The impact of Covid-19 on research into work and health

BACKGROUND

The global coronavirus (Covid-19) pandemic created a profound disruption to the delivery of planned scientific research with unknown immediate and potentially longer-term impacts.

AIMS

We explored researchers' experiences of the impact of the pandemic on the continued development and delivery of research into work and health, and on research infrastructure in this field.

METHODS

A cross-sectional study.

RESULTS

Thirty-three questionnaires were completed, representing a response rate of 15%. Sixty-one per cent of respondents were female, the majority (78%) had over 11 years of research experience and 76% worked mainly in academia. Most respondents (88%) were able to progress with research during the pandemic. A small proportion (4%) had studies paused or suspended due to the pandemic, while a larger proportion (19%) had research staff redeployed to assist with other studies or furloughed. Respondents described a range of emerging practical and logistical issues for research into work and health during the pandemic. Some benefited from increased opportunities to collaborate on new multidisciplinary studies, opportunities to engage participants in work and health research, and more flexible and inclusive work practices. Others experienced challenges that had an adverse impact, such as hampering research delivery (e.g. barriers to participant screening and intervention delivery), poor (home) working environments, reduced team cohesion and isolation. A range of future priorities for research was highlighted.

CONCLUSIONS

We describe lessons learned and opportunities that can be used to support or further research activities in the field of work and health research in the future.

Making Every Contact Count with people with MSK conditions: Exploring physiotherapist acceptability

 

There are known risk factors that are associated with the onset and exacerbation of musculoskeletal (MSK) conditions and pain. Physiotherapists are uniquely placed to deliver brief interventions with their patients. Healthy Conversation Skills is the main training component of the Wessex approach to Making Every Contact Count. Despite its potential for promoting MSK health and wellbeing, there is no evidence to support its acceptability within MSK services. This is the first known study to explore the use and perceptions of the Wessex model of MECC HCS within MSK services. A mixed method design was used. Phase one employed an online questionnaire, open to all professionals trained in MECC HCS, consisting of items relating to implementation outcomes. Barriers and facilitators to delivery were explored and mapped to the Theoretical Domains Framework. Phase two invited physiotherapists for a follow-up interview and qualitatively explored their acceptability of delivering MECC HCS to patients with MSK conditions. MECC HCS was found to be highly acceptable, appropriate, and feasible. Physiotherapists reported using their skills at least daily but missed opportunities for delivering MECC HCS were evident. Barriers mapped mostly to ‘Environmental Context and Resources’ on the Theoretical Domains Framework. Qualitative themes developed during phase two were: ‘Recognising the patient as the expert supports change', ‘MECC HCS improves physiotherapy practice', ‘MECC HCS shared problem solving reduces workload', ‘time as a perceived barrier to MECC HCS’ and ‘system-level support needed to sustain MECC HCS'. MECC HCS is a promising brief intervention for supporting people with MSK conditions. Further rollout of this intervention may be beneficial for meeting the goals of the NHS and Public Health England in prevention of MSK conditions and promotion of MSK health. Barriers associated with sustainability must, however, be addressed.

Key messages

• Making Every Contact Count Healthy Conversation Skills is considered a highly acceptable brief intervention for supporting behaviour change in people with musculoskeletal conditions.

• Organisational, system-level barriers to implementation must be addressed in order to increase sustainability and enhance future roll out of the brief intervention.

O-078 The VALUE study: a qualitative semi-structured interview study of add-on use by patients, clinicians, and embryologists in the UK and Australia

Study question

Why do patients, clinicians and embryologists opt to use IVF add-ons in fertility treatment?

Summary answer

Add-ons offer options, hope and control in a desperate situation. The perceived drivers differ between patients and professionals; however, both feel add-ons offer bespoke care.

What is known already

Evidence that add-ons offer clinical advantages for the outcomes of IVF is lacking or insufficient. However, they remain popular in the UK and Australia, with over three-quarters of couples opting to use them. Professionals, clinical societies, and the media have latched onto the ethical aspects of offering non-evidence-based add-ons, often provided at an additional cost to vulnerable patients. Conversely, it has also been suggested that patients are driving add-on use. The VALUE study is the first large qualitative study to include both patients and professionals that explores the drivers behind their use, and how the existing evidence is weighed up.

