The influence of socioeconomic status on the association between unhealthy lifestyle factors and adverse health outcomes: a systematic review

Background

Combinations of lifestyle factors (LFs) and socioeconomic status (SES) are independently associated with cardiovascular disease (CVD), cancer, and mortality. Less advantaged SES groups may be disproportionately vulnerable to unhealthy LFs but interactions between LFs and SES remain poorly understood. This review aimed to synthesise the available evidence for whether and how SES modifies associations between combinations of LFs and adverse health outcomes.

Methods

Systematic review of studies that examine associations between combinations of >3 LFs (eg.smoking/physical activity/diet) and health outcomes and report data on SES (eg.income/education/poverty-index) influences on associations. Databases (PubMed/EMBASE/CINAHL), references, forward citations, and grey-literature were searched from inception to December 2021. Eligibility criteria were analyses of prospective adult cohorts that examined all-cause mortality or CVD/cancer mortality/incidence.

Results

Six studies (n=42,467-399,537; 46.5-56.8 years old; 54.6-59.3% women) of five cohorts were included. All examined all-cause mortality; three assessed CVD/cancer outcomes. Four studies observed multiplicative interactions between LFs and SES, but in opposing directions. Two studies tested for additive interactions; interactions were observed in one cohort (UK Biobank) and not in another (National Health and Nutrition Examination Survey (NHANES)). All-cause mortality HRs (95% confidence intervals) for unhealthy LFs (versus healthy LFs) from the most advantaged SES groups ranged from 0.68 (0.32-1.45) to 4.17 (2.27-7.69). Equivalent estimates from the least advantaged ranged from 1.30 (1.13-1.50) to 4.00 (2.22-7.14). In 19 analyses (including sensitivity analyses) of joint associations between LFs, SES, and all-cause mortality, highest all-cause mortality was observed in the unhealthiest LF-least advantaged suggesting an additive effect.

Conclusions

Limited and heterogenous literature suggests that the influence of SES on associations between combinations of unhealthy LFs and adverse health could be additive but remains unclear. Additional prospective analyses would help clarify whether SES modifies associations between combinations of unhealthy LFs and health outcomes.

Registration

Protocol is registered with PROSPERO (CRD42020172588;25 June 2020).

True prevalence of long-COVID in a nationwide, population cohort study

Long-COVID prevalence estimates vary widely and should take account of symptoms that would have occurred anyway. Here we determine the prevalence of symptoms attributable to SARS-CoV-2 infection, taking account of background rates and confounding, in a nationwide population cohort study of 198,096 Scottish adults. 98,666 (49.8%) had symptomatic laboratory-confirmed SARS-CoV-2 infections and 99,430 (50.2%) were age-, sex-, and socioeconomically-matched and never-infected. While 41,775 (64.5%) reported at least one symptom 6 months following SARS-CoV-2 infection, this was also true of 34,600 (50.8%) of those never-infected. The crude prevalence of one or more symptom attributable to SARS-CoV-2 infection was 13.8% (13.2%,14.3%), 12.8% (11.9%,13.6%), and 16.3% (14.4%,18.2%) at 6, 12, and 18 months respectively. Following adjustment for potential confounders, these figures were 6.6% (6.3%, 6.9%), 6.5% (6.0%, 6.9%) and 10.4% (9.1%, 11.6%) respectively. Long-COVID is characterised by a wide range of symptoms that, apart from altered taste and smell, are non-specific. Care should be taken in attributing symptoms to previous SARS-CoV-2 infection.

Social connection and mortality in UK Biobank: a prospective cohort analysis

BACKGROUND

Components of social connection are associated with mortality, but research examining their independent and combined effects in the same dataset is lacking. This study aimed to examine the independent and combined associations between functional and structural components of social connection and mortality.

METHODS

Analysis of 458,146 participants with full data from the UK Biobank cohort linked to mortality registers. Social connection was assessed using two functional (frequency of ability to confide in someone close and often feeling lonely) and three structural (frequency of friends/family visits, weekly group activities, and living alone) component measures. Cox proportional hazard models were used to examine the associations with all-cause and cardiovascular disease (CVD) mortality.

RESULTS

Over a median of 12.6 years (IQR 11.9-13.3) follow-up, 33,135 (7.2%) participants died, including 5112 (1.1%) CVD deaths. All social connection measures were independently associated with both outcomes. Friends/family visit frequencies < monthly were associated with a higher risk of mortality indicating a threshold effect. There were interactions between living alone and friends/family visits and between living alone and weekly group activity. For example, compared with daily friends/family visits-not living alone, there was higher all-cause mortality for daily visits-living alone (HR 1.19 [95% CI 1.12-1.26]), for never having visits-not living alone (1.33 [1.22-1.46]), and for never having visits-living alone (1.77 [1.61-1.95]). Never having friends/family visits whilst living alone potentially counteracted benefits from other components as mortality risks were highest for those reporting both never having visits and living alone regardless of weekly group activity or functional components. When all measures were combined into overall functional and structural components, there was an interaction between components: compared with participants defined as not isolated by both components, those considered isolated by both components had higher CVD mortality (HR 1.63 [1.51-1.76]) than each component alone (functional isolation 1.17 [1.06-1.29]; structural isolation 1.27 [1.18-1.36]).

CONCLUSIONS

This work suggests (1) a potential threshold effect for friends/family visits, (2) that those who live alone with additional concurrent markers of structural isolation may represent a high-risk population, (3) that beneficial associations for some types of social connection might not be felt when other types of social connection are absent, and (4) considering both functional and structural components of social connection may help to identify the most isolated in society.

Natural history of long-COVID in a nationwide, population cohort study

Previous studies on the natural history of long-COVID have been few and selective. Without comparison groups, disease progression cannot be differentiated from symptoms originating from other causes. The Long-COVID in Scotland Study (Long-CISS) is a Scotland-wide, general population cohort of adults who had laboratory-confirmed SARS-CoV-2 infection matched to PCR-negative adults. Serial, self-completed, online questionnaires collected information on pre-existing health conditions and current health six, 12 and 18 months after index test. Of those with previous symptomatic infection, 35% reported persistent incomplete/no recovery, 12% improvement and 12% deterioration. At six and 12 months, one or more symptom was reported by 71.5% and 70.7% respectively of those previously infected, compared with 53.5% and 56.5% of those never infected. Altered taste, smell and confusion improved over time compared to the never infected group and adjusted for confounders. Conversely, late onset dry and productive cough, and hearing problems were more likely following SARS-CoV-2 infection.

The influence of socioeconomic status on the association between unhealthy lifestyle factors and adverse health outcomes: a systematic review

Background: Combinations of lifestyle factors (LFs) and socioeconomic status (SES) are independently associated with cardiovascular disease (CVD), cancer, and mortality. Less advantaged SES groups may be disproportionately vulnerable to unhealthy LFs but interactions between LFs and SES remain poorly understood. This review aimed to synthesise the available evidence for whether and how SES modifies associations between combinations of LFs and adverse health outcomes. Methods: Systematic review of studies that examine associations between combinations of >3 LFs and health outcomes and report data on SES influences on associations. Databases (PubMed/EMBASE/CINAHL), references, forward citations, and grey-literature were searched from inception to December 2021. Eligibility criteria were analyses of prospective adult cohorts that examined all-cause mortality or CVD or cancer mortality/incidence. Results: Six studies (n=42,467–399,537; 46.5–56.8 years old; 54.6–59.3% women) of five cohorts were included. All examined all-cause mortality; three assessed CVD/cancer outcomes. Four studies observed multiplicative interactions between LFs and SES, but in opposing directions. Two studies tested for additive interactions; interactions were observed in one cohort (UK Biobank) and not in another (NHANES). All-cause mortality HRs (95% CIs) for unhealthy LFs (versus healthy LFs) from the most advantaged SES groups ranged from 0.68 (0.32–1.45) to 4.17 (2.27–7.69). Equivalent estimates from the least advantaged ranged from 1.30 (1.13–1.50) to 4.00 (2.22–7.14). In 19 analyses (including sensitivity analyses) of joint associations between LFs, SES, and all-cause mortality, highest all-cause mortality was observed in the unhealthiest LF-least advantaged suggesting an additive effect. Conclusions: Limited and heterogenous literature suggests that the influence of SES on associations between combinations of unhealthy LFs and adverse health could be additive but remains unclear. Additional prospective analyses would help clarify whether SES modifies associations between combinations of unhealthy LFs and health outcomes. Registration: Protocol is registered with PROSPERO (CRD42020172588; 25 June 2020).

Associations between a weighted health behaviour score, socioeconomic status, and all-cause mortality in UK Biobank cohort: a prospective analysis

BACKGROUND

Unhealthy behaviours are associated with disproportionate mortality among socioeconomically deprived populations. Previous studies exploring that disproportionate harm do not examine weighted scores, or examine few behaviours. We aimed to create an extended weighted health behaviour score and examine the effect of socioeconomic status on the association between score and all-cause mortality.

