The impact of school-based creative bibliotherapy interventions on child and adolescent mental health: a systematic review and realist synthesis protocol

BACKGROUND

There is a need to identify evidence-based interventions to be delivered in schools that can be used to improve child and adolescent mental health and wellbeing. Creative bibliotherapy is one proposed intervention. However, there has been, to date, no comprehensive assessment of the evidence for its impact on mental health and wellbeing. To fill this gap, we will conduct a systematic review and realist synthesis.

METHODS

A systematic search of the bibliographic databases APA PsycINFO, Medline (via Ovid), CINAHL, ERIC, Education Research Complete (via EBSCOhost) and Web of Science (SCI, SSCI, AHCI, ESCI) for school-based creative bibliotherapy interventions on child and adolescent mental health. Types of study to be included: cohort studies, non-randomised comparative evaluations, randomised controlled trials. The data from all included studies will be summarised descriptively and strength of evidence appraised. This is a potentially large field of practice, with heterogeneous interventions; we will use methods from intervention components analysis to describe and categorise the range of components and approaches used in included interventions. To understand how interventions work and in which contexts, we will use methods from realist synthesis to develop an exploratory account of mechanisms in different settings and for different young people (contexts).

DISCUSSION

Findings will assess the range of evidence for the impact of creative bibliotherapy on child and adolescent mental health and wellbeing, the strength of evidence for the impact identified, and describe potential mechanisms. This review will be useful for a wide range of stakeholders considering implementing or developing interventions using creative bibliotherapy in school-based settings.

SYSTEMATIC REVIEW REGISTRATION

This protocol was registered at the International Prospective Register of Systematic Reviews ( https://www.crd.york.ac.uk/prospero/ ), registration number CRD42023410333. This review is funded by Wellcome Trust (221457/Z/20/Z).

"There should be one spot that you can go:" BRCA mutation carriers' perspectives on cancer risk management and a hereditary cancer registry

Individuals who carry BRCA1 or BRCA2 pathogenic variants are recommended to have extensive cancer prevention screening and risk-reducing surgeries. Uptake of these recommendations is variable, and there remains room for improvement in the risk management of BRCA carriers. This paper explores female BRCA carriers' experiences with the current model of care and their perspectives on (and interest in) an inherited cancer registry. Findings can inform the development of a dedicated high-risk screening and management program for these patients. Quantitative and qualitative data were gathered through a provincial descriptive survey and semi-structured qualitative interviews to assess BRCA carriers' opinions toward risk management services in the province of Newfoundland and Labrador (NL), Canada. Survey (n = 69) and interview data (n = 15) revealed continuity and coordination challenges with the current system of care of high-risk individuals. Respondents suggested an inherited cancer registry would help identify high-risk individuals and provide a centralized system of risk management for identified carriers. Respondents identified concerns about the privacy of their registry data, including who could access it. Findings suggest BRCA carriers see great value in an inherited cancer registry. Specifically, participants noted it could provide a centralized system to help improve the coordination of burdensome, life-long risk management. Important patient concerns about protecting their privacy and their health data confidentiality must be addressed in patient and public information and informed consent documents about a registry.

A latent class analysis of mental disorders, substance use, and aggressive antisocial behavior among Swedish forensic psychiatric patients

BACKGROUND

Patients in the forensic mental health services (FMHS) with a mental disorder, a co-occurring substance use disorder (SUD), and high risk of aggressive antisocial behavior (AAB) are sometimes referred to as the 'triply troubled'. They suffer poor treatment outcomes, high rates of criminal recidivism, and increased risk of drug related mortality. To improve treatment for this heterogeneous patient group, more insight is needed concerning their co-occurring mental disorders, types of substances used, and the consequent risk of AAB.

METHODS

A three-step latent class analysis (LCA) was used to identify clinically relevant subgroups in a sample of patients (n = 98) from a high-security FMHS clinic in Sweden based on patterns in their history of mental disorders, SUD, types of substances used, and AAB.

RESULTS

A four-class model best fit our data: class 1 (42%) had a high probability of SUD, psychosis, and having used all substances; class 2 (26%) had a high probability of psychosis and cannabis use; class 3 (22%) had a high probability of autism and no substance use; and class 4 (10%) had a high probability of personality disorders and having used all substances. Both polysubstance classes (1 and 4) had a significantly more extensive history of AAB compared to classes 2 and 3. Class 3 and class 4 had extensive histories of self-directed aggression.

CONCLUSIONS

The present study helps disentangle the heterogeneity of the 'triply troubled' patient group in FMHS. The results provide an illustration of a more person-oriented perspective on patient comorbidity and types of substances used which could benefit clinical assessment, treatment planning, and risk-management among patients in forensic psychiatric care.

Changing mobility practices. Can meta-ethnography inform transferable and policy-relevant theory?