Study design, size, duration

VALUE was a multinational semi-structured interview study in the UK and Australia. The interview schedule was reached through extensive patient and public involvement. Between January and May 2021, recruitment took place via social media advertisement, email invitation from professional societies, and snowballing. A purposive sampling strategy was planned; all eligible participants (25 patients, 25 embryologists, and 24 clinicians) were interviewed via recorded teleconference. Anonymised verbatim transcripts were analysed iteratively, and themes developed inductively.

Participants/materials, setting, methods

Patient and professional transcripts were coded separately using the software DedooseTM Two separate thematic analyses followed. An inductive approach to analysis was adopted, whereby themes emerged from the data, opposed to constructing a pre-conceived coding scheme. Codes were combined into broader themes, and sub-themes, which were discussed, debated, and named. The wider research team then commented upon and debated the themes and sub-themes, which were settled upon by consensus.

Main results and the role of chance

Thematic analysis of patient interviews identified five themes: ‘vulnerability’; ‘power of the trusted professional opinion’; ‘role of previous experience’; ‘acceptability of add-on’; and ‘the evidence doesn’t apply to me’. The professional interviews identified five themes: ‘Treating desperation’; ‘tensions within evidence-based practice’; ‘success, not profits’; ‘the patient shopper’; and ‘potential for harm’.

Analysis identified that that people undergoing IVF are vulnerable and opting for non-evidence-based treatments at additional cost because of a sense of desperation following unsuccessful cycles. For patients, utilising add-ons lends hope and a sense of control, with considerations of safety and efficacy being ranked lower than hope. For professionals, add-ons are reasonable given the absence of anything else to add, and allows patients the opportunity to exhaust every avenue. At odds with one-another are the themes regarding who is driving add-on use. Patients describe the power of a professional recommendation, believing it to be in their best interest. For professionals, it’s the patients who research and request add-ons, and failing to offer them risks losing patients. The tension between evidence and bespoke care was evident across both analyses, with testimonies being particularly powerful for patients, and for professionals, a belief that add-ons are helpful in the right context.

Limitations, reasons for caution

The VALUE study has captured patients and professionals who have volunteered to talk about this particularly contentious area of medicine. Participants are likely to be a motivated group of individuals who may potentially represent those with strong views regarding add-ons.

Wider implications of the findings

The theme of desperation runs through VALUE’s analyses and whilst we did find that patients drive add-on use, professional opinion for or against add-ons was powerful. Patients want autonomy, but only in the context of informed consent.

Trial registration number

https://osf.io/he7tn/

Return to work interventions for chronic pain: a systematic review

BACKGROUND

Chronic pain (CP) remains the second commonest reason for being off work. Tertiary return to work (RTW) interventions aim to improve psychological and physical capacity amongst workers already off sick. Their effectiveness for workers with CP is unclear.

AIMS

To explore which tertiary interventions effectively promote RTW for CP sufferers.

METHODS

We searched eight databases for randomized controlled trials evaluating the effectiveness of tertiary RTW interventions for CP sufferers. We employed the Cochrane Risk of Bias (ROB) and methodological quality assessment tools for all included papers. We synthesized findings narratively. Meta-analysis was not possible due to heterogeneity of study characteristics.

RESULTS

We included 16 papers pertaining to 13 trials. The types, delivery format and follow-up schedules of RTW interventions varied greatly. Most treatments were multidisciplinary, comprising psychological, physical and workplace elements. Five trials reported that tertiary interventions with multidisciplinary elements promoted RTW for workers with CP compared to controls. We gave a high ROB rating for one or more assessment criteria to three out of the five successful intervention trials. Two had medium- and low-risk elements across all categories. One compared different intensity multidisciplinary treatment and one comprised work-hardening with a job coach. Seven trials found treatment effects for secondary outcomes but no RTW improvement.

CONCLUSIONS

There is no conclusive evidence to support any specific tertiary RTW intervention for workers with CP, but multidisciplinary efforts should be considered. Workers' compensation is an important area for RTW policymakers to consider.

Resilience and return-to-work pain interventions: systematic review

BACKGROUND

Resilience is a developing concept in relation to pain, but has not yet been reviewed in return-to-work (RTW) contexts.