METHODS

Data was sourced from the UK Biobank population cohort, recruited in 2006-10. The main exposures included in the analysis were 11 health behaviours (baseline self-report): smoking status, alcohol consumption, physical activity, time spent watching television, sleep duration, added salt in diet, social isolation, intake of red meat, intake of processed meat, intake of oily fish, and intake of fruit and vegetables. Behaviours were classified as healthy or unhealthy according to national guidelines or latest evidence. Socioeconomic deprivation was measured with the Townsend deprivation index. Cox proportional hazard models of health behaviour data were prospectively linked to death registries to examine associations between health behaviours and all-cause mortality. Models were adjusted for demographics and health at baseline. Mortality associated with each behaviour alone was used to determine score weighting. For sensitivity analysis, we explored associations between weighted lifestyle score and all-cause mortality stratified by sex and ethnicity.

FINDINGS

The analysis included 229 107 participants with complete data. Median age was 53 years (IQR 47-60) for 119 634 (52·2%) women and 54 years (47-60) for 109 473 (47·8%) men. Over a median follow-up of 11·9 years (IQR 11.1-12.6), 9379 (4·1%) participants died. Compared with having no unhealthy behaviours, each behaviour was positively associated with all-cause mortality. Smoking (hazard ratio [HR] 2·47 [95% CI 2·25-2·70]) and social isolation (1·69 [1·54-1·86]) were associated with notably higher mortality. A weighted score was created by ascribing one point to each 40% increment in risk (four points for smoking, two points for social isolation, and one points for each of all other behaviours). A dose-response increment for all-cause mortality HR was noted with each additional point of weighted score. Associations were stronger in more deprived tertiles. With least deprived and lowest score as reference, HRs for highest scores were 2·22 (95% CI 1·72-2·86) in the least deprived and 4·10 (3·62-4·65) in the most deprived. An additive interaction between sex and lifestyle score for all-cause mortality was suggested by the data; men had slightly higher HRs at each level of the lifestyle score. However, a statistical test for interaction on a multiplicative scale was not significant. No evidence was found of interaction (either additive or multiplicative) between ethnicity and lifestyle score.

INTERPRETATION

An extended weighted health behaviour score has strong associations with mortality, and associations are stronger in more deprived participants. Weighted health behaviour scores that account for socioeconomic deprivation could convey personalised risk and inform healthy living policy. Further work with adequate numbers of participants from minority ethnic groups is required to make more accurate estimates of mortality associated with a weighted health behaviour score in these populations.

FUNDING

HMEF is supported by a Medical Research Council Clinical Research Training Fellowship (grant number MR/T001585/1), which covered the costs of accessing the data herein.

Which combinations of health behaviours are associated with highest risk? An exploration of the UK Biobank population cohort

BACKGROUND

Combinations of unhealthy behaviours are associated with greater mortality than single behaviours, but some combinations might have stronger associations than others. High-risk combinations might be more prevalent among socioeconomically deprived populations. We examined associations between combinations of 11 unhealthy behaviours and mortality and explored socioeconomic distributions of high-risk combinations.

METHODS

We used the UK Biobank population cohort (n=502 459; aged 37-73 years) recruited between 2006 and 2010. Analysis included 229 197 participants with complete data. Main exposures were any combination of smoking, alcohol, physical activity, television time, sleep, added salt, social isolation, intake of red meat, processed meat, oily fish, and fruit and vegetables (each classified as healthy or unhealthy via guidelines or latest evidence). Townsend index was used to explore socioeconomic distribution. Cox proportional hazard models were used to examine associations between behaviours and all-cause mortality. Models were adjusted for demographic, health, and socioeconomic factors.

FINDINGS

Over a median follow-up of 11·6 years, 9739 (4·2%) of 229 197 participants died. From 716 unique combinations, 77 (11%) were associated with mortality with hazard ratios (HRs) greater than that for smoking alone (2·31 [95% CI 2·11-2·53]); HRs ranged from 9·44 to 2·34. Of these 77 high-risk combinations, smoking featured in 61 (79%), low fruit and vegetables in 45 (58%), and low oily fish in 41 (53%). All combinations featuring social isolation (18 [23%] of 77) had HRs greater than 3·00. Participants with high-risk combinations had greater deprivation scores than those with no unhealthy behaviours. Median deprivation scores of the ten highest risk combinations ranged from -2·0 to 2·1, whereas for participants with no unhealthy behaviours the score was -2·5. Examining women and men separately resulted in similar findings. Examination of ethnic differences was severely limited by small numbers of participants in minority ethnic groups.

INTERPRETATION

Many unique unhealthy behaviour combinations are strongly associated with mortality and high-risk combinations are more prevalent among more deprived populations than among more affluent populations. Exploring unique combinations of a wide range of health behaviours can identify high-risk populations. Future work with adequately sampled minority ethnic groups is required to examine high-risk combinations by ethnicity. Supporting healthy living in deprived populations, including tackling structural barriers to health, could address a wide range of health behaviours in combination.

FUNDING

UK Medical Research Council.

Outcomes among confirmed cases and a matched comparison group in the Long-COVID in Scotland study

With increasing numbers infected by SARS-CoV-2, understanding long-COVID is essential to inform health and social care support. A Scottish population cohort of 33,281 laboratory-confirmed SARS-CoV-2 infections and 62,957 never-infected individuals were followed-up via 6, 12 and 18-month questionnaires and linkage to hospitalization and death records. Of the 31,486 symptomatic infections,1,856 (6%) had not recovered and 13,350 (42%) only partially. No recovery was associated with hospitalized infection, age, female sex, deprivation, respiratory disease, depression and multimorbidity. Previous symptomatic infection was associated with poorer quality of life, impairment across all daily activities and 24 persistent symptoms including breathlessness (OR 3.43, 95% CI 3.29-3.58), palpitations (OR 2.51, OR 2.36-2.66), chest pain (OR 2.09, 95% CI 1.96-2.23), and confusion (OR 2.92, 95% CI 2.78-3.07). Asymptomatic infection was not associated with adverse outcomes. Vaccination was associated with reduced risk of seven symptoms. Here we describe the nature of long-COVID and the factors associated with it.

Widening or narrowing inequalities? The equity implications of digital tools to support COVID-19 contact tracing: A qualitative study

Background

As digital tools are increasingly used to support COVID‐19 contact tracing, the equity implications must be considered. As part of a study to understand the public's views of digital contact tracing tools developed for the national ‘Test and Protect’ programme in Scotland, we aimed to explore the views of groups often excluded from such discussions. This paper reports on their views about the potential for contact tracing to exacerbate inequalities.

Methods

A qualitative study was carried out; interviews were conducted with key informants from organizations supporting people in marginalized situations, followed by interviews and focus groups with people recruited from these groups. Participants included, or represented, minority ethnic groups, asylum seekers and refugees and those experiencing multiple disadvantage including severe and enduring poverty.

Results

A total of 42 people participated: 13 key informants and 29 members of the public. While public participants were supportive of contact tracing, key informants raised concerns. Both sets of participants spoke about how contact tracing, and its associated digital tools, might increase inequalities. Barriers included finances (inability to afford smartphones or the data to ensure access to the internet); language (digital tools were available only in English and required a degree of literacy, even for English speakers); and trust (many marginalized groups distrusted statutory organizations and there were concerns that data may be passed to other organizations). One strength was that NHS Scotland, the data guardian, is seen as a generally trustworthy organization. Poverty was recognized as a barrier to people's ability to self‐isolate. Some participants were concerned about giving contact details of individuals who might struggle to self‐isolate for financial reasons.

Conclusions

The impact of contact tracing and associated digital tools on marginalized populations needs careful monitoring. This should include the contact tracing process and the ability of people to self‐isolate. Regular clear messaging from trusted groups and community members could help maintain trust and participation in the programme.

Patient and Public Contribution

Our patient and public involvement coapplicant, L. L., was involved in all aspects of the study including coauthorship. Interim results were presented to our local Public and Patient Involvement and Engagement Group, who commented on interpretation and made suggestions about further recruitment.

The association between a lifestyle score, socioeconomic status, and COVID-19 outcomes within the UK Biobank cohort

BACKGROUND

Infection with SARS-CoV-2 virus (COVID-19) impacts disadvantaged groups most. Lifestyle factors are also associated with adverse COVID-19 outcomes. To inform COVID-19 policy and interventions, we explored effect modification of socioeconomic-status (SES) on associations between lifestyle and COVID-19 outcomes.