Social practice theories have attracted attention for their potential insights into how to change transport systems towards "healthier" states. However, most evidence is from small-scale qualitative case studies. We explored whether a synthesis of qualitative evidence on mobility practices in one country, informed by meta-ethnography and a Bourdieusian approach to practice, could produce theory that is of sufficient abstraction to be transferable, yet also capable of informing intervention planning. The synthesis identified three third order constructs: mobility practices result from habitus plus capital in fields; specific configurations of local mobility practices are shaped, but not determined, by material infrastructures and social structures; and changes in practice happen across a number of scales and temporalities. This body of evidence as a whole was then interpreted as an integrative "storyline": Mobility systems are complex, in that outcomes from interventions are neither unilinear nor necessarily predictable from aggregations of individual practice changes. Infrastructure changes may be a necessary, but not sufficient, condition for change. Moving systems towards "healthier" states requires changing habitus such that "healthier" practices align with fields, and that interventions take sufficient account of the power relations that materially and symbolically constrain or enable attachments to and changes in mobility practices. Meta-ethnography is a useful approach for integrating qualitative evidence for informing policy.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

TRIPLE C reporting principles for case study evaluations of the role of context in complex interventions

BACKGROUND

Guidance and reporting principles such as CONSORT (for randomised trials) and PRISMA (for systematic reviews) have greatly improved the reporting, discoverability, transparency and consistency of published research. We sought to develop similar guidance for case study evaluations undertaken to explore the influence of context on the processes and outcomes of complex interventions.

METHODS

A range of experts were recruited to an online Delphi panel, sampling for maximum diversity in disciplines (e.g. public health, health services research, organisational studies), settings (e.g. country), and sectors (e.g. academic, policy, third sector). To inform panel deliberations, we prepared background materials based on: [a] a systematic meta-narrative review of empirical and methodological literatures on case study, context and complex interventions; [b] the collective experience of a network of health systems and public health researchers; and [c] the established RAMESES II standards (which cover one kind of case study). We developed a list of topics and issues based on these sources and encouraged panel members to provide free text comments. Their feedback informed development of a set of items in the form of questions for potential inclusion in the reporting principles. We circulated these by email, asking panel members to rank each potential item twice (for relevance and validity) on a 7-point Likert scale. This sequence was repeated twice.

RESULTS

We recruited 51 panel members from 50 organisations across 12 countries, who brought experience of a range of case study research methods and applications. 26 completed all three Delphi rounds, reaching over 80% consensus on 16 items covering title, abstract, definitions of terms, philosophical assumptions, research question(s), rationale, how context and complexity relates to the intervention, ethical approval, empirical methods, findings, use of theory, generalisability and transferability, researcher perspective and influence, conclusions and recommendations, and funding and conflicts of interest.

CONCLUSION

The 'Triple C' (Case study, Context, Complex interventions) reporting principles recognise that case studies are undertaken in different ways for different purposes and based on different philosophical assumptions. They are designed to be enabling rather than prescriptive, and to make case study evaluation reporting on context and complex health interventions more comprehensive, accessible and useable.

The reality of advanced airway management during out of hospital cardiac arrest; why did paramedics deviate from their allocated airway management strategy during the AIRWAYS-2 randomised trial?

Background

AIRWAYS-2 was a large multi-centre cluster randomised controlled trial investigating the effect on functional outcome of a supraglottic airway device (i-gel) versus tracheal intubation (TI) as the initial advanced airway during out-of-hospital cardiac arrest. We aimed to understand why paramedics deviated from their allocated airway management algorithm during AIRWAYS-2.

Methods

This study employed a pragmatic sequential explanatory design utilising retrospective study data collected during the AIRWAYS-2 trial. Airway algorithm deviation data were analysed to categorise and quantify the reasons why paramedics did not follow their allocated strategy of airway management during AIRWAYS-2. Recorded free text entries provided additional context to the paramedic decision-making related to each category identified.

Results

In 680 (11.7%) of 5800 patients the study paramedic did not follow their allocated airway management algorithm. There was a higher percentage of deviations in the TI group (399/2707; 14.7%) compared to the i-gel group (281/3088; 9.1%). The predominant reason for a paramedic not following their allocated airway management strategy was airway obstruction, occurring more commonly in the i-gel group (109/281; 38.7%) versus (50/399; 12.5%) in the TI group.

Conclusion

There was a higher proportion of deviations from the allocated airway management algorithm in the TI group (399; 14.7%) compared to the i-gel group (281; 9.1%). The most frequent reason for deviating from the allocated airway management algorithm in AIRWAYS-2 was obstruction of the patient's airway by fluid. This occurred in both groups of the AIRWAYS-2 trial, but was more frequent in the i-gel group.

Implementing clinical guidelines for co-occurring substance use and major mental disorders in Swedish forensic psychiatry: An exploratory, qualitative interview study with mental health care staff

INTRODUCTION

Patients with substance use disorders (SUD) and co-occurring mental disorders (COD) within forensic psychiatric care often suffer poor treatment outcomes and high rates of criminal recidivism, substance use, and psychiatric problems. This study aimed to describe the conditions for, and mental health care staff's experiences with, implementing integrated SUD-focused clinical guidelines, including assessment and treatment for patients with COD at a high-security forensic mental health services (FMHS) facility in Sweden.

METHODS

Study staff conducted nineteen semi-structured interviews with health care staff experienced in administering the new SUD assessment and treatment. The study conducted a thematic analysis to describe the health care staff's experiences with these guidelines and suggestions for improvement.

RESULTS

Most participants reported appreciation for the implementation of clinical guidelines with an SUD focus, an area they considered to have previously been neglected, but also noted the need for more practical guidance in the administration of the assessments. Participants reported the dual roles of caregiver and warden as difficult to reconcile and a similar, hindering division was also present in the health care staff's attitudes toward SUD. Participants' reports also described an imbalance prior to the implementation, whereby SUD was rarely assessed but treatment was still initiated. One year after the implementation, an imbalance still existed, but in reverse: SUD was more frequently assessed, but treatment was difficult to initiate.