AIMS

To explore the role of resilience enhancement in promoting work participation for chronic pain sufferers, by reviewing the effectiveness of existing interventions.

METHODS

Resilience was operationalized as: self-efficacy, active coping, positive affect, positive growth, positive reinforcement, optimism, purpose in life and acceptance. Five databases were searched for randomized controlled trials (RCTs) whose interventions included an element of resilience designed to help RTW/staying at work for chronic pain sufferers. Study appraisal comprised the Cochrane risk of bias (RoB) tool and additional quality assessment. Findings were synthesized narratively and between-group differences of outcomes were reported. Heterogeneous PICO (population, intervention, comparator, outcome) elements precluded meta-analysis.

RESULTS

Thirty-four papers from 24 RCTs were included. Interventions varied; most were multidisciplinary, combining behavioural, physical and psychological pain management and vocational rehabilitation. Four found RTW/staying at work improved with intensive multidisciplinary interventions compared with less intensive, or no, treatment. Of these, one had low RoB; three scored poorly on allocation concealment and selective outcome reporting. Four trials had mixed results, e.g. interventions enabling reduced sick leave for people on short-term not long-term leave; 16 showed no improvement. Five trials reported resilience outcomes were improved by interventions but these were not always trials in which RTW improved.

CONCLUSIONS

Effectiveness of resilience interventions for chronic pain sufferers on RTW is uncertain and not as helpful as anticipated. Further agreement on its conceptualization and terminology and that of RTW is needed.

Learning professional touch: an exploration of pre-registration Physiotherapy students' experiences

Physical touch is considered a core competency in Physiotherapy, central to clinical reasoning and communication. Nevertheless, there is a dearth of research into how the skill is learned and the experiences of students in that process. The aim of this paper is to explore that learning experience among pre-registration physiotherapy students. An approach underpinned by phenomenology and ethnographic methods was undertaken over an 8-month period in one Higher Education Institution in the UK. Data came from a series of observations and focus groups, complemented by personal reflective learning diaries with first- and second-year undergraduate students. Focus group data were analyzed thematically and triangulated with other data sources. Three themes were developed: 1) 'Uncertainty, self-awareness and anxiety' explores the discomfort experienced in the early stages; 2) 'Emerging familiarity and awareness of inter-action' demonstrates developing confidence in bodily capability and communicative capacity; and 3) 'Realities of touch in a clinical environment' focuses on the shift from the pre-clinical to clinical context and highlights the cyclical processes of embodied learning. This study highlights the complexity and immediacy of the embodied learning of touch and its interactions with the development of professional identity. Negotiation of boundaries, both seen and unseen, creates jeopardy in that process through the first two years of the course.

The development of a theory informed behaviour change intervention to improve adherence to dietary and physical activity treatment guidelines in individuals with familial hypercholesterolaemia (FH)

BACKGROUND

Familial hypercholesterolaemia (FH) is a genetic condition characterised by elevated levels of low-density lipoprotein cholesterol (LDL-C) and an increased risk of cardiovascular disease (CVD). Following dietary and physical activity guidelines could help minimise this risk but adherence is low. Interventions to target these behaviours are therefore required. A comprehensive understanding of the target behaviours and behaviour change theory should drive the process of intervention development to increase intervention effectiveness and scalability. This paper describes the application of a theoretical framework to the findings of a qualitative evidence synthesis (QES) to inform the content and delivery of an intervention to improve adherence to dietary and physical activity guidelines in individuals with FH.

METHODS

The Behaviour Change Wheel (BCW) was used to guide intervention development. Factors influencing dietary and physical activity behaviours were identified from an earlier QES and mapped onto factors within the BCW. A comprehensive behavioural diagnosis of these factors was conducted through application of the theoretical domains framework (TDF). Using these data, the most appropriate intervention functions and behaviour change techniques (BCTs) for inclusion in the intervention were identified. Decision making was guided by evaluation criteria recommended by BCW guidance and feedback from individuals with FH.