METHODS

Using data from UK-Biobank, a large prospective cohort of 502,536 participants aged 37-73 years recruited between 2006 and 2010, we assigned participants a lifestyle score comprising nine factors. Poisson regression models with penalised splines were used to analyse associations between lifestyle score, deprivation (Townsend), and COVID-19 mortality and severe COVID-19. Associations between each exposure and outcome were examined independently before participants were dichotomised by deprivation to examine exposures jointly. Models were adjusted for sociodemographic/health factors.

RESULTS

Of 343,850 participants (mean age > 60 years) with complete data, 707 (0.21%) died from COVID-19 and 2506 (0.76%) had severe COVID-19. There was evidence of a nonlinear association between lifestyle score and COVID-19 mortality but limited evidence for nonlinearity between lifestyle score and severe COVID-19 and between deprivation and COVID-19 outcomes. Compared with low deprivation, participants in the high deprivation group had higher risk of COVID-19 outcomes across the lifestyle score. There was evidence for an additive interaction between lifestyle score and deprivation. Compared with participants with the healthiest lifestyle score in the low deprivation group, COVID-19 mortality risk ratios (95% CIs) for those with less healthy scores in low versus high deprivation groups were 5.09 (1.39-25.20) and 9.60 (4.70-21.44), respectively. Equivalent figures for severe COVID-19 were 5.17 (2.46-12.01) and 6.02 (4.72-7.71). Alternative SES measures produced similar results.

CONCLUSIONS

Unhealthy lifestyles are associated with higher risk of adverse COVID-19, but risks are highest in the most disadvantaged, suggesting an additive influence between SES and lifestyle. COVID-19 policy and interventions should consider both lifestyle and SES. The greatest public health benefit from lifestyle focussed COVID-19 policy and interventions is likely to be seen when greatest support for healthy living is provided to the most disadvantaged groups.

Implementing social prescribing in primary care in areas of high socioeconomic deprivation: process evaluation of the 'Deep End' community Links Worker Programme

BACKGROUND

Social prescribing involving primary care-based 'link workers' is a key UK health policy that aims to reduce health inequalities. However, the process of implementation of the link worker approach has received little attention despite this being central to the desired impact and outcomes.

AIM

To explore the implementation process of such an approach in practice.

DESIGN AND SETTING

Qualitative process evaluation of the 'Deep End' Links Worker Programme (LWP) over a 2-year period, in seven general practices in deprived areas of Glasgow.

METHOD

The study used thematic analysis to identify the extent of LWP integration in each practice and the key factors associated with implementation. Analysis was informed by normalisation process theory (NPT).

RESULTS

Only three of the seven practices fully integrated the LWP into routine practice within 2 years, based on the NPT constructs of coherence, cognitive participation, and collective action. Compared with 'partially integrated practices', 'fully integrated practices' had better shared understanding of the programme among staff, higher staff engagement with the LWP, and were implementing all aspects of the LWP at patient, practice, and community levels of intervention. Successful implementation was associated with GP buy-in, collaborative leadership, good team dynamics, link worker support, and the absence of competing innovations.

CONCLUSION

Even in a well-resourced government-funded programme, the majority of practices involved had not fully integrated the LWP within the first 2 years. Implementing social prescribing and link workers within primary care at scale is unlikely to be a 'quick fix' for mitigating health inequalities in deprived areas.

'Reluctant pioneer': A qualitative study of doctors' experiences as patients with long COVID

BACKGROUND

The coronavirus disease (COVID-19) pandemic has had far-reaching effects upon lives, healthcare systems and society. Some who had an apparently 'mild' COVID-19 infection continue to suffer from persistent symptoms, including chest pain, breathlessness, fatigue, cognitive impairment, paraesthesia, muscle and joint pains. This has been labelled 'long COVID'. This paper reports the experiences of doctors with long COVID.

METHODS

A qualitative study; interviews with doctors experiencing persistent symptoms were conducted by telephone or video call. Interviews were transcribed and analysis conducted using an inductive and thematic approach.

RESULTS

Thirteen doctors participated. The following themes are reported: making sense of symptoms, feeling let down, using medical knowledge and connections, wanting to help and be helped, combining patient and professional identity. Experiencing long COVID can be transformative: many expressed hope that good would come of their experiences. Distress related to feelings of being 'let down' and the hard work of trying to access care. Participants highlighted that they felt better able to care for, and empathize with, patients with chronic conditions, particularly where symptoms are unexplained.

CONCLUSIONS

The study adds to the literature on the experiences of doctors as patients, in particular where evidence is emerging and the patient has to take the lead in finding solutions to their problems and accessing their own care.

PATIENT AND PUBLIC CONTRIBUTION

The study was developed with experts by experience (including co-authors HA and TAB) who contributed to the protocol and ethics application, and commented on analysis and implications. All participants were given the opportunity to comment on findings.

Understanding the influence of socioeconomic status on the association between combinations of lifestyle factors and adverse health outcomes: a systematic review protocol

INTRODUCTION

Combinations of unhealthy lifestyle factors are strongly associated with mortality, cardiovascular disease (CVD) and cancer. It is unclear how socioeconomic status (SES) affects those associations. Lower SES groups may be disproportionately vulnerable to the effects of unhealthy lifestyle factors compared with higher SES groups via interactions with other factors associated with low SES (eg, stress) or via accelerated biological ageing. This systematic review aims to synthesise studies that examine how SES moderates the association between lifestyle factor combinations and adverse health outcomes. Greater understanding of how lifestyle risk varies across socioeconomic spectra could reduce adverse health by (1) identifying novel high-risk groups or targets for future interventions and (2) informing research, policy and interventions that aim to support healthy lifestyles in socioeconomically deprived communities.

METHODS AND ANALYSIS

Three databases will be searched (PubMed, EMBASE, CINAHL) from inception to March 2020. Reference lists, citations and grey literature will also be searched. Inclusion criteria are: (1) prospective cohort studies; (2) investigations of two key exposures: (a) lifestyle factor combinations of at least three lifestyle factors (eg, smoking, physical activity and diet) and (b) SES (eg, income, education or poverty index); (3) an assessment of the impact of SES on the association between combinations of unhealthy lifestyle factors and health outcomes; (4) at least one outcome from-mortality (all cause, CVD and cancer), CVD or cancer incidence. Two independent reviewers will screen titles, abstracts and full texts of included studies. Data extraction will focus on cohort characteristics, exposures, direction and magnitude of SES effects, methods and quality (via Newcastle-Ottawa Scale). If appropriate, a meta-analysis, pooling the effects of SES, will be performed. Alternatively, a synthesis without meta-analysis will be conducted.

ETHICS AND DISSEMINATION

Ethical approval is not required. Results will be disseminated via peer-reviewed publication, professional networks, social media and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020172588.

Finding the 'right' GP: a qualitative study of the experiences of people with long-COVID

BACKGROUND

An unknown proportion of people who had an apparently mild COVID-19 infection continue to suffer with persistent symptoms, including chest pain, shortness of breath, muscle and joint pains, headaches, cognitive impairment ('brain fog'), and fatigue. Post-acute COVID-19 ('long-COVID') seems to be a multisystem disease, sometimes occurring after a mild acute illness; people struggling with these persistent symptoms refer to themselves as 'long haulers'.

AIM

To explore experiences of people with persisting symptoms following COVID-19 infection, and their views on primary care support received.

DESIGN & SETTING

Qualitative methodology, with semi-structured interviews to explore perspectives of people with persisting symptoms following suspected or confirmed COVID-19 infection. Participants were recruited via social media between July-August 2020.

METHOD

Interviews were conducted by telephone or video call, digitally recorded, and transcribed with consent. Thematic analysis was conducted applying constant comparison techniques. People with experience of persisting symptoms contributed to study design and data analysis.

RESULTS

This article reports analysis of 24 interviews. The main themes include: the ' hard and heavy work ' of enduring and managing symptoms and accessing care; living with uncertainty, helplessness and fear, particularly over whether recovery is possible; the importance of finding the 'right' GP (understanding, empathy, and support needed); and recovery and rehabilitation: what would help?

CONCLUSION

This study will raise awareness among primary care professionals, and commissioners, of long-COVID and the range of symptoms people are experiencing. Patients require their GP to believe their symptoms and to demonstrate empathy and understanding. Ongoing support by primary care professionals during recovery and rehabilitation is crucial.

Comparison of two different frailty measurements and risk of hospitalisation or death from COVID-19: findings from UK Biobank

BACKGROUND

Frailty has been associated with worse prognosis following COVID-19 infection. While several studies have reported the association between frailty and COVID-19 mortality or length of hospital stay, there have been no community-based studies on the association between frailty and risk of severe infection. Considering that different definitions have been identified to assess frailty, this study aimed to compare the association between frailty and severe COVID-19 infection in UK Biobank using two frailty classifications: the frailty phenotype and the frailty index.