CONCLUSIONS

Despite indications of some ambivalence among staff regarding the necessity of the assessment and treatment guidelines, many participants considered it helpful to have a structured way to assess and treat SUD in this patient group. The imbalance between frequent assessment and infrequent treatment may have been due to difficulties transitioning patients across the "gap" between assessment and treatment. To bridge this gap, mental health services should make efforts to increase patients' insight concerning their SUD, flexibility in the administration of treatment, and the motivational skills of the health care staff working with this patient group. Participants considered important for enhancing treatment quality a shared knowledge base regarding SUD, and increased collaboration between different professions and between in- and outpatient services.

Case study research and causal inference

Case study methodology is widely used in health research, but has had a marginal role in evaluative studies, given it is often assumed that case studies offer little for making causal inferences. We undertook a narrative review of examples of case study research from public health and health services evaluations, with a focus on interventions addressing health inequalities. We identified five types of contribution these case studies made to evidence for causal relationships. These contributions relate to: (1) evidence about system actors' own theories of causality; (2) demonstrative examples of causal relationships; (3) evidence about causal mechanisms; (4) evidence about the conditions under which causal mechanisms operate; and (5) inference about causality in complex systems. Case studies can and do contribute to understanding causal relationships. More transparency in the reporting of case studies would enhance their discoverability, and aid the development of a robust and pluralistic evidence base for public health and health services interventions. To strengthen the contribution that case studies make to that evidence base, researchers could: draw on wider methods from the political and social sciences, in particular on methods for robust analysis; carefully consider what population their case is a case 'of'; and explicate the rationale used for making causal inferences.

Feeling the clunk: Managing and attributing uncertainty in screening for developmental dysplasia of the hip in infancy

The management of uncertainty in clinical practice has been an enduring topic of sociological scholarship. However, little of this addresses how uncertainty and non-knowledge are attributed to the self and other actors. We take the example of checking for developmental dysplasia of the hip (DDH), part of infant screening in UK primary care, to examine the 'double contingency' of attributions of uncertainty and ignorance. Our data come from interviews with parents and General Practitioners (GPs), and observations of the six-week check conducted as part of a study to develop a checklist to aid GPs' diagnostic and referral decisions. Parents' pervasive uncertainties about managing with a new-born infant place them in a trusting relation to biomedicine, in which knowledge about infant hips is delegated to the clinical team: most described themselves as not-knowing about DDH. GPs focus on the uncertainties of applying sensory and experiential knowledge of infant bodies, in a consultation with more diffuse aims than screening for DDH. A prototype checklist, developed by orthopaedic specialists, was an explicit attempt to reduce uncertainty around thresholds for referral. However, using the checklist surfaced multiple logics of uncertainty. It also surfaced attributions of uncertainty and non-knowledge to other actors: orthopaedic specialists' assumptions about GPs' uncertain technical knowledge; GPs' assumptions about orthopaedic specialists' ignorance of the primary care setting; and clinicians' assumptions about the role of parental ignorance. This 'double contingency' of attributions of other actors' non-knowledge is a salient additional dimension to the uncertainty that infuses biomedical practice.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Welfare concerns associated with captive lions (Panthera leo) and the implications for commercial lion farms in South Africa

Breeding and housing wild animals in captive environments can pose challenges for their welfare. In South Africa, thousands of lions (Panthera leo) are bred and raised at commercial captive breeding facilities, so called 'lion farms', for use in tourism, trophy hunting and traditional medicine. To gain a better understanding of the potential welfare challenges faced by lions on farms we reviewed 91 peer-reviewed articles relating to lion welfare, identified via a systematic review of the scientific literature. Across these studies, we identified 170 different terms relating to negative behaviours and physical health afflictions. The majority of these terms were associated with disease and injury (124; 73%), followed by negative behaviours (19; 11%), negative mental experiences (15; 9%), nutritional concerns (7; 4%), and environmental challenges or discomfort arising from the animal's surroundings (5; 3%). Of the 91 articles, 32 (35%) focused on data concerning captive lions. Only two studies focused specifically on data obtained from lion farms in South Africa, whilst the remainder reported on data collected from zoos, wildlife parks, sanctuaries, game reserves and private ownership. Our preliminary review of the scientific literature draws attention to some of the challenges associated with caring for lions in captivity, and outlines the potential significance of these welfare challenges for commercial lion farms. Our data highlight the apparent lack of scientific research involving captive lion welfare generally, particularly data collected at commercial breeding facilities in South Africa and the consequences this could have for the welfare of thousands of lions within the industry.

Pedestrian injuries in collisions with pedal cycles in the context of increased active travel: Trends in England, 2005-2015

INTRODUCTION

Increasing levels of active travel in the population brings many public health benefits, but may also change the risks of road injury for different road users. We examined changes in rates of pedestrian injuries resulting from collisions with pedal cycles and motor vehicles in England during 2005-2015, a period of increased cycling activity, and described the gender, age distribution and locations of pedestrians injured in collisions with pedal cycles and motor vehicles.

METHODS

Collisions data were obtained from police STATS19 datasets. We used two measures of cycle/motor vehicle use; miles per annum, and estimated average travel time, and assessed evidence for trends towards increase over time using Poisson regression analysis.

