Challenges and solutions: surveying researchers on what type of community engagement and involvement activities are feasible in low and middle income countries during the COVID-19 pandemic

OBJECTIVES

Measures to limit the spread of infection during the COVID-19 global pandemic have made engaging and involving members of the community in global health research more challenging. This research aimed to explore how global health researchers adapted to the imposed pandemic measures in low and middle income countries (LMICs) and how they overcame challenges to effective community engagement and involvement (CEI).

DESIGN

A qualitative two-stage mixed-methods study involving an online survey and a virtual round table.

SETTING

The survey and round table were completed online.

PARTICIPANTS

Of 53 participants, 43 were LMIC-based or UK-based global health researchers and/or CEI professionals, and 10 worked for the National Institute for Health Research or UK Government's Department of Health and Social Care.

OUTCOME MEASURES

This study aimed to capture data on: the number of CEI activities halted and adapted because of the COVID-19 pandemic; where CEI is possible; how it has been adapted; what the challenges and successes were; and the potential impact of adapted or halted CEI on global health research.

RESULTS

Pandemic control measures forced the majority of researchers to stop or amend their planned CEI activities. Most face-to-face CEI activities were replaced with remote methods, such as online communication. Virtual engagement enabled researchers to maintain already established relationships with community members, but was less effective when developing new relationships or addressing challenges around the inclusion of marginalised community groups.

CONCLUSIONS

COVID-19 has highlighted the need for contingency planning and flexibility in CEI. The redesigning and adopting of remote methods has come with both advantages and disadvantages, and required new skills, access to technology, funding, reliable services and enthusiasm from stakeholders. The methods suggested have the potential to augment or substitute previously preferred CEI activities. The effectiveness and impact of these remote CEI activities need to be assessed.

The introduction of integrated out-of-hours arrangements in England: a discrete choice experiment of public preferences for alternative models of care

OBJECTIVE

To establish which generic attributes of general practice out-of-hours health services are important to the public.

METHODS

A discrete choice experiment postal survey conducted in three English general practitioner (GP) co-operatives. A total of 871 individuals aged 20-70 years registered with a GP. Outcomes were preferences for, and trade-offs between: time to making initial contact, time waiting for advice/treatment, informed of expected waiting time, type of contact, professional providing advice, chance contact relieves anxiety, and utility estimates for valuing current models of care.

RESULTS

Response rate was 37%. Respondents valued out-of-hours contact for services for reducing anxiety but this was not the only attribute of importance. They had preferences for the way in which services were organized and valued information about expected waiting time, supporting findings from elsewhere. Participants were most willing to make trade-offs between waiting time and professional person. Of the predicted utility for three models of care utility was higher for fully integrated call management.

CONCLUSIONS

Greater utility might be achieved if existing services are re-configured more in line with the government's fully integrated call management model. Because the attributes were described in generic terms, the findings can be applied more generally to the plethora of models that exist (and many that might exist in the future). The approach used is important for achieving greater public involvement in how health services develop. Few experiments have elicited public preferences for health services in the UK to date. This study showed valid preferences were expressed but there were problems obtaining representative views from the public.

An analysis of the skin care patient mix attending a primary care-based nurse-led NHS Walk-in Centre

BACKGROUND

NHS Walk-in Centres (WiCs) are a new and expanding point of nurse-led primary care access for patients requiring skin care. Little is known about the dermatology case profile of such patients.

OBJECTIVES

To investigate the skin care patient mix attending a WiC and the feasibility and usefulness of retrieving data from the NHS Clinical Assessment System (CAS), as used by NHS Direct.

METHODS

Patients over 2 years of age presenting to a WiC in southern England with a nurse-assessed skin condition were recruited over a 12-week period (n = 233). A data set was extracted from CAS and analysed using Excel.