METHODS

A total of 383,845 UK Biobank participants recruited 2006-2010 in England (211,310 [55.1%] women, baseline age 37-73 years) were included. COVID-19 test data were provided by Public Health England (available up to 28 June 2020). An adapted version of the frailty phenotype derived by Fried et al. was used to define frailty phenotype (robust, pre-frail, or frail). A previously validated frailty index was derived from 49 self-reported questionnaire items related to health, disease and disability, and mental wellbeing (robust, mild frailty, and moderate/severe frailty). Both classifications were derived from baseline data (2006-2010). Poisson regression models with robust standard errors were used to analyse the associations between both frailty classifications and severe COVID-19 infection (resulting in hospital admission or death), adjusted for sociodemographic and lifestyle factors.

RESULTS

Of UK Biobank participants included, 802 were admitted to hospital with and/or died from COVID19 (323 deaths and 479 hospitalisations). After analyses were adjusted for sociodemographic and lifestyle factors, a higher risk of COVID-19 was observed for pre-frail (risk ratio (RR) 1.47 [95% CI 1.26; 1.71]) and frail (RR 2.66 [95% CI 2.04; 3.47]) individuals compared to those classified as robust using the frailty phenotype. Similar results were observed when the frailty index was used (RR mildly frail 1.46 [95% CI 1.26; 1.71] and RR moderate/severe frailty 2.43 [95% CI 1.91; 3.10]).

CONCLUSIONS

Frailty was associated with a higher risk of severe COVID-19 infection resulting in hospital admission or death, irrespective of how it was measured and independent of sociodemographic and lifestyle factors. Public health strategies need to consider the additional risk that COVID-19 poses in individuals with frailty, including which additional preventive measures might be required.

Vitamin D concentrations and COVID-19 infection in UK Biobank

BACKGROUND AND AIMS

COVID-19 and low levels of vitamin D appear to disproportionately affect black and minority ethnic individuals. We aimed to establish whether blood 25-hydroxyvitamin D (25(OH)D) concentration was associated with COVID-19 risk, and whether it explained the higher incidence of COVID-19 in black and South Asian people.

METHODS

UK Biobank recruited 502,624 participants aged 37-73 years between 2006 and 2010. Baseline exposure data, including 25(OH)D concentration and ethnicity, were linked to COVID-19 test results. Univariable and multivariable logistic regression analyses were performed for the association between 25(OH)D and confirmed COVID-19, and the association between ethnicity and both 25(OH)D and COVID-19.

RESULTS

Complete data were available for 348,598 UK Biobank participants. Of these, 449 had confirmed COVID-19 infection. Vitamin D was associated with COVID-19 infection univariably (OR = 0.99; 95% CI 0.99-0.999; p = 0.013), but not after adjustment for confounders (OR = 1.00; 95% CI = 0.998-1.01; p = 0.208). Ethnicity was associated with COVID-19 infection univariably (blacks versus whites OR = 5.32, 95% CI = 3.68-7.70, p-value<0.001; South Asians versus whites OR = 2.65, 95% CI = 1.65-4.25, p-value<0.001). Adjustment for 25(OH)D concentration made little difference to the magnitude of the association.

CONCLUSIONS

Our findings do not support a potential link between vitamin D concentrations and risk of COVID-19 infection, nor that vitamin D concentration may explain ethnic differences in COVID-19 infection.

Ethnic and socioeconomic differences in SARS-CoV-2 infection: prospective cohort study using UK Biobank

BACKGROUND

Understanding of the role of ethnicity and socioeconomic position in the risk of developing SARS-CoV-2 infection is limited. We investigated this in the UK Biobank study.

METHODS

The UK Biobank study recruited 40-70-year-olds in 2006-2010 from the general population, collecting information about self-defined ethnicity and socioeconomic variables (including area-level socioeconomic deprivation and educational attainment). SARS-CoV-2 test results from Public Health England were linked to baseline UK Biobank data. Poisson regression with robust standard errors was used to assess risk ratios (RRs) between the exposures and dichotomous variables for being tested, having a positive test and testing positive in hospital. We also investigated whether ethnicity and socioeconomic position were associated with having a positive test amongst those tested. We adjusted for covariates including age, sex, social variables (including healthcare work and household size), behavioural risk factors and baseline health.

RESULTS

Amongst 392,116 participants in England, 2658 had been tested for SARS-CoV-2 and 948 tested positive (726 in hospital) between 16 March and 3 May 2020. Black and south Asian groups were more likely to test positive (RR 3.35 (95% CI 2.48-4.53) and RR 2.42 (95% CI 1.75-3.36) respectively), with Pakistani ethnicity at highest risk within the south Asian group (RR 3.24 (95% CI 1.73-6.07)). These ethnic groups were more likely to be hospital cases compared to the white British. Adjustment for baseline health and behavioural risk factors led to little change, with only modest attenuation when accounting for socioeconomic variables. Socioeconomic deprivation and having no qualifications were consistently associated with a higher risk of confirmed infection (RR 2.19 for most deprived quartile vs least (95% CI 1.80-2.66) and RR 2.00 for no qualifications vs degree (95% CI 1.66-2.42)).

CONCLUSIONS

Some minority ethnic groups have a higher risk of confirmed SARS-CoV-2 infection in the UK Biobank study, which was not accounted for by differences in socioeconomic conditions, baseline self-reported health or behavioural risk factors. An urgent response to addressing these elevated risks is required.

What works and why in the identification and referral of adults with comorbid obesity in primary care: A realist review

Primary care practitioners (PCPs) are well placed to identify individuals with obesity and weight-related comorbidities and to refer them to weight management services (WMS), but this does not often happen in practice. In this realist review, we searched six databases for intervention studies targeted at PCPs to improve the identification and referral of adults with comorbid obesity. Realist analysis was used to identify context-mechanism-outcome (CMO) configurations across 30 included papers (reporting on 27 studies). Most studies used multiple intervention strategies, categorised into: (a) training, (b) tools to improve identification, (c) tools to improve ease of referral, (d) audit/feedback, (e) working in networks/quality circles, and (f) other. The realist synthesis identified 12 mechanisms through which interventions work to improve identification and referral, including increasing knowledge about obesity and awareness of and confidence in WMS among practitioners, improved communication and trust between practitioners and WMS, and higher priority given to weight management among primary care teams. The theory of "candidacy" (a person's eligibility for medical attention and intervention) provided a robust explanatory framework but required refinement: (a) to take account of the different services (primary care and weight management) that patients must navigate to access support; and (b) to acknowledge the importance of wider contextual factors.

What do we know about demand, use and outcomes in primary care out-of-hours services? A systematic scoping review of international literature

OBJECTIVE

To synthesise international evidence for demand, use and outcomes of primary care out-of-hours health services (OOHS).

DESIGN

Systematic scoping review.

DATA SOURCES

CINAHL; Medline; PsyARTICLES; PsycINFO; SocINDEX; and Embase from 1995 to 2019.

STUDY SELECTION

English language studies in UK or similar international settings, focused on services in or directly impacting primary care.

RESULTS

105 studies included: 54% from mainland Europe/Republic of Ireland; 37% from UK. Most focused on general practitioner-led out-of-hours cooperatives. Evidence for increasing patient demand over time was weak due to data heterogeneity, infrequent reporting of population denominators and little adjustment for population sociodemographics. There was consistent evidence of higher OOHS use in the evening compared with overnight, at weekends and by certain groups (children aged <5, adults aged >65, women, those from socioeconomically deprived areas, with chronic diseases or mental health problems). Contact with OOHS was driven by problems perceived as urgent by patients. Respiratory, musculoskeletal, skin and abdominal symptoms were the most common reasons for contact in adults; fever and gastrointestinal symptoms were the most common in the under-5s. Frequent users of daytime services were also frequent OOHS users; difficulty accessing daytime services was also associated with OOHS use. There is some evidence to suggest that OOHS colocated in emergency departments (ED) can reduce demand in EDs.

CONCLUSIONS

Policy changes have impacted on OOHS over the past two decades. While there are generalisable lessons, a lack of comparable data makes it difficult to judge how demand has changed over time. Agreement on collection of OOHS data would allow robust comparisons within and across countries and across new models of care. Future developments in OOHS should also pay more attention to the relationship with daytime primary care and other services.

PROSPERO REGISTRATION NUMBER

CRD42015029741.

Effectiveness of Community-Links Practitioners in Areas of High Socioeconomic Deprivation

PURPOSE

To assess the effect of a primary care-based community-links practitioner (CLP) intervention on patients' quality of life and well-being.

METHODS

Quasi-experimental cluster-randomized controlled trial in socioeconomically deprived areas of Glasgow, Scotland. Adult patients (aged 18 years or older) referred to CLPs in 7 intervention practices were compared with a random sample of adult patients from 8 comparison practices at baseline and 9 months.

PRIMARY OUTCOME

health-related quality of life (EQ-5D-5L, a standardized measure of self-reported health-related quality of life that assesses 5 dimensions at 5 levels of severity).