RESULTS

There were 3414 pedestrians injured in collisions with one or more pedal cycles in England during 2005-2015, 763 of whom were killed or seriously injured (KSI). This accounted for 1.3% of the total pedestrians KSI from all vehicles. Of those KSI in collisions with cycles, 62% were female; 42% over the age of 60; 26% were on the footway or verge and 24% were on a pedestrian crossing. There was a 6% (IRR 1.056; 95% CI 1.032-1.080, p < 0.001) annual increase in the pedestrian KSI rate per billion vehicle miles cycled in England over the time span. This increase was disproportionate to the increase in cycle use measured by vehicle miles or time spent cycling.

CONCLUSIONS

Increases in cycling were associated with disproportionate increases in pedestrian injuries in collisions with pedal cycles in England, although these collisions remain a very small proportion of all road injury. Increased active travel is essential for meeting a range of public health goals, but needs to be planned for with consideration for potential impact on pedestrians, particularly older citizens.

A systematic review of gut microbiota composition in observational studies of major depressive disorder, bipolar disorder and schizophrenia

The emerging understanding of gut microbiota as 'metabolic machinery' influencing many aspects of physiology has gained substantial attention in the field of psychiatry. This is largely due to the many overlapping pathophysiological mechanisms associated with both the potential functionality of the gut microbiota and the biological mechanisms thought to be underpinning mental disorders. In this systematic review, we synthesised the current literature investigating differences in gut microbiota composition in people with the major psychiatric disorders, major depressive disorder (MDD), bipolar disorder (BD) and schizophrenia (SZ), compared to 'healthy' controls. We also explored gut microbiota composition across disorders in an attempt to elucidate potential commonalities in the microbial signatures associated with these mental disorders. Following the PRISMA guidelines, databases were searched from inception through to December 2021. We identified 44 studies (including a total of 2510 psychiatric cases and 2407 controls) that met inclusion criteria, of which 24 investigated gut microbiota composition in MDD, seven investigated gut microbiota composition in BD, and 15 investigated gut microbiota composition in SZ. Our syntheses provide no strong evidence for a difference in the number or distribution (α-diversity) of bacteria in those with a mental disorder compared to controls. However, studies were relatively consistent in reporting differences in overall community composition (β-diversity) in people with and without mental disorders. Our syntheses also identified specific bacterial taxa commonly associated with mental disorders, including lower levels of bacterial genera that produce short-chain fatty acids (e.g. butyrate), higher levels of lactic acid-producing bacteria, and higher levels of bacteria associated with glutamate and GABA metabolism. We also observed substantial heterogeneity across studies with regards to methodologies and reporting. Further prospective and experimental research using new tools and robust guidelines hold promise for improving our understanding of the role of the gut microbiota in mental and brain health and the development of interventions based on modification of gut microbiota.

The (failed) promise of multimorbidity: chronicity, biomedical categories, and public health

Multimorbidity has become an increasingly prominent lens through which public health focuses on the 'burden' of ill health in ageing populations, with the promise of a more upstream and holistic approach. We use a situational analysis (drawing on documentary analysis and interviews with service providers, policy actors and people living with multiple conditions) in south London, UK, to explore what this lens brings into focus, and what it obscures. Local initiatives mobilised the concept of multimorbidity in initiatives for integrating health care systems and for commissioning for prevention as well as care. However, as the latest of a series of historical attempts to address system fragmentation, these initiatives generated more complexity, and a system orientated to constant transformation, rather than repair or restoration. Service providers and patients continued to struggle to navigate the system. Dominant policy and practice narratives framed patient self-management as the primary route for addressing individualised risk factors on a trajectory to multimorbidity, whereas the narratives of those living with multiple conditions were more oriented to a relational model of health. The findings suggest possibilities and limitations for leveraging the concept of multimorbidity for public health. In this field, the promise arose from its potential to make spaces for a focus on populations, not patients with discrete diseases. Realising this promise, however, was limited by the inherent tensions of biomedical nosologies, which separate discrete diseases within individual bodies, and from epidemiological approaches that reify the socio-material contexts of failing health as risks for individuals.

Experiences of UK African-Caribbean prostate cancer survivors of discharge to primary care

Objective: Black men are three times more likely to develop prostate cancer (PCa), to do so at a younger age and to experience a more aggressive form than White men. This study aims to understand the experiences of African-Caribbean men with respect to their discharge to primary care following successful PCa treatment and the challenges associated with survivorship.Design: Eight African-Caribbean men, who had been successfully treated for PCa, were recruited through the charity BME Cancer Communities. They participated in a focus group, which took place on the premises of the charity and was audio-recorded. The recording was transcribed and the data were analysed employing thematic analysis.Results: Three overarching themes were developed: Discharge - misconceptions and uncertainties; Survivorship - challenges and ways of coping; Black men and PCa: real and potential discrimination. Participants expressed concerns regarding the lack of information and clarity about what discharge meant, the quality of follow-up care, especially the levels of specialist knowledge among GPs, and the impact of side-effects, particularly erectile dysfunction (ED). Participants linked ED with stereotypes of Black male sexuality, particularly in relation to difficulties of expressing their emotions and psychological distress. African-Caribbean men face particular challenges in dealing with the side-effects of treatment for PCa, which are linked to socially-constructed ideas of masculinity.Conclusion: There needs to be a greater focus in primary care on understanding these issues and providing individualised culturally-sensitive care. In particular, GPs should be aware of sensitivities concerning help-seeking related to culturally-mediated understandings of masculinity.

Evaluating complex interventions in context: systematic, meta-narrative review of case study approaches

BACKGROUND

There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research.

METHODS

Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing 'hybrid papers' (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions.