RESULTS

Of the total 31 591 patients attending the WiC in the first 2 years, 21% had a skin-related problem. During the 12-week study period, 88 of 233 eligible patients (38%) consented to participate. The typical patient profile was of female patients, 17-35 years (27%) attending during the week before 9 a.m. (35%) or after 5 p.m. (27%) from the locality (72%). CAS employs generic algorithms to specify clinical problems (e.g. rash) rather than medical diagnoses. Most patients presented with a rash (89%). No physical treatment was required in 77% of patients, although this was advised for 46%; 49% were advised to seek help but not return to the WiC; 16% were recommended to contact their general practitioner. There were practical difficulties accessing data from CAS software for research due to research governance requirements.

CONCLUSIONS

A significant number of patients with dermatological conditions could be seeking primary care through new NHS WiCs. Detailed dermatological appraisal of the patient mix is difficult due to the system of clinical categorization. There is scope to investigate further the nature of dermatological need and the patient education given. CAS is a cumbersome data extraction tool for research.

Effect of introduction of integrated out of hours care in England: observational study

OBJECTIVES

To quantify service integration achieved in the national exemplar programme for single call access to out of hours care through NHS Direct, and its effect on the wider health system.

DESIGN

Observational before and after study of demand, activity, and trends in the use of other health services.

PARTICIPANTS

34 general practice cooperatives with NHS Direct partners (exemplars): four were case exemplars; 10 control cooperatives.

SETTING

England.

MAIN OUTCOME MEASURES

Extent of integration; changes in demand, activity, and trends in emergency ambulance transports; attendances at emergency departments, minor injuries units, and NHS walk-in centres; and emergency admissions to hospital in the first year.

RESULTS

Of 31 distinct exemplars, 21 (68%) integrated all out of hours call management. Nine (29%) achieved single call access for all patients. In the only case exemplar where direct comparison was possible, a higher proportion of telephone calls were handled by cooperative nurses before integration than by NHS Direct afterwards (2622/6687 (39%) v 2092/7086 (30%): P < 0.0001). Other case exemplars did not achieve 30%. A small but significant downturn in overall demand for care seen in two case exemplars was also seen in the control cooperatives. The number of emergency ambulance transports increased in three of the four case exemplars after integration, reaching statistical significance in two (5%, -0.02% to 10%, P = 0.06; 6%, 1% to 12%, P = 0.02; 7%, 3% to 12%, P = 0.001). This was always accompanied by a significant reduction in the number of calls to the integrated service.

CONCLUSION

Most exemplars achieved integration of call management but not single call access for patients. Most patients made at least two telephone calls to contact NHS Direct, and then waited for a nurse to call back. Evidence for transfer of demand from case exemplars to 999 ambulance services may be amenable to change, but NHS Direct may not have sufficient capacity to support national implementation of the programme.

Infant immunization and family size

BACKGROUND

To investigate whether a delay in infant immunization is associated with the number of older siblings.

METHODS

A cohort analysis of cumulative immunization uptake in 616 children aged 1-4 years recruited for a case-control study of atopic dermatitis in Norwich, UK was performed. The main outcome measures were the age of third pertussis and MMR immunizations. Delayed immunization was defined as a pertussis immunization age 6 months or greater, and MMR immunization aged 16 months or greater.

RESULTS

Having a larger number of older siblings was associated with a delay in pertussis immunization (6.2 per cent for children with no older siblings versus 23.3 per cent for children with two or more older siblings), but not in MMR immunization.

CONCLUSION

Infants with older siblings are at greater risk of pertussis infection from intrafamilial contagion yet are less likely to be immunized on time.

Atopic dermatitis and the hygiene hypothesis: a case-control study

BACKGROUND

The notion that lack of exposure to infection in early life leads to development of atopic disease has come to be known as the hygiene hypothesis. It has arisen from observations of the rapidly rising prevalence of atopic diseases in recent decades and the lower prevalence of atopy with rising birth order. Direct evidence for the hypothesis to date is inconsistent.

METHODS

A case-control study set in Norfolk, UK of 602 children aged 1-5 years. Cases and controls were defined using the UK Diagnostic Criteria for atopic dermatitis (AD) and a range of direct and indirect methods were used to measure exposure to infection during infancy. Odds ratios (OR) for the effect of these measures were calculated using logistic regression with adjustment for possible biological and social confounding factors.