SECONDARY OUTCOMES

well-being (Investigating Choice Experiments for the Preferences of Older People Capability Measure for Adults [ICECAP-A]), depression (Hospital Anxiety and Depression Scale, Depression [HADS-D]), anxiety (Hospital Anxiety and Depression Scale, Anxiety [HADS-A]), and self-reported exercise. Multilevel, multiregression analyses adjusted for baseline differences. Patients were not blinded to the intervention, but outcome analysis was masked.

RESULTS

Data were collected on 288 and 214 (74.3%) patients in the intervention practices at baseline and follow-up, respectively, and on 612 and 561 (92%) patients in the comparison practices. Intention-to-treat analysis found no differences between the 2 groups for any outcome. In subgroup analyses, patients who saw the CLP on 3 or more occasions (45% of those referred) had significant improvements in EQ-5D-5L, HADS-D, HADS-A, and exercise levels. There was a high positive correlation between CLP consultation rates and patient uptake of suggested community resources.

CONCLUSIONS

We were unable to prove the effectiveness of referral to CLPs based in primary care in deprived areas for improving patient outcomes. Future efforts to boost uptake and engagement could improve overall outcomes, although the apparent improvements in those who regularly saw the CLPs may be due to reverse causality. Further research is needed before wide-scale deployment of this approach.

Facilitators and barriers to safer care in Scottish general practice: a qualitative study of the implementation of the trigger review method using normalisation process theory

OBJECTIVES

Patient safety is a key concern of modern health systems, with numerous approaches to support safety. One, the trigger review method (TRM), is promoted nationally in Scotland as an approach to improve the safety of care in general medical practice. However, it remains unclear which factors are facilitating or hindering its implementation. The aim of this study was to identify the important factors that facilitate or hinder the implementation of the TRM in this setting.

DESIGN

Qualitative study employing semi-structured interviews. Data analysis was theoretically informed using normalisation process theory (NPT).

SETTING

Scottish general practice.

PARTICIPANTS

We conducted 28 semistructured interviews with general practitioners (n=12), practice nurses (n=11) and practice managers (n=5) in Scotland.

RESULTS

We identified four important factors that facilitated or hindered implementation: (1) the amount of time and allocated resources; (2) integration of the TRM into existing initiatives and frameworks facilitated implementation and justified participants' involvement; (3) the characteristics of the reviewers-implementation was facilitated by experienced, reflective clinicians with leadership roles in their teams; (4) the degree to which participants perceived the TRM as acceptable, feasible and useful.

CONCLUSIONS

This study is the first known attempt to investigate how the TRM is implemented and perceived by general practice clinicians and staff. The four main factors that facilitated TRM implementation are comparable with the wider implementation science literature, suggesting that a small number of specific factors determine the success of most, if not all, complex healthcare interventions. These factors can be identified, described and understood through theoretical frameworks such as NPT and are amenable to intervention. Researchers and policymakers should proactively identify and address these factors.

No such thing as bad publicity? A quantitative content analysis of print media representations of primary care out-of-hours services

OBJECTIVE

To explore how out-of-hours primary healthcare services (OOHS) are represented in UK national newspapers, focusing on content and tone of reporting and the use of personal narratives to frame stories.

DESIGN

A retrospective cross-sectional quantitative content analysis of articles published in 2005, 2010 and 2015.

DATA SOURCES

Nexis database used to search 10 UK national newspapers covering quality, middle-market and tabloid publications.

INCLUSION/EXCLUSION CRITERIA

All articles containing the terms 'out-of-hours' (≥3 mentions per article) or ('NHS 24' OR 'NHS 111' OR 'NHS Direct') AND 'out-of-hours' (≥1 mention per article) were included. Letters, duplicate news items, opinion pieces and articles without a substantial portion of the story (>50% of an article's word count, as judged by researchers) concerning OOHS were excluded.

RESULTS

332 newspaper articles were identified: 113 in 2005 (34.1%), 140 in 2010 (42.2%) and 79 in 2015 (23.8%). Of these, 195 (58.7%) were in quality newspapers, 99 (29.8%) in middle-market and 38 (11.3%) in tabloids. The most commonly reported themes were OOHS organisation, personal narratives and telephone triage. Stories about service-level crises and personal tragedy, including unsafe doctors and missed or delayed identification of rare conditions, predominated. The majority of articles (252, 75.9%) were negative in tone. This was observed for all included newspapers and by publication genre; middle-market newspapers had the highest percentage of negative articles (Pearson χ²=35.72, p<0.001). Articles presented little supporting contextual information, such as call rates per annum, or advice on how to access OOHS.

CONCLUSION

In this first reported analysis of UK national newspaper coverage of OOHS, media representation is generally negative in tone, with frequent reports of 'negative exemplars' of OOHS crises and fatal individual patient cases with little or no contextualisation. We present recommendations for the future reporting of OOHS, which could apply to the reporting of healthcare services more generally.

The effect of socioeconomic deprivation on the association between an extended measurement of unhealthy lifestyle factors and health outcomes: a prospective analysis of the UK Biobank cohort

BACKGROUND

Combinations of lifestyle factors interact to increase mortality. Combinations of traditional factors such as smoking and alcohol are well described, but the additional effects of emerging factors such as television viewing time are not. The effect of socioeconomic deprivation on these extended lifestyle risks also remains unclear. We aimed to examine whether deprivation modifies the association between an extended score of lifestyle-related risk factors and health outcomes.

METHODS

Data for this prospective analysis were sourced from the UK Biobank, a prospective population-based cohort study. We assigned all participants an extended lifestyle score, with 1 point for each unhealthy lifestyle factor (incorporating sleep duration and high television viewing time, in addition to smoking, excessive alcohol, poor diet [low intake of oily fish or fruits and vegetables, and high intake of red meat or processed meats], and low physical activity), categorised as most healthy (score 0-2), moderately healthy (score 3-5), or least healthy (score 6-9). Cox proportional hazards models were used to examine the association between lifestyle score and health outcomes (all-cause mortality and cardiovascular disease mortality and incidence), and whether this association was modified by deprivation. All analyses were landmark analyses, in which participants were excluded if they had an event (death or cardiovascular disease event) within 2 years of recruitment. Participants with non-communicable diseases (except hypertension) and missing covariate data were excluded from analyses. Participants were also excluded if they reported implausible values for physical activity, sleep duration, and total screen time. All analyses were adjusted for age, sex, ethnicity, month of assessment, history of hypertension, systolic blood pressure, medication for hypercholesterolaemia or hypertension, and body-mass index categories.

FINDINGS

328 594 participants aged 40-69 years were included in the study, with a mean follow-up period of 4·9 years (SD 0·83) after the landmark period for all-cause and cardiovascular disease mortality, and 4·1 years (0·81) for cardiovascular disease incidence. In the least deprived quintile, the adjusted hazard ratio (HR) in the least healthy lifestyle category, compared with the most healthy category, was 1·65 (95% CI 1·25-2·19) for all-cause mortality, 1·93 (1·16-3·20) for cardiovascular disease mortality, and 1·29 (1·10-1·52) for cardiovascular disease incidence. Equivalent HRs in the most deprived quintile were 2·47 (95% CI 2·04-3·00), 3·36 (2·36-4·76), and 1·41 (1·25-1·60), respectively. The HR for trend for one increment change towards least healthy in the least deprived quintile compared with that in the most deprived quintile was 1·25 (95% CI 1·12-1·39) versus 1·55 (1·40-1·70) for all-cause mortality, 1·30 (1·05-1·61) versus 1·83 (1·54-2·18) for cardiovascular disease mortality, and 1·10 (1·04-1·17) versus 1·16 (1·09-1·23) for cardiovascular disease incidence. A significant interaction was found between lifestyle and deprivation for all-cause and cardiovascular disease mortality (both p_interaction<0·0001), but not for cardiovascular disease incidence (p_interaction=0·11).

INTERPRETATION

Wide combinations of lifestyle factors are associated with disproportionate harm in deprived populations. Social and fiscal policies that reduce poverty are needed alongside public health and individual-level interventions that address a wider range of lifestyle factors in areas of deprivation.

FUNDING

None.

Exploring barriers to primary care for migrants in Greece in times of austerity: Perspectives of service providers

Background: Migration in Europe is increasing at an unprecedented rate. There is an urgent need to develop ‘migrant-sensitive healthcare systems’. However, there are many barriers to healthcare for migrants. Despite Greece’s recent, significant experiences of inward migration during a period of economic austerity, little is known about Greek primary care service providers’ experiences of delivering care to migrants.

Objectives: To identify service providers’ views on the barriers to migrant healthcare.

Methods: Qualitative study involving six participatory learning and action (PLA) focus group sessions with nine service providers. Data generation was informed by normalization process theory (NPT). Thematic analysis was applied to identify barriers to efficient migrant healthcare.