RESULTS

We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently-respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of 'the case' and 'context' or considered the implications of such conceptualisations for methods and knowledge production.

CONCLUSIONS

Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.

564 Freedom from Urethral Catherisation – Using QI Methodology to Improve Patient Outcome and Experiences

Aim

To reduce catheter burden on patients who could instead be free of urethral catheter and taught intermittent self-catheterisation (ISC).

Method

2 PDSA (Plan, Do, Study, Act) cycles were performed over a 21-month period from February 2018 to November 2020. Using multiple nurse-led TWOC clinics, data was extracted using nurse-completed proformas and electronic patient records to determine: TWOC rate; urethral catheter-free rate; and ISC rate. Following baseline measurement, interventions were made, such as centralisation of TWOC services, emphasis on ISC teaching and the introduction of industry-nurse led clinics.

Results

At baseline, TWOC rate, urethral catheter-free rate and ISC rate were 55.7%, 68% and 28.2%, respectively. Following centralisation of TWOC services and emphasis on ISC teaching in Cycle 1, urethral catheter-free rate rose to 77.8% whilst ISC rate fell to 25%. Cycle 2 followed the introduction of industry-nurse led clinics. Following this, urethral catheter-free rate rose further to 81.6%, with ISC rate rising dramatically to 56.3%

Conclusions

To those capable, ISC frees patients of catheter burden and its sequalae. Evidently, a greater onus on ISC training will increase the number of patients left catheter-free.

123 Supporting A Learning System in Paediatric Emergency Pathways; Using Organisational Comparisons, Serious Incidents and Near Miss Events To Improve The Diagnosis And Treatment Of Testicular Torsion

Introduction

Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion. Using national data we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to improving outcomes.

Method

A freedom of information request was made to all Trusts in England that manage testicular torsion. Serious Incidents (SI's) were analysed to see if those with Paediatric Emergency Departments fared better than those without. In addition, a qualitative thematic analysis of the NHS England Strategic Executive Information System database from 2007-2019 was undertaken, identifying common themes associated with orchidectomies and ‘near miss’ events in children.

Results

304 serious incidents were returned with 62 Orchidectomies and 242 Near Miss Events. Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialists (OR = 1.46, p = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED to specialists (OR = 6, p = 0.0355). Near miss events are due to a variety of factors. There was no statistical significance in incidents when comparing ED's caring for all ages with Paediatric EDs U = 807.5, z = -1.124, p = 0.261.

Conclusions

There's a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It's also vital that specialist teams are cognisant of the standard operating procedures relevant to scrotal pain. Finally, there should be a drive for annual audit in Urology and ED units with regards to testicular torsion as SI's may be under-reported.

AB0872-HPR IMPACT OF COVID-19 ON A PHYSICAL ACTIVITY FEASIBILITY PILOT STUDY: THE PIPPRA EXPERIENCE

Background:

The PIPPRA (Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis) project is a feasibility project examining the impact of a physical activity behaviour change intervention in people who have rheumatoid arthritis (RA). The PIPPRA study recruitment commenced in October 2019, with participant assessment and intervention commencing in November 2019. In the Republic of Ireland people who have RA are categorised as high risk category for Covid-19, due to immunosuppression [1], although this categorisation contrasts with EULAR’s provisional recommendations [2].

Objectives:

To examine the impact of the Covid-19 pandemic and public health restrictions on a pilot randomised controlled feasibility study in 2020.

Methods:

Participants (aged 18 years+, diagnosis of RA, independently mobile and low levels of physical activity [3]) were recruited from a rheumatology clinic at an urban hospital. Target recruitment was four participants per month for one year (N=48). Assessments were planned at baseline, eight and twenty-four weeks (N=144). Participants were randomised to intervention group or control group. The intervention group received four 1:1 sixty minute sessions with a physiotherapist (N=96). The intervention was delivered over eight weeks. Intervention and control groups received a physical activity information leaflet.

Results:

The Covid-19 pandemic and associated public health restrictions forced the study to be formally paused in April 2020 and the study formally resumed in August 2020. N=48 participants were recruited between October 2019 and March 2020 (six months). N=20 participants have commenced in the study, N=16 are awaiting baseline assessment, N=6 withdrew and N=6 were lost to follow-up prior to baseline. Trial protocol planned for the delivery of N=55 assessments and N=36 intervention sessions for participants who had commenced in the study. N=22 assessments and N=26 intervention sessions were delivered between November 2019 and March 2020. N=5 assessments and N=6 intervention sessions were conducted between August and October 2020. No assessment or intervention delivery occurred in November-December 2020 due to participant hesitancy in attending for assessment and/or intervention with increased public health restrictions. The impact of Covid-19 restrictions resulted in N=33 (60%) deviations from assessment protocol and N=10 (27%) deviations from intervention delivery protocol (Figure 1).

Figure 1.

Deviations from assessment and intervention protocol in the PIPPRA study

Conclusion:

The Covid-19 pandemic has had a significant impact on the delivery of the PIPPRA study. Feasibility study outcomes, including participant retention rate, and study delivery as per protocol, have been affected due to the Covid-19 pandemic. Participant reluctance to attend face-to-face sessions demonstrates the need to consider alternative methods of delivery, e.g. virtual delivery of interventions, where attending in person is not acceptable to participants [4], in future studies.

References:

[1]Health Service Executive. (2019). People at higher risk from COVID-19.Accessed 5th Jan 2020 https://www2.hse.ie/conditions/coronavirus/people-at-higher-risk.html.

