in knowledge and awareness of dementia and mild cognitive impairment, and this leads to problematic behaviour being viewed as a disciplinary issue rather than a health issue. Local initiatives to improve the lives of prisoners with dementia and mild cognitive impairment are often disadvantaged by not being part of commissioned services, making them difficult to sustain. Multidisciplinary working is hampered by agencies continuing to work in silos, with inadequate communication across professional boundaries. A step-by-step care pathway for prisoners with dementia and mild cognitive impairment was developed, and two tiers of training materials were produced for staff and prisoners.

Limitations

Our prevalence rate was based on the results of a standardised assessment tool, rather than on clinical diagnosis by a mental health professional, and therefore it may represent an overestimation. Furthermore, we were unable to distinguish subcategories of dementia. We were also unable to distinguish between a likely diagnosis of dementia and other conditions presenting with mild cognitive impairment, including learning disability, severe depression and hearing impairment. Questionnaires regarding current service provision were collected over an extended period of time, so they do not reflect a ‘snapshot’ of service provision at a particular point.

Conclusions

We hypothesise that implementing the step-by-step care pathway and the training resources developed in this study will improve the care of older prisoners with dementia and mild cognitive impairment.

Future work

The care pathway and training materials should be evaluated in situ. Alternatives to prison for those with dementia or mild cognitive impairment should be developed and evaluated.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 27. See the NIHR Journals Library website for further project information.

Lessons for the future: Reflections on a review of child death overview panels through a local lens in the United Kingdom

Child death overview panels (CDOPs) were set up in the United Kingdom following the confidential enquiry into maternal and child health. Their scope is to identify learning points and modifiable factors that focus on improving services and prevent further deaths. In the light of UK national review and subsequent legislative changes to local safeguarding arrangements, we wanted to share the lessons learnt from our local network study during this time of transition. At times of system change, organizational memory can be eroded, which results in lost opportunities to further strengthen multi-agency working in practice. Overall, our local study highlighted key learning points which could be of use in emergent safeguarding partnerships. Professionals need to continue to actively pursue and create opportunities to collect and collate comprehensive data and promote collaborative multi-agency arrangements. Panels need to be responsive to all partners involved in the safeguarding process, which includes parents. A level of reciprocity needs to be nurtured for safeguarding panel members and acute care providers to work in ways which promote learning, consider emotional support systems and explore ways to define and mobilize knowledge that can inform the safeguarding process and prevent future avoidable child deaths.

Implementing a digital patient feedback system: an analysis using normalisation process theory

BACKGROUND

Patient feedback in the English NHS is now widespread and digital methods are increasingly used. Adoption of digital methods depends on socio-technical and contextual factors, alongside human agency and lived experience. Moreover, the introduction of these methods may be perceived as disruptive of organisational and clinical routines. The focus of this paper is on the implementation of a particular digital feedback intervention that was co-designed with health professionals and patients (the DEPEND study).

METHODS

The digital feedback intervention was conceptualised as a complex intervention and thus the study focused on the contexts within which it operated, and how the different participants made sense of the intervention and engaged with it (or not). Four health care sites were studied: an acute setting, a mental health setting, and two general practices. Qualitative data was collected through interviews and focus groups with professionals, patients and carers. In total 51 staff, 24 patients and 8 carers were included. Forty-two observations of the use of the digital feedback system were carried out in the four settings. Data analysis was based on modified grounded theory and Normalisation Process Theory (NPT) formed the conceptual framework.

RESULTS

Digital feedback made sense to health care staff as it was seen as attractive, fast to complete and easier to analyse. Patients had a range of views depending on their familiarity with the digital world. Patients mentioned barriers such as kiosk not being visible, privacy, lack of digital know-how, technical hitches with the touchscreen. Collective action in maintaining participation again differed between sites because of workload pressure, perceptions of roles and responsibilities; and in the mental health site major organisational change was taking place. For mental health service users, their relationship with staff and their own health status determined their digital use.

CONCLUSION

The potential of digital feedback was recognised but implementation should take local contexts, different patient groups and organisational leadership into account. Patient involvement in change and adaptation of the intervention was important in enhancing the embedding of digital methods in routine feedback. NPT allowed for a in-depth understanding of actions and interactions of both staff and patients.

Patient safety in marginalised groups: a narrative scoping review

Background

Marginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising.

Methods

Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day.

Results

The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors.

Conclusions

This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks.

Trial registration

Not applicable for a scoping review.

Engagement and Participant Experiences With Consumer Smartwatches for Health Research: Longitudinal, Observational Feasibility Study

BACKGROUND

Wearables provide opportunities for frequent health data collection and symptom monitoring. The feasibility of using consumer cellular smartwatches to provide information both on symptoms and contemporary sensor data has not yet been investigated.