Results: Three main provider and system-related barriers emerged: (a) emphasis on major challenges in healthcare provision, (b) low perceived control and effectiveness to support migrant healthcare, and (c) attention to impoverished local population.

Conclusion: The study identified major provider and system-related barriers in the provision of primary healthcare to migrants. It is important for the healthcare system in Greece to provide appropriate supports for communication in cross-cultural consultations for its diversifying population.

Modifiable Risk Factors for Prevention of Dementia in Midlife, Late Life and the Oldest-Old: Validation of the LIBRA Index

BACKGROUND

Recently, the LIfestyle for BRAin health (LIBRA) index was developed to assess an individual's prevention potential for dementia.

OBJECTIVE

We investigated the predictive validity of the LIBRA index for incident dementia in midlife, late life, and the oldest-old.

METHODS

9,387 non-demented individuals were recruited from the European population-based DESCRIPA study. An individual's LIBRA index was calculated solely based on modifiable risk factors: depression, diabetes, physical activity, hypertension, obesity, smoking, hypercholesterolemia, coronary heart disease, and mild/moderate alcohol use. Cox regression was used to test the predictive validity of LIBRA for dementia at follow-up (mean 7.2 y, range 1-16).

RESULTS

In midlife (55-69 y, n = 3,256) and late life (70-79 y, n = 4,320), the risk for dementia increased with higher LIBRA scores. Individuals in the intermediate- and high-risk groups had a higher risk of dementia than those in the low-risk group. In the oldest-old (80-97 y, n = 1,811), higher LIBRA scores did not increase the risk for dementia.

CONCLUSION

LIBRA might be a useful tool to identify individuals for primary prevention interventions of dementia in midlife, and maybe in late life, but not in the oldest-old.

Lifestyle for Brain Health (LIBRA): a new model for dementia prevention

OBJECTIVE

Modifiable risk factors for dementia were recently identified and compiled in a systematic review. The 'Lifestyle for Brain Health' (LIBRA) score, reflecting someone's potential for dementia prevention, was studied in a large longitudinal population-based sample with respect to predicting cognitive change over an observation period of up to 16 years.

METHODS

Lifestyle for Brain Health was calculated at baseline for 949 participants aged 50-81 years from the Maastricht Ageing Study. The predictive value of LIBRA for incident dementia and cognitive impairment was examined by using Cox proportional hazard models and by testing its relation with cognitive decline.

RESULTS

Lifestyle for Brain Health predicted future risk of dementia, as well as risk of cognitive impairment. A one-point increase in LIBRA score related to 19% higher risk for dementia and 9% higher risk for cognitive impairment. LIBRA predicted rate of decline in processing speed, but not memory or executive functioning.

CONCLUSIONS

Lifestyle for Brain Health (LIBRA) may help in identifying and monitoring risk status in dementia-prevention programmes, by targeting modifiable, lifestyle-related risk factors. Copyright © 2017 John Wiley & Sons, Ltd.

The role of primary care in adult weight management: qualitative interviews with key stakeholders in weight management services

Background

Primary care has a key role to play in the prevention and management of obesity, but there remain barriers to engagement in weight management by primary care practitioners. The aim of this study was to explore the views of key stakeholders in adult weight management services on the role of primary care in adult weight management.

Methods

Qualitative study involving semi-structured interviews with nine senior dietitians involved in NHS weight management from seven Scottish health boards. Transcripts were analysed using an inductive thematic approach.

Results

A range of tensions were apparent within three key themes: weight management service issues, the role of primary care, and communication with primary care. For weight management services, these tensions were around funding, the management model of obesity, and how to configure access to services. For primary care, they were around what primary care should be doing, who should be doing it, and where this activity should fit within wider weight management policy. With regard to communication between weight management services and primary care, there were tensions related to the approach taken (locally adapted versus centralised), the message being communicated (weight loss versus wellbeing), and the response from practitioners (engagement versus resistance).

Conclusions

Primary care can do more to support adult weight management, but this requires better engagement and communication with weight management services, to overcome the tensions highlighted in this study. This, in turn, requires more secure, sustained funding. The example of smoking cessation in the UK, where there is a network of well-resourced NHS Stop Smoking Services, accessible via different means, could be a model to follow.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2729-7) contains supplementary material, which is available to authorized users.

Patient and practice characteristics predicting attendance and completion at a specialist weight management service in the UK: a cross-sectional study

OBJECTIVE

To determine the association between patient and referring practice characteristics and attendance and completion at a specialist health service weight management service (WMS).

DESIGN

Cross-sectional study.

SETTING

Regional specialist WMS located in the West of Scotland.

PARTICIPANTS

9677 adults with obesity referred between 2012 and 2014; 3250 attending service and 2252 completing.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measure was attendance at the WMS; secondary outcome was completion, defined as attending four or more sessions.

ANALYSIS

Multilevel binary logistic regression models constructed to determine the association between patient and practice characteristics and attendance and completion.

RESULTS

Approximately one-third of the 9677 obese adults referred attended at least one session (n=3250, 33.6%); only 2252 (23%) completed by attending four or more sessions. Practice referrals ranged from 1 to 257. Patient-level characteristics were strongest predictors of attendance; odds of attendance increased with age (OR 4.14, 95% CI 3.27 to 5.26 for adults aged 65+ compared with those aged 18-24), body mass index (BMI) category (OR 1.83, 95% CI 1.56 to 2.15 for BMI 45+ compared with BMI 30-35) and increasing affluence (OR 1.96, 95% CI 1.17 to 3.28). Practice-level characteristics most strongly associated with attendance were being a non-training practice, having a larger list size and not being located in the most deprived areas.

CONCLUSIONS

There was wide variation in referral rates across general practice, suggesting that there is still much to do to improve engagement with weight management by primary care practitioners. The high attrition rate from referral to attendance and from attendance to completion suggests ongoing barriers for patients, particularly those from the most socioeconomically deprived areas. Patient and practice-level characteristics can help us understand the observed variation in attendance at specialist WMS following general practitioner (GP) referral and the underlying explanations for these differences merit further investigation.

Material practices for meaningful engagement: An analysis of participatory learning and action research techniques for data generation and analysis in a health research partnership

BACKGROUND

The material practices which researchers use in research partnerships may enable or constrain the nature of engagement with stakeholder groups. Participatory learning and action (PLA) research approaches show promise, but there has been no detailed analysis of stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis.

OBJECTIVES

To explore stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis.

DESIGN

The EU RESTORE implementation science project employed a participatory approach to investigate and support the implementation of guidelines and training initiatives (GTIs) to enhance communication in cross-cultural primary care consultations. We developed a purposeful sample of 78 stakeholders (migrants, general practice staff, community interpreters, service providers, service planners) from primary care settings in Austria, England, Greece, Ireland and The Netherlands. We used speed evaluations and participatory evaluations to explore their experiences of two PLA techniques-Commentary Charts and Direct Ranking-which were intended to generate data for co-analysis by stakeholders about the GTIs under analysis. We evaluated 16 RESTORE researchers' experiences using interviews. We conducted thematic and content analysis of all evaluation data.

RESULTS

PLA Commentary Charts and Direct Ranking techniques, with their visual, verbal and tangible nature and inherent analytical capabilities, were found to be powerful tools for involving stakeholders in a collaborative analysis of GTIs. Stakeholders had few negative experiences and numerous multifaceted positive experiences of meaningful engagement, which resonated with researchers' accounts.

CONCLUSION

PLA techniques and approaches are valuable as material practices in health research partnerships.

Supporting the use of theory in cross-country health services research: a participatory qualitative approach using Normalisation Process Theory as an example

OBJECTIVES

To describe and reflect on the process of designing and delivering a training programme supporting the use of theory, in this case Normalisation Process Theory (NPT), in a multisite cross-country health services research study.

DESIGN

Participatory research approach using qualitative methods.

SETTING

Six European primary care settings involving research teams from Austria, England, Greece, Ireland, The Netherlands and Scotland.

PARTICIPANTS

RESTORE research team consisting of 8 project applicants, all senior primary care academics, and 10 researchers. Professional backgrounds included general practitioners/family doctors, social/cultural anthropologists, sociologists and health services/primary care researchers.

PRIMARY OUTCOME MEASURES

Views of all research team members (n=18) were assessed using qualitative evaluation methods, analysed qualitatively by the trainers after each session.

RESULTS

Most of the team had no experience of using NPT and many had not applied theory to prospective, qualitative research projects. Early training proved didactic and overloaded participants with information. Drawing on RESTORE's methodological approach of Participatory Learning and Action, workshops using role play, experiential interactive exercises and light-hearted examples not directly related to the study subject matter were developed. Evaluation showed the study team quickly grew in knowledge and confidence in applying theory to fieldwork.Recommendations applicable to other studies include: accepting that theory application is not a linear process, that time is needed to address researcher concerns with the process, and that experiential, interactive learning is a key device in building conceptual and practical knowledge. An unanticipated benefit was the smooth transition to cross-country qualitative coding of study data.