RESULTS

Factors influencing dietary and physical activity behaviours mapped onto twelve of the fourteen TDF domains, with seven intervention functions deemed suitable to target the domains' theoretical constructs. Twenty-six BCTs were identified as being appropriate for delivery within these functions and were included in the intervention. For instance, within the enablement intervention function, the BCT problem solving was incorporated by inclusion of a 'barriers and solutions' section. Guided by evaluation criteria and feedback from individuals with FH, the intervention will be delivered as an hour-long family-based appointment, followed up with four telephone calls.

CONCLUSIONS

The novel application of the BCW and TDF to the results of a QES has enabled the development of a theory and evidence informed behaviour change intervention. This systematic approach facilitates evaluation of the intervention as part of an ongoing feasibility trial. The transparent approach taken can be used to guide intervention development by researchers in other fields.

The body-space relations of research(ed) on bodies: The experiences of becoming participant researchers

This paper heeds calls for reflections on how the research field is defined through embodied socio-spatial presence and immediacy. Focusing on classroom "body-training" observations that were part of a larger qualitative research project, and on the field notes and reflections of three researchers, we explore the transition from observer-researchers to participant-researchers. That is, we explore how, by researching others, we unexpectedly became researched on as our own bodies became instruments in the research process and were used to elicit knowledge on embodied learning, body-mapping and corporeal trace. As a methodological intervention, conducting research through the body, the positioning of bodies and body-to-body interaction, can tell us much about the often ignored embodied and emotional dimensions of the research field. But, in addition, it can elucidate the power relations between, and the fluidity of, researcher and researched positions in the jolting of secured researcher identity. Here we detail how different researchers performed different embodied and emotional subjectivities in different training research spaces. We explore how ontological anxieties of our own placed bodies, based around constructed notions of femininity, religion and researcher professionalism, shape this immediate body-to-body encounter and the subsequent research process.

HIV-1–Related Cardiovascular Disease Is Associated With Chronic Inflammation, Frequent Pericardial Effusions, and Probable Myocardial Edema

Background—

Patients with treated HIV infection have clear survival benefits although with increased cardiac morbidity and mortality. Mechanisms of heart disease may be partly related to untreated chronic inflammation. Cardiovascular magnetic resonance imaging allows a comprehensive assessment of myocardial structure, function, and tissue characterization. We investigated, using cardiovascular magnetic resonance, subclinical inflammation and myocardial disease in asymptomatic HIV-infected individuals.

Methods and Results—

Myocardial structure and function were assessed using cardiovascular magnetic resonance at 1.5-T in treated HIV-infected individuals without known cardiovascular disease (n=103; mean age, 45±10 years) compared with healthy controls (n=92; mean age, 44±10 years). Assessments included left ventricular volumes, ejection fraction, strain, regional systolic, diastolic function, native T1 mapping, edema, and gadolinium enhancement. Compared with controls, subjects with HIV infection had 6% lower left ventricular ejection fraction ( P <0.001), 7% higher myocardial mass ( P =0.02), 29% lower peak diastolic strain rate ( P <0.001), 4% higher short-tau inversion recovery values ( P =0.02), and higher native T1 values (969 versus 956 ms in controls; P =0.01). Pericardial effusions and myocardial fibrosis were 3 and 4× more common, respectively, in subjects with HIV infection (both P <0.001).

Conclusions—

Treated HIV infection is associated with changes in myocardial structure and function in addition to higher rates of subclinical myocardial edema and fibrosis and frequent pericardial effusions. Chronic systemic inflammation in HIV, which involves the myocardium and pericardium, may explain the high rate of myocardial fibrosis and increased cardiac dysfunction in people living with HIV.

Identification of effective subdominant anti-HIV-1 CD8+ T cells within entire post-infection and post-vaccination immune responses