OBJECTIVE

This study aimed to investigate the feasibility and acceptability of using cellular smartwatches to capture multiple patient-reported outcomes per day alongside continuous physical activity data over a 3-month period in people living with knee osteoarthritis (OA).

METHODS

For the KOALAP (Knee OsteoArthritis: Linking Activity and Pain) study, a novel cellular smartwatch app for health data collection was developed. Participants (age ≥50 years; self-diagnosed knee OA) received a smartwatch (Huawei Watch 2) with the KOALAP app. When worn, the watch collected sensor data and prompted participants to self-report outcomes multiple times per day. Participants were invited for a baseline and follow-up interview to discuss their motivations and experiences. Engagement with the watch was measured using daily watch wear time and the percentage completion of watch questions. Interview transcripts were analyzed using grounded thematic analysis.

RESULTS

A total of 26 people participated in the study. Good use and engagement were observed over 3 months: most participants wore the watch on 75% (68/90) of days or more, for a median of 11 hours. The number of active participants declined over the study duration, especially in the final week. Among participants who remained active, neither watch time nor question completion percentage declined over time. Participants were mainly motivated to learn about their symptoms and enjoyed the self-tracking aspects of the watch. Barriers to full engagement were battery life limitations, technical problems, and unfulfilled expectations of the watch. Participants reported that they would have liked to report symptoms more than 4 or 5 times per day.

CONCLUSIONS

This study shows that capture of patient-reported outcomes multiple times per day with linked sensor data from a smartwatch is feasible over at least a 3-month period.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/10238.

Training to enhance user and carer involvement in mental health-care planning: the EQUIP research programme including a cluster RCT

Background

Service users and carers using mental health services want more involvement in their care and the aim of this research programme was to enhance service user and carer involvement in care planning in mental health services.

Objectives

Co-develop and co-deliver a training intervention for health professionals in community mental health teams, which aimed to enhance service user and carer involvement in care planning. Develop a patient-reported outcome measure of service user involvement in care planning, design an audit tool and assess individual preferences for key aspects of care planning involvement. Evaluate the clinical effectiveness and the cost-effectiveness of the training. Understand the barriers to and facilitators of implementing service user- and carer-involved care planning. Disseminate resources to stakeholders.

Methods

A systematic review, focus groups and interviews with service users/carers/health professionals informed the training and determined the priorities underpinning involvement in care planning. Data from focus groups and interviews were combined and analysed using framework analysis. The results of the systematic review, focus groups/interviews and a review of the training interventions were synthesised to develop the final training intervention. To develop and validate the patient-reported outcome measure, items were generated from focus groups and interviews, and a psychometric analysis was conducted. Patient-reported outcome measure items and a three-round consensus exercise were used to develop an audit tool, and a stated preference survey was undertaken to assess individual preferences for key aspects of care planning. The clinical effectiveness and cost-effectiveness of the training were evaluated using a pragmatic cluster trial with cohort and cross-sectional samples. A nested longitudinal qualitative process evaluation using multiple methods, including semistructured interviews with key informants involved locally and nationally in mental health policy, practice and research, was undertaken. A mapping exercise was used to determine current practice, and semistructured interviews were undertaken with service users and mental health professionals from both the usual-care and the intervention arms of the trial at three time points (i.e. baseline and 6 months and 12 months post intervention).

Results

The results from focus groups (n = 56) and interviews (n = 74) highlighted a need to deliver training to increase the quality of care planning and a training intervention was developed. We recruited 402 participants to develop the final 14-item patient-reported outcome measure and a six-item audit tool. We recruited 232 participants for the stated preference survey and found that preferences were strongest for the attribute ‘my preferences for care are included in the care plan’. The training was delivered to 304 care co-ordinators working in community mental health teams across 10 NHS trusts. The cluster trial and cross-sectional survey recruited 1286 service users and 90 carers, and the primary outcome was the Health Care Climate Questionnaire. Training was positively evaluated. The results showed no statistically significant difference on the primary outcome (the Health Care Climate Questionnaire) (adjusted mean difference –0.064, 95% confidence interval –0.343 to 0.215; p = 0.654) or secondary outcomes at the 6-month follow-up. Overall, the training intervention was associated with a net saving of –£54.00 (95% confidence interval –£193.00 to £84.00), with a net quality-adjusted life-year loss of –0.014 (95% confidence interval –0.034 to 0.005). The longitudinal process evaluation recruited 54 service users, professionals and carers, finding a failure of training to become embedded in routine care.

Limitations

Our pragmatic study was designed to improve service user and care involvement in care planning among routine community mental health services. We intervened in 18 sites with > 300 care co-ordinators. However, our volunteer sites may not be fully representative of the wider population, and we lacked data with which to compare our participants with the eligible population.