[2]Landewé RB et al (2020). EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2. Annals of the Rheumatic Diseases 79:851-858.

[3]Godin, G. (2011). The Godin-Shephard leisure-time physical activity questionnaire. The Health & Fitness Journal of Canada, 4(1):18-22.

[4]Inan, OT et al. (2020). Digitizing clinical trials. npj Digit. Med. 3:10.

Disclosure of Interests:

None declared

The use of Qualitative Comparative Analysis (QCA) to address causality in complex systems: a systematic review of research on public health interventions

Background

Qualitative Comparative Analysis (QCA) is a method for identifying the configurations of conditions that lead to specific outcomes. Given its potential for providing evidence of causality in complex systems, QCA is increasingly used in evaluative research to examine the uptake or impacts of public health interventions. We map this emerging field, assessing the strengths and weaknesses of QCA approaches identified in published studies, and identify implications for future research and reporting.

Methods

PubMed, Scopus and Web of Science were systematically searched for peer-reviewed studies published in English up to December 2019 that had used QCA methods to identify the conditions associated with the uptake and/or effectiveness of interventions for public health. Data relating to the interventions studied (settings/level of intervention/populations), methods (type of QCA, case level, source of data, other methods used) and reported strengths and weaknesses of QCA were extracted and synthesised narratively.

Results

The search identified 1384 papers, of which 27 (describing 26 studies) met the inclusion criteria. Interventions evaluated ranged across: nutrition/obesity (n = 8); physical activity (n = 4); health inequalities (n = 3); mental health (n = 2); community engagement (n = 3); chronic condition management (n = 3); vaccine adoption or implementation (n = 2); programme implementation (n = 3); breastfeeding (n = 2), and general population health (n = 1). The majority of studies (n = 24) were of interventions solely or predominantly in high income countries. Key strengths reported were that QCA provides a method for addressing causal complexity; and that it provides a systematic approach for understanding the mechanisms at work in implementation across contexts. Weaknesses reported related to data availability limitations, especially on ineffective interventions. The majority of papers demonstrated good knowledge of cases, and justification of case selection, but other criteria of methodological quality were less comprehensively met.

Conclusion

QCA is a promising approach for addressing the role of context in complex interventions, and for identifying causal configurations of conditions that predict implementation and/or outcomes when there is sufficiently detailed understanding of a series of comparable cases. As the use of QCA in evaluative health research increases, there may be a need to develop advice for public health researchers and journals on minimum criteria for quality and reporting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10926-2.

92 Reshaping the Diagnostic Pathways for Investigation of Haematuria During and After The COVID-19 Pandemic: Diagnostic Accuracy of Strategies for Detection of Bladder Cancer from The IDENTIFY Cohort Study

Introduction

Diagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.

Method

The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.

Results

8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.

Conclusions

We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

Understanding physician behaviour in the 6-8 weeks hip check in primary care: a qualitative study using the COM-B

OBJECTIVES

A compulsory hip check is performed on an infant at 6-8 weeks in primary care for the detection of developmental dysplasia of the hip (DDH). Missed diagnoses and infants incorrectly labelled with DDH remain an important problem. The nature of physician behaviour as a likely source of this problem has not been explored. The aims of this study were to make a behavioural diagnosis of general practitioners (GPs) who perform these hip checks, and identify potential behavioural change techniques that could make the hip checks more effective.

DESIGN

Qualitative study with in-depth semistructured interviews of 6-8 weeks checks. We used the Capability, Opportunity, Motivation and Behaviour model in making a behavioural diagnosis and elicited factors that can be linked to improving the assessment.

SETTING

Primary care.

PARTICIPANTS

17 GPs (15 female) who had between 5 and 34 years of work experience were interviewed.

RESULTS

Capability related to knowledge of evidence-based criteria and skill to identify DDH were important behavioural factors. Both physical (clinic time and space) and social (practice norms), opportunity were essential for optimal behaviour. Furthermore, motivation related to the importance of the 6-8 weeks check and confidence to perform the check and refer appropriately were identified in the behavioural diagnosis.

CONCLUSION

Aspects of capability, opportunity and motivation affect GPs' diagnosis and referral behaviours in relation to DDH. The findings from this work extend current knowledge and will inform the development of an intervention aimed at improving the diagnosis of DDH.

Integrated health Services for Children: a qualitative study of family perspectives

BACKGROUND

There is increasing evidence that integrated care improves child related quality of life and reduces health service use. However, there is limited evidence on family perspectives about the quality of integrated care for children's services. This study aimed to understand children, young people, and caregivers' perceptions of a new integrated care service, and to identify essential components of integrated care for children and young people with ongoing conditions.

METHODS

A qualitative analysis of in-depth interviews with caregivers and children included families (N = 37) with children with one of four ongoing conditions (asthma, eczema, epilepsy, constipation) who had experienced a new integrated care service delivered in South London, UK.

RESULTS

Four key components of integrated services identified were: that the key health-worker understood the health needs of the family in context; that professionals involved children and caregivers in treatment; that holistic care that supported the family unit was provided; and that families experienced coordination across health, social, and education systems.

CONCLUSIONS

Children and families identify care navigation and a holistic approach as key components that make high quality integrated care services. Service developments strengthening these aspects will align well with family perspectives on what works and what matters.