CONCLUSION

A structured programme of training enhanced and supported the prospective application of a theory, NPT, to our work but raised challenges. These were not unique to NPT but could arise with the application of any theory, especially in large multisite, international projects. The lessons learnt are applicable to other theoretically informed studies.

Understanding factors affecting patient and public engagement and recruitment to digital health interventions: a systematic review of qualitative studies

Background

Numerous types of digital health interventions (DHIs) are available to patients and the public but many factors affect their ability to engage and enrol in them. This systematic review aims to identify and synthesise the qualitative literature on barriers and facilitators to engagement and recruitment to DHIs to inform future implementation efforts.

Methods

PubMed, MEDLINE, CINAHL, Embase, Scopus and the ACM Digital Library were searched for English language qualitative studies from 2000 – 2015 that discussed factors affecting engagement and enrolment in a range of DHIs (e.g. ‘telemedicine’, ‘mobile applications’, ‘personal health record’, ‘social networking’). Text mining and additional search strategies were used to identify 1,448 records. Two reviewers independently carried out paper screening, quality assessment, data extraction and analysis. Data was analysed using framework synthesis, informed by Normalization Process Theory, and Burden of Treatment Theory helped conceptualise the interpretation of results.

Results

Nineteen publications were included in the review. Four overarching themes that affect patient and public engagement and enrolment in DHIs emerged; 1) personal agency and motivation; 2) personal life and values; 3) the engagement and recruitment approach; and 4) the quality of the DHI. The review also summarises engagement and recruitment strategies used. A preliminary DIgital Health EnGagement MOdel (DIEGO) was developed to highlight the key processes involved. Existing knowledge gaps are identified and a number of recommendations made for future research. Study limitations include English language publications and exclusion of grey literature.

Conclusion

This review summarises and highlights the complexity of digital health engagement and recruitment processes and outlines issues that need to be addressed before patients and the public commit to digital health and it can be implemented effectively. More work is needed to create successful engagement strategies and better quality digital solutions that are personalised where possible and to gain clinical accreditation and endorsement when appropriate. More investment is also needed to improve computer literacy and ensure technologies are accessible and affordable for those who wish to sign up to them.

Systematic review registration

International Prospective Register of Systematic Reviews CRD42015029846

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0359-3) contains supplementary material, which is available to authorized users.

Barriers and facilitators to patient and public engagement and recruitment to digital health interventions: protocol of a systematic review of qualitative studies

INTRODUCTION

Patients and the public are beginning to use digital health tools to assist in managing chronic illness, support independent living and self-care, and remain connected to health and care providers. However, engaging with and enrolling in digital health interventions, such as telehealth systems, mobile health applications, patient portals and personal health records, in order to use them varies considerably. Many factors affect people's ability to engage with and sign up to digital health platforms.

OBJECTIVES

The primary aim is to identify the barriers and facilitators patients and the public experience to engagement and recruitment to digital health interventions. The secondary aim is to identify engagement and enrolment strategies, leading if possible to a taxonomy of such approaches, and a conceptual framework of digital health engagement and recruitment processes.

METHODS

A systematic review of qualitative studies will be conducted by searching six databases: MEDLINE, CINAHL, PubMed, EMBASE, Scopus and the ACM Digital Library for papers published between 2000 and 2015. Titles and abstracts along with full-text papers will be screened by two independent reviewers against predetermined inclusion and exclusion criteria. A data extraction form will be used to provide details of the included studies. Quality assessment will be conducted using the Consolidated Criteria for Reporting Qualitative Research checklist. Any disagreements will be resolved through discussion with an independent third reviewer. Analysis will be guided by framework synthesis and informed by normalization process theory and burden of treatment theory, to aid conceptualisation of digital health engagement and recruitment processes.

DISCUSSION

This systematic review of qualitative studies will explore factors affecting engagement and enrolment in digital health interventions. It will advance our understanding of readiness for digital health by examining the complex factors that affect patients' and the public's ability to take part.

TRIAL REGISTRATION NUMBER

CRD42015029846.

Learning from doing: the case for combining normalisation process theory and participatory learning and action research methodology for primary healthcare implementation research

Background

The implementation of research findings is not a straightforward matter. There are substantive and recognised gaps in the process of translating research findings into practice and policy. In order to overcome some of these translational difficulties, a number of strategies have been proposed for researchers. These include greater use of theoretical approaches in research focused on implementation, and use of a wider range of research methods appropriate to policy questions and the wider social context in which they are placed. However, questions remain about how to combine theory and method in implementation research. In this paper, we respond to these proposals.

Discussion

Focussing on a contemporary social theory, Normalisation Process Theory, and a participatory research methodology, Participatory Learning and Action, we discuss the potential of their combined use for implementation research. We note ways in which Normalisation Process Theory and Participatory Learning and Action are congruent and may therefore be used as heuristic devices to explore, better understand and support implementation. We also provide examples of their use in our own research programme about community involvement in primary healthcare.

Conclusions

Normalisation Process Theory alone has, to date, offered useful explanations for the success or otherwise of implementation projects post-implementation. We argue that Normalisation Process Theory can also be used to prospectively support implementation journeys. Furthermore, Normalisation Process Theory and Participatory Learning and Action can be used together so that interventions to support implementation work are devised and enacted with the expertise of key stakeholders. We propose that the specific combination of this theory and methodology possesses the potential, because of their combined heuristic force, to offer a more effective means of supporting implementation projects than either one might do on its own, and of providing deeper understandings of implementation contexts, rather than merely describing change.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1587-z) contains supplementary material, which is available to authorized users.

Engaging migrants and other stakeholders to improve communication in cross-cultural consultation in primary care: a theoretically informed participatory study

OBJECTIVES

Guidelines and training initiatives (G/TIs) are available to support communication in cross-cultural consultations but are rarely implemented in routine practice in primary care. As part of the European Union RESTORE project, our objective was to explore whether the available G/TIs make sense to migrants and other key stakeholders and whether they could collectively choose G/TIs and engage in their implementation in primary care settings.

SETTING

As part of a comparative analysis of 5 linked qualitative case studies, we used purposeful and snowball sampling to recruit migrants and other key stakeholders in primary care settings in Austria, England, Greece, Ireland and the Netherlands.

PARTICIPANTS

A total of 78 stakeholders participated in the study (Austria 15, England 9, Ireland 11, Greece 16, Netherlands 27), covering a range of groups (migrants, general practitioners, nurses, administrative staff, interpreters, health service planners).

PRIMARY AND SECONDARY OUTCOME MEASURES

We combined Normalisation Process Theory (NPT) and Participatory Learning and Action (PLA) research to conduct a series of PLA style focus groups. Using a standardised protocol, stakeholders' discussions about a set of G/TIs were recorded on PLA commentary charts and their selection process was recorded through a PLA direct-ranking technique. We performed inductive and deductive thematic analysis to investigate sensemaking and engagement with the G/TIs.

RESULTS

The need for new ways of working was strongly endorsed by most stakeholders. Stakeholders considered that they were the right people to drive the work forward and were keen to enrol others to support the implementation work. This was evidenced by the democratic selection by stakeholders in each setting of one G/TI as a local implementation project.

CONCLUSIONS

This theoretically informed participatory approach used across 5 countries with diverse healthcare systems could be used in other settings to establish positive conditions for the start of implementation journeys for G/TIs to improve healthcare for migrants.

Factors Affecting Participation in the eRedBook: A Personal Child Health Record

A personal child health record called the eRedBook was recently piloted in the United Kingdom. A qualitative exploratory case study was used to examine how public health nurses engaged or recruited parents and what factors hindered participation. Interviews and focus groups were conducted with those implementing the eRedBook and those taking part in the pilot study. A range of project documentation was also reviewed. Thematic analysis using the framework approach was applied to draw out themes. Numerous socio-technical factors such as the usability of the software, concerns over data protection and costs, poor digital literacy skills and a lack of Internet connectivity emerged. These barriers need to be addressed before the eRedBook is implemented nationwide.

Barriers to Co-Designing Mobile Technology with Persons with Dementia and Their Carers

Mobile applications can be used to help manage different aspects of long-term illnesses but many are not designed to meet the specific needs of people with dementia or their carers. This case study explores the barriers experienced when co-producing a memory and reminiscence app. A focus group and interviews were conducted with patient/carer dyads, an occupational therapist, project manager and software engineer involved in the design of the app. Data was analysed thematically using the framework approach. Several limitations such as poor technical knowledge and skills, negative attitudes and inaccurate perceptions of people with dementia slowed down or changed how the mobile app was developed. Compromises also had to be made over the final design of the app. More research to explore how mobile apps are co-designed with patients is needed.