RESULTS

Reduced odds of AD were associated with rising birth order (OR for one older sibling 0.59, 95% CI: 0.42, 0.84 and for >or=2 older siblings 0.49, 95% CI: 0.31, 0.77). None of the measures of infection reduced the odds of AD significantly, either in the unadjusted or adjusted analyses. None of the measures of infection explained the protective effect of older siblings.

CONCLUSIONS

Increased exposure to infection does not explain the reduced risk of AD in second and subsequent siblings. More generally, these data cast doubt on the hygiene hypothesis as a causal explanation for AD in young children.

What criteria do patients use when judging the effectiveness of psoriasis management?

Judgements on the effectiveness of psoriasis management are based on clinical criteria employed by dermatologists, and how they take account of patients' experiences in the process of history taking. In this study the aim was to gain the in-depth patients' perspective and investigate the criteria that they employ when making judgements about the effectiveness of their therapy. These findings were then compared with the clinical and research literature on the clinical effectiveness of psoriasis treatments. The study design is exploratory-descriptive, using a qualitative ethnographic approach. In-depth interviews were undertaken in an outpatient department dermatology clinic. A purposive sample of 20 adult patients currently attending represented the following types of psoriasis: guttate, chronic plaque and scalp. A key comparable finding between the literature and the interview data is that dermatologists emphasize observable criteria of effectiveness, such as clearance of the lesion, whereas patients emphasis focuses on the subjective concerns, such as suppleness, softness and alleviation of itch. This discrepancy needs to be considered during history taking, in relation to its impact on therapy concordance and in the use and development of outcome measures used for clinical assessment and evaluations of psoriasis therapy.

The recruitment and training crisis in community paediatrics: what do registrars think?

OBJECTIVE

There is currently a crisis in the recruitment of trainees into community paediatrics. Focus groups were conducted to explore the views of paediatric specialist registrars about this crisis.

DESIGN

A total of 18 registrars participated in two focus groups. Data were analysed qualitatively by content analysis.

RESULTS

The overriding theme was the poor status and image of community compared with acute paediatrics. This existed at five levels, which could be arranged from a 'macro' structural level down to a 'micro' individual level. These were: the hospital/community divide, issues related to training, practical experience, the influence of role models, and personal factors.

CONCLUSIONS

We identified several specific implications for community paediatric training. However, the deep divide between acute and community paediatrics, as perceived by registrars, is unlikely to change unless training programmes are designed to produce paediatricians suited to the needs of future child health services rather than existing models of acute and community paediatricians.

Development and evaluation of an antibody capture ELISA for detection of IgG to Epstein-Barr virus in oral fluid samples

The development of an EBV IgG antibody capture ELISA (GACELISA) for detection of EBV viral capsid antigen specific IgG in oral fluids is described. The assay was optimised and evaluated using paired serum and oral fluid samples from healthy laboratory staff (n=82) and oral fluids collected either for routine measles, mumps, and rubella testing (n=629) or for an epidemiological study of atopic dermatitis (n=252). Statistical analysis by mixture modelling was used to determine the GACELISA cut-off and to estimate the sensitivity and specificity of the assay. Sensitivity and specificity was also assessed by comparing the results of immunofluorescence assay for EBV specific IgG in serum with those of GACELISA in 82 matching oral fluids. Compared to serum immunofluorescence assay, oral fluid GACELISA was found to have a sensitivity of 82.2 and 88.9% specificity with these samples. Mixture modelling, predicted the GACELISA to be 88.4% sensitive and of 99.4% specific. The prevalence of antibody to EBV in oral fluids was found to be 73.8% in laboratory staff, 34.4--73.9% in measles, mumps, and rubella patients and 22.2% in atopic dermatitis study participants. A robust, reliable and reproducible EBV GACELISA has been developed which will be a useful tool for epidemiological investigations.