Influence of respiratory and inflammatory parameters preceding intubation on survival of patients with COVID-19 ARDS- A single centre retrospective analysis

It remains unclear if intubation and ventilation earlier in the disease course confers a survival advantage in acute respiratory distress syndrome. Our objective was to determine whether patients with COVID-19 who died following mechanical ventilation were more advanced in their disease compared to survivors. Forty-seven patients admitted directly to our centre received ventilation, of who 26 (57%) patients died. The rate of fall in SpO₂:FiO₂ ratio (p = 0.478) and increasing respiratory rate (p = 0.948) prior to IMV were similar between survivors and non-survivors. Our data support a trial of continuous positive airway pressure prior to IMV in patients with moderate-to-severe COVID-19 ARDS.

Study protocol for evaluation of aid to diagnosis for developmental dysplasia of the hip in general practice: controlled trial randomised by practice

INTRODUCTION

In the UK, a compulsory '6-week hip check' is performed in primary care for the detection of developmental dysplasia of the hip (DDH). However, missed diagnoses and infants incorrectly labelled with DDH remain a problem, potentially leading to adverse consequences for infants, their families and the National Health Service. National policy states that infants should be referred to hospital if the 6-week check suggests DDH, though there is no available tool to aid examination or offer guidelines for referral. We developed standardised diagnostic criteria for DDH, based on international Delphi consensus, and a 9-item checklist that has the potential to enable non-experts to diagnose DDH in a manner approaching that of experts.

METHODS AND ANALYSIS

We will conduct a controlled trial randomised by practice that will compare a diagnostic aid against standard care for the hip check. The primary objective is to determine whether an aid to the diagnosis of DDH reduces the number of clinically insignificant referrals from primary care to hospital and the number of late diagnosed DDH. The trial will include a qualitative process evaluation, an assessment of professional behavioural change and a full health economic evaluation. We will recruit 152 general practitioner practices in England. These will be randomised to conduct the hip checks with use of the study diagnostic aid and/or as per usual practice. The total number of infants seen during a 15-month recruitment period will be 110 per practice. Two years after the 6-week hip check, we will measure the number of referred infants that are (1) clinically insignificant for DDH and (2) those that constitute appropriate referrals.

ETHICS AND DISSEMINATION

This study has approval from the Health Research Authority (16/1/2020) and the Confidentiality Advisory Group (18/2/2020). Results will be published in peer-reviewed academic journals, disseminated to patient organisations and the media.

TRIAL REGISTRATION NUMBER

NCT04101903; Pre-results.

Case study research for better evaluations of complex interventions: rationale and challenges

BACKGROUND

The need for better methods for evaluation in health research has been widely recognised. The 'complexity turn' has drawn attention to the limitations of relying on causal inference from randomised controlled trials alone for understanding whether, and under which conditions, interventions in complex systems improve health services or the public health, and what mechanisms might link interventions and outcomes. We argue that case study research-currently denigrated as poor evidence-is an under-utilised resource for not only providing evidence about context and transferability, but also for helping strengthen causal inferences when pathways between intervention and effects are likely to be non-linear.

MAIN BODY

Case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings. Empirical case studies typically enable dynamic understanding of complex challenges and provide evidence about causal mechanisms and the necessary and sufficient conditions (contexts) for intervention implementation and effects. This is essential evidence not just for researchers concerned about internal and external validity, but also research users in policy and practice who need to know what the likely effects of complex programmes or interventions will be in their settings. The health sciences have much to learn from scholarship on case study methodology in the social sciences. However, there are multiple challenges in fully exploiting the potential learning from case study research. First are misconceptions that case study research can only provide exploratory or descriptive evidence. Second, there is little consensus about what a case study is, and considerable diversity in how empirical case studies are conducted and reported. Finally, as case study researchers typically (and appropriately) focus on thick description (that captures contextual detail), it can be challenging to identify the key messages related to intervention evaluation from case study reports.

CONCLUSION

Whilst the diversity of published case studies in health services and public health research is rich and productive, we recommend further clarity and specific methodological guidance for those reporting case study research for evaluation audiences.

Maxillofacial education in the time of COVID-19: the West Midlands experience

COVID-19 has accelerated a reliance on virtual technology for the delivery of postgraduate surgical education. We sought to develop a regional teaching programme with robust quality assurance. Webinars were delivered on a weekly basis by subspecialty experts using Zoom™ augmented with interactive polling software. Trainee feedback comprised Likert item rating on content and delivery, free text comments and self-assessed confidence levels using visual analogue scale (VAS) scores. A focus group was also convened and transcripts assessed with grounded theory analysis. Likert items revealed 442 (93.2%) positive responses regarding content and 642 (96.7%) positive responses regarding trainer delivery. There were statistically significant improvements in VAS scores across all programme content. Key themes from the focus group analysis were the pragmatics of delivering online education, issues surrounding trainer interactivity in the virtual world, the identification of the FRCS as a driving factor and a desire for case-based content and pre-learning of information (the ‘flipped classroom’). We are continuing to be reactive to trainee feedback in developing our online learning programme which will also include a regional Moodle-based virtual learning environment (VLE), the subject of future educational research in our region.