Reducing dementia risk by targeting modifiable risk factors in mid-life: study protocol for the Innovative Midlife Intervention for Dementia Deterrence (In-MINDD) randomised controlled feasibility trial

Background

Dementia prevalence is increasing as populations live longer, with no cure and the costs of caring exceeding many other conditions. There is increasing evidence for modifiable risk factors which, if addressed in mid-life, can reduce the risk of developing dementia in later life. These include physical inactivity, low cognitive activity, mid-life obesity, high blood pressure, and high cholesterol. This study aims to assess the acceptability and feasibility and impact of giving those in mid-life, aged between 40 and 60 years, an individualised dementia risk modification score and profile and access to personalised on-line health information and goal setting in order to support the behaviour change required to reduce such dementia risk. A secondary aim is to understand participants’ and practitioners’ views of dementia prevention and explore the acceptability and integration of the Innovative Midlife Intervention for Dementia Deterrence (In-MINDD) intervention into daily life and routine practice.

Methods/design

In-MINDD is a multi-centre, primary care-based, single-blinded randomised controlled feasibility trial currently being conducted in four European countries (France, Ireland, the Netherlands and the UK). Participants are being recruited from participating general practices. Inclusion criteria will include age between 40 and 60 years; at least one modifiable risk factor for dementia risk (including diabetes, hypertension, obesity, renal dysfunction, current smoker, raised cholesterol, coronary heart disease, current or previous history of depression, self-reported sedentary lifestyle, and self-reported low cognitive activity) access to the Internet. Primary outcome measure will be a change in dementia risk modification score over the timescale of the trial (6 months). A qualitative process evaluation will interview a sample of participants and practitioners about their views on the acceptability and feasibility of the trial and the links between modifiable risk factors and dementia prevention. This work will be underpinned by Normalisation Process Theory.

Discussion

This study will explore the feasibility and acceptability of a risk profiler and on-line support environment to help individuals in mid-life assess their risk of developing dementia in later life and to take steps to alleviate that risk by tackling health-related behaviour change. Testing the intervention in a robust and theoretically informed manner will inform the development of a future, full-scale randomised controlled trial.

Trial registration

ISRCTN Registry: ISRCTN 98553005 (DOI: 10.1186/ISRCTN98553005).

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-015-0035-x) contains supplementary material, which is available to authorized users.

Delivering digital health and well-being at scale: lessons learned during the implementation of the dallas program in the United Kingdom

Objective To identify implementation lessons from the United Kingdom Delivering Assisted Living Lifestyles at Scale (dallas) program—a large-scale, national technology program that aims to deliver a broad range of digital services and products to the public to promote health and well-being.

Materials and Methods Prospective, longitudinal qualitative research study investigating implementation processes. Qualitative data collected includes semi-structured e-Health Implementation Toolkit–led interviews at baseline/mid-point ( n = 38), quarterly evaluation, quarterly technical and barrier and solutions reports, observational logs, quarterly evaluation alignment interviews with project leads, observational data collected during meetings, and ethnographic data from dallas events ( n > 200 distinct pieces of qualitative data). Data analysis was guided by Normalization Process Theory, a sociological theory that aids conceptualization of implementation issues in complex healthcare settings.

Results Five key challenges were identified: 1) The challenge of establishing and maintaining large heterogeneous, multi-agency partnerships to deliver new models of healthcare; 2) The need for resilience in the face of barriers and set-backs including the backdrop of continually changing external environments; 3) The inherent tension between embracing innovative co-design and achieving delivery at pace and at scale ; 4) The effects of branding and marketing issues in consumer healthcare settings; and 5) The challenge of interoperability and information governance, when commercial proprietary models are dominant.

Conclusions The magnitude and ambition of the dallas program provides a unique opportunity to investigate the macro level implementation challenges faced when designing and delivering digital health and wellness services at scale. Flexibility, adaptability, and resilience are key implementation facilitators when shifting to new digitally enabled models of care.

Guidelines and training initiatives that support communication in cross-cultural primary-care settings: appraising their implementability using Normalization Process Theory

BACKGROUND

Guidelines and training initiatives (G/TIs) available to support communication in cross-cultural primary health care consultations are not routinely used. We need to understand more about levers and barriers to their implementation and identify G/TIs likely to be successfully implemented in practice.

OBJECTIVE

To report a mapping process used to identify G/TIs and to prospectively appraise their implementability, using Normalization Process Theory (NPT).

METHODS

RESTORE is a 4-year EU FP-7 project. We used purposeful and network sampling to identify experts in statutory and non-statutory agencies across Austria, England, Greece, Ireland, Scotland and the Netherlands who recommended G/TI data from the grey literature. In addition, a peer review of literature was conducted in each country. Resulting data were collated using a standardized Protocol Mapping Document. G/TIs were identified for inclusion by (i) initial elimination of incomplete G/TI material; (ii) application of filtering criteria; and (iii) application of NPT.

RESULTS

20 G/TIs met selection criteria: 8 guidelines and 12 training initiatives. Most G/TIs were identified in the Netherlands (n = 7), followed by Ireland (n = 6) and England (n = 5). Fewer were identified in Scotland (n = 2), and none in Greece or Austria. The majority (n = 13) were generated without the inclusion of migrant service users. All 20 were prospectively appraised for potential implementability by applying NPT.

CONCLUSIONS

NPT is useful as a means of prospectively testing G/TIs for implementability. Results indicate a need to initiate meaningful engagement of migrants in the development of G/TIs. A European-based professional standard for development and assessment of cross-cultural communication resources is advised.

Interventions targeted at primary care practitioners to improve the identification and referral of patients with co-morbid obesity: a realist review protocol

BACKGROUND

Obesity is one of the most significant public health challenges in the developed world. Recent policy has suggested that more can be done in primary care to support adults with obesity. In particular, general practitioners (GPs) and practice nurses (PNs) could improve the identification and referral of adults with obesity to appropriate weight management services. Previous interventions targeted at primary care practitioners in this area have had mixed results, suggesting a more complex interplay between patients, practitioners, and systems. The objectives of this review are (i) to identify the underlying 'programme theory' of interventions targeted at primary care practitioners to improve the identification and referral of adults with obesity and (ii) to explore how and why GPs and PNs identify and refer individuals with obesity, particularly in the context of weight-related co-morbidity. This protocol will explain the rationale for using a realist review approach and outline the key steps in this process.

METHODS

Realist review is a theory-led approach to knowledge synthesis that provides an explanatory analysis aimed at discerning what works, for whom, in what circumstances, how, and why. In this review, scoping interviews with key stakeholders involved in the planning and delivery of adult weight management services in Scotland helped to inform the identification of formal theories - from psychology, sociology, and implementation science - that will be tested as the review progresses. A comprehensive search strategy is described, including scope for iterative searching. Data analysis is outlined in three stages (describing context-mechanism-outcome configurations, exploring patterns in these configurations, and developing and testing middle-range theories, informed by the formal theories previously identified), culminating in the production of explanatory programme theory that considers individual, interpersonal, and institutional/systems-level components.

DISCUSSION

This is the first realist review that we are aware of looking at interventions targeted at primary care practitioners to improve the weight management of adults with obesity. Engagement with stakeholders at an early stage is a unique feature of realist review. This shapes the scope of the review, identification of candidate theories and dissemination strategies. The findings of this review will inform policy and future interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014009391.

What is the 'problem' that outreach work seeks to address and how might it be tackled? Seeking theory in a primary health prevention programme

BACKGROUND

Preventive approaches to health are disproportionately accessed by the more affluent and recent health improvement policy advocates the use of targeted preventive primary care to reduce risk factors in poorer individuals and communities. Outreach has become part of the health service response. Outreach has a long history of engaging those who do not otherwise access services. It has, however, been described as eclectic in its purpose, clientele and mode of practice; its effectiveness is unproven.Using a primary prevention programme in the UK as a case, this paper addresses two research questions: what are the perceived problems of non-engagement that outreach aims to address; and, what specific mechanisms of outreach are hypothesised to tackle these.

METHODS

Drawing on a wider programme evaluation, the study undertook qualitative interviews with strategically selected health-care professionals. The analysis was thematically guided by the concept of 'candidacy' which theorises the dynamic process through which services and individuals negotiate appropriate service use.

RESULTS

The study identified seven types of engagement 'problem' and corresponding solutions. These 'problems' lie on a continuum of complexity in terms of the challenges they present to primary care. Reasons for non-engagement are congruent with the concept of 'candidacy' but point to ways in which it can be expanded.

CONCLUSIONS

The paper draws conclusions about the role of outreach in contributing to the implementation of inequalities focused primary prevention and identifies further research needed in the theoretical development of both outreach as an approach and candidacy as a conceptual framework.