Conclusions

We co-developed and co-delivered a training intervention and developed a unidimensional measure of service user and carer involvement in care planning and an audit tool. Despite a high level of satisfaction with the training, no significant effect was found; therefore, the intervention was ineffective. There was a failure of training to become embedded and normalised because of a lack of organisational readiness to accept change. Working with NHS trusts in our ‘Willing Adopters’ programme with enhanced organisational buy-in yielded some promising results.

Future work

Research should focus on developing and evaluating new organisational initiatives in addition to training health-care professionals to address contextual barriers to service and carer involvement in care planning, and explore co-designing and delivering new ways of enhancing service users’ and carers’ capabilities to engage in care planning.

Trial registration

Current Controlled Trials ISRCTN16488358.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 9. See the NIHR Journals Library website for further project information.

Reasons for Underreporting of Uremic Pruritus in People With Chronic Kidney Disease: A Qualitative Study

CONTEXT

Uremic pruritus, or itch, is common in people with chronic kidney disease (CKD) and has a negative impact on their lives and well-being. However, for reasons currently unknown, itch often remains unreported and therefore untreated.

OBJECTIVES

To explore reasons for underreporting of itch to provide pointers for improving itch reporting and management in people with CKD.

METHODS

We interviewed adult patients with CKD who self-reported experiencing itching in the last three years (n = 25), nephrologists (n = 10), and nurses (n = 12) from three kidney services in the U.K. Topic guides were informed by previous studies and a theoretical model of self-regulation. We conducted a thematic analysis of verbatim transcripts using framework analysis.

RESULTS

We identified the following three main themes reflecting factors that may influence whether itch is reported: knowledge on causes and treatment of itch (lack of awareness of the relationship between itch and CKD, and lack of knowledge of treatment options); attitudes toward importance of itch as a health issue (patients' and clinicians' attitudes); and prompts for itch assessment during consultations (routine practice, itch as a marker, and itch severity).

CONCLUSION

Underreporting of itch is related to patients being unaware of its causes, accepting it as something to live with, prioritizing other health issues, and the length and timing of consultations. Health care professionals' assessment and management of itch vary widely and are not necessarily evidence-based. Better patient information, development of clinical practice guidelines, and incorporation of routine symptom assessments into care may improve itch reporting and management in people with CKD.

Understanding the diagnosis of pre-diabetes in patients aged over 85 in English primary care: a qualitative study

Background

The benefit of a “diagnosis” of pre-diabetes in very elderly patients is debated. How clinicians manage pre-diabetic blood results in these patients is unknown. This study aims to understand how clinicians are “diagnosing” older patients with pre-diabetic blood parameters.

Methods

Semi-structured interviews and focus groups with health care staff (24 total participants) were conducted in the north of England. Interviews and focus groups were recorded, transcribed and analysed thematically. A grounded theory approach was taken with the theory of candidacy being used as a sensitising concept through which questions were framed and results interpreted.

Results

There is a complex system of competing pressures that influence a clinician in deciding whether, and in what way, to inform a very elderly patient that they have pre-diabetes. The majority of clinicians adjust their management of pre-diabetes to the age and perceived risk/benefit for the patient. Whilst some clinicians choose not to inform certain patients of their blood results, many clinicians maintain, what could be seen as a somewhat paradoxical approach of labeling all older patients with pre-diabetes but downplaying the significance to the patient. The policy, organisational context, workload and professional constraints under which clinicians work, play a significant role in shaping how they deal with pre-diabetic blood results in the very elderly.

Conclusion

There has been recent acknowledgement of how policy and organisational context frames decision-making, but there is a lack of evidence on how this influences uncertainty and dilemmas in decision-making in practice. These findings add further weight for the argument that treatment burden should be included in clinical guidelines.

Evaluating a telehealth intervention for urinalysis monitoring in children with neurogenic bladder

Telehealth as a community-monitoring project within children's urology care is an innovative development. There is limited evidence of the inclusion of staff and parents in the early-stage development and later adoption of telehealth initiatives within routine urological nursing care or families' management of their child's bladder. The aim was to explore the experiences of key stakeholders (parents, clinicians, and technical experts) of the proof of concept telehealth intervention in terms of remote community-based urinalysis monitoring by parents of their child's urine. A concurrent mixed-methods research design used soft systems methodology tools to inform data collection and analysis following interviews, observation, and e-surveys with stakeholders. Findings showed that the parents adopted aspects of the telehealth intervention (urinalysis) but were less engaged with the voiding diary and weighing. The parents gained confidence in decision-making and identified that the intervention reduced delays in their child receiving appropriate treatment, decreased the time burden, and improved engagement with general practitioners. Managing the additional workload was a challenge for the clinical team. Parental empowerment and self-efficacy were clear outcomes from the intervention. Parents exercised their confidence and control and were selective about which aspects of the intervention they perceived as having credibility and which they valued.