The gridded retarding ion drift sensor for the petitSat cubeSat mission

The Gridded Retarding Ion Drift Sensor (GRIDS) is a small sensor that will fly on the 6 U petitSat CubeSat. It is designed to measure the three-dimensional plasma drift velocity vector in the Earth's ionosphere. The GRIDS also supplies information about the ion temperature, ion density, and the ratio of light to heavy ions present in the ionospheric plasma. It utilizes well-proven techniques that have been successfully validated by similar instruments on larger satellite missions while meeting CubeSat-compatible requirements for low mass, size, and power consumption. GRIDS performs the functions of a Retarding Potential Analyzer (RPA) and an Ion Drift Meter (IDM) by combining the features of both types of instruments in a single package. The sensor alternates RPA and IDM measurements to produce the full set of measurement parameters listed above. On the petitSat mission, GRIDS will help identify and characterize a phenomenon known as plasma blobs (or enhancements).

Lack of efficient killing of purified dormant spores of Bacillales and Clostridiales species by glycerol monolaurate in a non-aqueous gel

Inactivation of Bacillales and Clostridiales spores is of interest, since some cause food spoilage and human diseases. A recent publication (mSphere 3: e00597-1, 2018) reported that glycerol monolaurate (GML) in a non-aqueous gel (GMLg) effectively killed spores of Bacillus subtilis, Bacillus cereus and Clostridioides difficile, and Bacillus anthracis spores to a lesser extent. We now show that (i) the B. subtilis spores prepared as in the prior work were impure; (ii) if spore viability was measured by diluting spores 1/10 in GMLg, serially diluting incubations 10-fold and spotting aliquots on recovery plates, there was no colony formation from the 1/10 to 1/1000 dilutions due to GMLg carryover, although thorough ethanol washes of incubated spores eliminated this problem and (iii) GMLg did not kill highly purified spores of B. subtilis, B. cereus, Bacillus megaterium and C. difficile in 3-20 h in the conditions used in the recent publication. GMLg also gave no killing of crude B. subtilis spores prepared as in the recent publication in 5 h but gave ~1·5 log killing at 24 h. Thus, GMLg does not appear to be an effective sporicide, although the gel likely inhibits spore germination and could kill spores somewhat upon long incubations. SIGNIFICANCE AND IMPACT OF THE STUDY: Given potential deleterious effects of spores of Bacillales and Clostridiales, there is an ongoing interest in new ways of spore killing. A recent paper (mSphere 3: e00597-1, 2018) reported that glycerol monolaurate (GML) in a non-aqueous gel (GMLg) effectively killed spores of many species. We now find that (i) the Bacillus subtilis spores prepared as in the previous report were impure and (ii) GMLg gave no killing of purified spores of Bacillales and Clostridiales species in ≤5 h under the published conditions. Thus, GMLg is not an effective sporicide, though may prevent spore germination or kill germinated spores.

The public health implications of telematic technologies: An exploratory qualitative study in the UK

INTRODUCTION

Reducing motorised transport is crucial for achieving public health goals, but cars will continue to be essential for many in the medium term. The role of emerging technologies in mitigating the public health disadvantages of this private car use has been under-examined to date. Telematics are increasingly used by novice drivers in the UK to reduce insurance premiums. An exploratory study of novice drivers' experiences of telematics identified implications for public health that warrant urgent further research.

METHODS

An exploratory qualitative study, using semi-structured interviews with 12 drivers aged 17-25 in three regions of the UK (Aberdeenshire, Hertfordshire and London).

RESULTS

Telematics were acceptable to young drivers, and reported to mitigate some negative health consequences of driving (injury risks, over-reliance on car transport), without reducing access to determinants of health such as employment or social life. However, there were suggestions that those at higher risk were less likely to adopt telematics.

CONCLUSION

Market-based mechanisms such as telematics are potential alternatives to well-evaluated policy interventions such as Graduated Driver Licensing for reducing road injury risks for novice drivers, with a different mix of risks and benefits. However, claims to date from insurance companies about the contribution of telematics to public health outcomes should be evaluated carefully to account for biases in uptake.

The ALERT-B questionnaire: A screening tool for the detection of gastroenterological late effects after radiotherapy for prostate cancer

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ALERT-B provides an effective screening tool for gastroenterological late effects.

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84.4% and 95.7% of patients demonstrated complications at 6 and 12 months post-treatment.

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ROC curves at baseline indicated an AUC of 0.867 compared to the GSRS diarrhoea subscale.

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ROC curves at baseline indicated an AUC of 0.765 compared to the EPIC bowel subscale.

There is an increasing need to measure treatment-related side effects in normal tissues following cancer therapy. The ALERT-B (Assessment of Late Effects of RadioTherapy - Bowel) questionnaire is a screening tool that is composed of four items related specifically to bowel symptoms. Those patients that respond with a “yes” to any of these items are referred on to gastroenterologist in order to improve the long-term consequences of these side effects of radiological treatment. Here we wish to test the ability of this questionnaire to identify these subsequent gastroenterological complications by tracking prostate cancer patients that were positive with respect to ALERT-B. We also carry out receiver-operator curve (ROC) analysis for baseline data for an overall ALERT-B questionnaire score with respect to subscale data for the Gastrointestinal Symptom Rating Scale (GSRS) and the Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire. 84.4% and 95.7% of patients identified by the ALERT-B questionnaire demonstrated complications diagnosed at 6 and 12 months post-treatment, respectively. ROC curve analysis of baseline data showed that ALERT-B detected clinically relevant levels of side effects established at baseline by the GSRS diarrhoea subscale (AUC = 0.867, 95% CI = 0.795 to 0.926) and at the minimally important level of side effects for the EPIC bowel subscale (AUC = 0.765, 95% CI = 0.617 to 0.913). These results show that ALERT-B provides a simple and effective screening tool for identifying gastroenterological complications after treatment for prostate cancer.