Defining the components of an HIV immunogen that could induce effective CD8+ T cell responses is critical to vaccine development. We addressed this question by investigating the viral targets of CD8+ T cells that potently inhibit HIV replication in vitro, as this is highly predictive of virus control in vivo. We observed broad and potent ex vivo CD8+ T cell-mediated viral inhibitory activity against a panel of HIV isolates among viremic controllers (VC, viral loads <5000 copies/ml), in contrast to unselected HIV-infected HIV Vaccine trials Network (HVTN) participants. Viral inhibition of clade-matched HIV isolates was strongly correlated with the frequency of CD8+ T cells targeting vulnerable regions within Gag, Pol, Nef and Vif that had been identified in an independent study of nearly 1000 chronically infected individuals. These vulnerable and so-called “beneficial” regions were of low entropy overall, yet several were not predicted by stringent conservation algorithms. Consistent with this, stronger inhibition of clade-matched than mismatched viruses was observed in the majority of subjects, indicating better targeting of clade-specific than conserved epitopes. The magnitude of CD8+ T cell responses to beneficial regions, together with viral entropy and HLA class I genotype, explained up to 59% of the variation in viral inhibitory activity, with magnitude of the T cell response making the strongest unique contribution. However, beneficial regions were infrequently targeted by CD8+ T cells elicited by vaccines encoding full-length HIV proteins, when the latter were administered to healthy volunteers and HIV-positive ART-treated subjects, suggesting that immunodominance hierarchies undermine effective anti-HIV CD8+ T cell responses. Taken together, our data support HIV immunogen design that is based on systematic selection of empirically defined vulnerable regions within the viral proteome, with exclusion of immunodominant decoy epitopes that are irrelevant for HIV control.

Attempts to develop an HIV vaccine that elicits potent cell-mediated immunity have so far been unsuccessful. This is due in part to the use of immunogens that appear to recapitulate responses induced naturally by HIV that are, at best, partially effective. We previously showed that the capacity of CD8+ T cells from patients to block HIV replication in culture is strongly correlated with HIV control in vivo, therefore, we investigated the virological determinants of potent CD8+ T cell inhibitory activity. We observed that CD8+ T cells from patients with naturally low plasma viral loads (viremic controllers) were better able to inhibit the replication of diverse HIV strains in vitro than CD8+ T cells from HIV-noncontroller patients. Importantly, we also found that the potency of the antiviral activity in the latter group was strongly correlated with recognition of selected regions across the viral proteome that are critical to viral fitness. Vaccines that encode full-length viral proteins rarely elicited responses to these vulnerable regions. Taken together, our results provide insight into the characteristics of effective cell-mediated immune responses against HIV and how these may inform the design of better immunogens.

The impact of the 2011 UK post-exposure prophylaxis for HIV following sexual exposure guidelines: a regional retrospective audit

A re-audit of prescribing of post-exposure prophylaxis for HIV following sexual exposure in the Thames Valley demonstrated that an updated proforma has led to significant improvements in clinician-led outcomes, but had no impact on completion or follow-up rates.

HIV is an independent predictor of aortic stiffness

BACKGROUND

Patients with treated Human Immunodeficiency Virus-1 (HIV) infection are at increased risk of cardiovascular events. Traditionally much of this risk has been attributed to metabolic and anthropometric abnormalities associated with HIV, which are similar to the metabolic syndrome (MS), an established risk factor for cardiovascular mortality. It remains unclear whether treated HIV infection is itself associated with increased risk, via increase vascular stiffness.

METHODS

226 subjects (90 with HIV) were divided into 4 groups based on HIV and MS status: 1) HIV-ve/MS-ve, 2) HIV-ve/MS + ve, 3) HIV + ve/MS-ve and 4)HIV + ve/MS + ve. CMR was used to determine aortic pulse wave velocity (PWV) and regional aortic distensibility (AD).

RESULTS

PWV was 11% higher and regional AD up to 14% lower in the HIV + ve/MS-ve group when compared to HIV-ve/MS-ve (p < 0.01 all analyses). PWV and AD in the HIV + ve/MS-ve group was similar to that observed in the HIV-ve/MS + ve group (p > 0.99 all analyses). The HIV + ve/MS + ve group had 32% higher PWV and 30-34% lower AD than the HIV-ve/MS-ve group (all p < 0.001), and 19% higher PWV and up to 31% lower AD than HIV + ve/MS-ve subjects (all p < 0.05). On multivariable regression, age, systolic blood pressure and treated HIV infection were all independent predictors of both PWV and regional AD.

CONCLUSION

Across multiple measures, treated HIV infection is associated with increased aortic stiffness and is also an independent predictor of both PWV and regional AD. The magnitude of the effect of treated HIV and MS are similar, with additive detrimental effects on central vascular elasticity.

United Kingdom National Guideline on the Management of Trichomonas vaginalis 2014

The main objective is to assist practitioners in managing men and women diagnosed withTrichomonas vaginalis(TV) infection. This guideline offers recommendations on the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of TV, covering the management of the initial presentation, as well as how to prevent transmission and future infection.

Hypophosphataemia with non-tenofovir-containing antiretroviral therapy

Hypophosphataemia with tenofovir (TDF) treatment has been well described. The role of HIV infection and of other antiretroviral (ART) agents in hypophosphataemia has received less attention. The aim of this study was to determine the prevalence of hypophosphataemia in HIV-positive adults. We measured the fasting plasma phosphate level and estimated glomerular filtration rate (eGFR) in 123 HIV-positive patients. A total of 26% had hypophosphataemia and 11% had hypophosphataemia of grades 2-4 (0.65 mmol/L or less). Hypophosphataemia of any grade was more frequent in those who were ART-treated than ART-naive (35% versus 10%; P = 0.0001). Multiple linear regression analysis showed no significant association between phosphate level and gender, TDF status, duration of ART, duration of HIV infection and eGFR. Increasing age was significantly associated with a very small rise in phosphate level. Isolated hypophosphataemia was significantly more frequent in HIV-positive subjects receiving ART than ART-naive individuals, irrespective of the drug regimen.

Comprehensive cardiac magnetic resonance imaging and spectroscopy reveal a high burden of myocardial disease in HIV patients

BACKGROUND

HIV infection continues to be endemic worldwide. Although treatments are successful, it remains controversial whether patients receiving optimal therapy have structural, functional, or biochemical cardiac abnormalities that may underlie their increased cardiac morbidity and mortality. The purpose of this study was to characterize myocardial abnormalities in a contemporary group of HIV-infected individuals undergoing combination antiretroviral therapy.

METHODS AND RESULTS

Volunteers with HIV who were undergoing combination antiretroviral therapy and age-matched control subjects without a history of cardiovascular disease underwent cardiac magnetic resonance imaging and spectroscopy for the determination of cardiac function, myocardial fibrosis, and myocardial lipid content. A total of 129 participants were included in this analysis. Compared with age-matched control subjects (n=39; 30.23%), HIV-infected subjects undergoing combination antiretroviral therapy (n=90; 69.77%) had 47% higher median myocardial lipid levels (P <0.003) and 74% higher median plasma triglyceride levels (both P<0.001). Myocardial fibrosis, predominantly in the basal inferolateral wall of the left ventricle, was observed in 76% of HIV-infected subjects compared with 13% of control subjects (P<0.001). Peak myocardial systolic and diastolic longitudinal strain were also lower in HIV-infected individuals than in control subjects and remained statistically significant after adjustment for available confounders.

CONCLUSIONS

Comprehensive cardiac imaging revealed cardiac steatosis, alterations in cardiac function, and a high prevalence of myocardial fibrosis in a contemporary group of asymptomatic HIV-infected subjects undergoing combination antiretroviral therapy. Cardiac steatosis and fibrosis may underlie cardiac dysfunction and increased cardiovascular morbidity and mortality in subjects with HIV.

The means of correct training: embodied regulation in training for body work among mothers

In the main, the literature on body work has focused on the workplace, overlooking the spaces and places of training for work. Drawing on tutors' understandings of teaching and mothers' varied experiences of training for body work in areas of health, beauty and social care, this paper explores the learning environment as a liminal space. For many mothers, it is a space that sits at the nexus of home, work and leisure and is where the individual moves from student to practitioner/worker. These transitions require gender and maternal identities, among others, to be negotiated and regulated. By conceptualising body work as the interaction between bodies and the (self)disciplining of one's own body, this paper discusses various regulatory processes of learning, from embedding and embodying of 'professional' knowledge and identities to the repressing of cultural norms and behaviour. In so doing, the paper also considers how students struggle with, and occasionally resist and subvert, regulatory norms, imbuing the learning environment with their own meaning and sense of self. With this focus, we highlight the resonance of the body work concept for drawing together a wide range of subject areas, and suggest the closer the work with the body the more urgent the need for regulation of one's own body and the more fine-tuned the embodied discipline.