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Abstract Background Policymakers across countries promote cross-sector collaboration as a route to improving health and health equity. In England, major health system reforms in 2022 established 42 integrated care systems (ICSs)—area-based partnerships between health care, social care, public health, and other sectors—to plan and coordinate local services. ICSs cover the whole of England and have been given explicit policy objectives to reduce health inequalities, alongside other national priorities. Methods We used qualitative methods to understand how local health care and social services organizations are collaborating to reduce health inequalities under England’s reforms. We conducted in-depth interviews between August and December 2022—soon after the reforms were implemented—with 32 senior leaders from NHS, social care, public health, and community-based organizations in three ICSs experiencing high levels of socioeconomic deprivation. We used a framework based on international evidence on cross-sector collaboration to help analyse the data. Results Leaders described strong commitment to working together to reduce health inequalities, but faced a combination of conceptual, cultural, capacity, and other challenges in doing so. A mix of factors shaped local collaboration—from how national policy aims are defined and understood, to the resources and relationships among local organizations to deliver them. These factors interact and have varying influence. The national policy context played a dominant role in shaping local collaboration experiences—frequently making it harder not easier. Organizational restructuring to establish ICSs also caused major disruption, with unintended effects on the partnership working it aimed to promote. Conclusions The major influences on cross-sector collaboration in England mirror key areas identified in international research, offering opportunities for learning between countries. But our data highlight the pervasive—frequently perverse—influence of national policy on local collaboration in England. National policymakers risked undermining their own reforms. Closer alignment between policy, process, and resources to reduce health inequalities is likely needed to avoid policy failure as ICSs evolve.

Background Within outpatient services, a broad range of innovations are being pursued to better manage care and reduce unnecessary appointments. One of the least-studied innovations is Patient-Initiated Follow-Up, which allows patients to book appointments if and when they need them, rather than follow a standard schedule. Objectives To use routine national hospital data to identify innovations in outpatient services implemented, in recent years, within the National Health Service in England. To carry out a rapid mixed-methods evaluation of the implementation and impact of Patient-Initiated Follow-Up. Methods The project was carried out in four sequential workstreams: (1) a rapid scoping review of outpatient innovations; (2) the application of indicator saturation methodology for scanning national patient-level data to identify potentially successful local interventions; (3) interviews with hospitals identified in workstream 2; and (4) a rapid mixed-methods evaluation of Patient-Initiated Follow-Up. The evaluation of Patient-Initiated Follow-Up comprised an evidence review, interviews with 36 clinical and operational staff at 5 National Health Service acute trusts, a workshop with staff from 13 National Health Service acute trusts, interviews with four patients, analysis of national and local data, and development of an evaluation guide. Results Using indicator saturation, we identified nine services with notable changes in follow-up to first attendance ratios. Of three sites interviewed, two queried the data findings and one attributed the change to a clinical assessment service. Models of Patient-Initiated Follow-Up varied widely between hospital and clinical specialty, with a significant degree of variation in the approach to patient selection, patient monitoring and discharge. The success of implementation was dependent on several factors, for example, clinical condition, staff capacity and information technology systems. From the analysis of national data, we found evidence of an association between greater use of Patient-Initiated Follow-Up and a lower frequency of outpatient attendance within 15 out of 29 specialties and higher frequency of outpatient attendance within 7 specialties. Four specialties had less frequent emergency department visits associated with increasing Patient-Initiated Follow-Up rates. Patient-Initiated Follow-Up was viewed by staff and the few patients we interviewed as a positive intervention, although there was varied impact on individual staff roles and workload. It is important that sites and services undertake their own evaluations of Patient-Initiated Follow-Up. To this end we have developed an evaluation guide to support trusts with data collection and methods. Limitations The Patient-Initiated Follow-Up evaluation was affected by a lack of patient-level data showing who is on a Patient-Initiated Follow-Up pathway. Engagement with local services was also challenging, given the pressures facing sites and staff. Patient recruitment was low, which affected the ability to understand experiences of patients directly. Conclusions The study provides useful insights into the evolving national outpatient transformation policy and for local practice. Patient-Initiated Follow-Up is often perceived as a positive intervention for staff and patients, but the impact on individual outcomes, health inequalities, wider patient experience, workload and capacity is still uncertain. Future research Further research should include patient-level analysis to determine clinical outcomes for individual patients on Patient-Initiated Follow-Up and health inequalities, and more extensive investigation of patient experiences. Study registration This study is registered with the Research Registry (UIN: researchregistry8864). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/17) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 38. See the NIHR Funding and Awards website for further award information. Plain language summary When someone visits hospital for an operation or an ongoing condition, they are given follow-up appointments at clinics, often after 6 months. The National Health Service thinks that many of these appointments are not necessary because they are not useful to patients. Also, outside fixed appointments, patients are not always being seen when they are most in need. Hospitals have been testing new ways to improve services. We looked at hospital data and discussed interesting findings with hospitals themselves to see if we could find approaches that worked. We then looked at one new approach called Patient-Initiated Follow-Up. Patients using Patient-Initiated Follow-Up can book appointments when they are needed, rather than at a pre-planned time. We explored how Patient-Initiated Follow-Up was being used in hospitals, what effect it was having and what patients and National Health Service staff thought about it. We studied hospital data and interviewed patients and National Health Service staff. We found that Patient-Initiated Follow-Up works differently depending on the hospital and the patient’s condition. Patient-Initiated Follow-Up is most frequently used for patients needing short-term follow-up, such as after an operation. It is also starting to be used for patients with long-term chronic conditions. National Health Service staff think that Patient-Initiated Follow-Up can benefit patients, although some may find it easier to use than others. Patients appear to like Patient-Initiated Follow-Up, but some still prefer to let the hospital schedule appointments. From data it appears that for some conditions, where more patients use Patient-Initiated Follow-Up, fewer follow-up visits are required. For a few conditions, there is evidence of fewer emergency department visits, but the overall impact is small. We interviewed staff from a small number of hospitals and four patients, so what we found may not apply across the National Health Service. We also developed a guide to help hospitals evaluate the success of their own Patient-Initiated Follow-Up services. Scientific summary Background The number of outpatient attendances in the UK has increased in recent years, outstripping population growth and unmatched by comparable increases in workforce or capacity. Improving the value of outpatient care has therefore become a key priority for the NHS in England, which aimed to reduce follow-up outpatient attendances by 25% from 2019 to 2020 levels by March 2024. Across the outpatient care pathway, a broad range of innovations are being pursued to better manage outpatient care and reduce unnecessary appointments. The NHS also aims to link such innovations to a more patient-centred service by making better use of primary, secondary, and community services and helping people to manage their own health. However, there is limited understanding of which interventions are effective and what factors contribute to their success. We aimed to devise a methodology for using data to identify potentially successful innovations in outpatient services and to select up to two for more in-depth evaluation. The innovation we chose was Patient-Initiated Follow-Up (PIFU) because it was not well studied, was becoming widely implemented across the NHS and NHS England were interested in it being evaluated, with findings informing the evolving outpatient transformation policy. With PIFU, patients can make their own follow-up appointments when they need them rather than be called back at pre-planned times (e.g. every 6 months). The intention is that follow-up appointments become more clinically valuable by increasing the chances that patients are seen at the right time. However, when we began the evaluation, it was little known what impact PIFU would have on patient outcomes, service resources, and patient and staff experience. Objectives This study aimed to identify innovations in outpatient services implemented in recent years in the English NHS and to carry out a rapid evaluation of PIFU. The study was divided into four sequential workstreams with the following aims: To understand the scope and breadth of interventions being pursued to improve efficiency in outpatient service delivery, and to understand key evidence gaps and research needs. To identify trusts and/or specialties where there is quantitative evidence of a positive change to outpatient activity, for example, a reduction in the numbers of attendances or a substitution between different modes of attendance (e.g. from face-to-face consultation to teleconsultation). To undertake interviews of selected trusts and specialties identified in workstream 2. To investigate whether changes in their outpatient activity were the result of specific innovations in care management. To conduct a mixed-methods evaluation of PIFU, considering its implementation, impact, and the experiences of patients and staff. Methods The project was supported throughout by an advisory group and patient and public involvement representatives. The approaches we used within each workstream were as follows: Workstream 1: scoping review of innovations We adopted an evidence-mapping approach and a literature search to understand the extent to which different outpatient service innovations have been studied and the potential benefits they evaluated. Data were synthesised narratively by type of intervention and their anticipated benefit using a pre-specified framework. The results of this review would inform the choice of innovation to evaluate in workstream 4. Workstream 2: identifying innovations using routine hospital data We developed a methodology to scan routine hospital outpatient data to identify notable positive changes in activity measures. We applied a modelling approach called indicator saturation (IS) to multiple time series extracted from the data. These time series covered a range of clinical specialties within hospital trusts. Four outpatient activity measures were selected where changes might have indicated the impact of a service change or innovation. We built a series of metrics to define the scale and other characteristics of positive changes detected within the time series. Combining these, we ranked all time series to identify those most likely to show the impact of an active service change, or innovation. While this work began with a general focus (with any type of service change in scope), we adapted the methods to support the evaluation of PIFU by focusing on a single activity measure: the ratio of follow-up to first attendances. Workstream 3: interviews with trusts We invited services to be interviewed about recent notable falls in the ratio of follow-up to first attendances. Interviewees were presented with details of the findings and were asked to reflect on any service changes that may have driven the changes. Workstream 4: evaluation of Patient-Initiated Follow-Up Workstream 4 was a rapid mixed-methods evaluation of PIFU conducted across two phases with a preliminary scoping review intended to both provide a context for and inform the rest of the evaluation. For the review, we adopted an evidence-mapping approach to understand what was already known about the impact of personalised follow-up initiatives on service use, patient experience, and outcomes. We included studies published between January 2015 and June 2022. Phase 1 was a 4-month evaluation using national data sets alongside interviews with local and national stakeholders. The qualitative aspects focused on how PIFU was being implemented within specialties where it was most established. We analysed national data to assess the impact of implementing PIFU on a range of outcomes relating to a patient’s use of hospital services. Phase 2 built on the insights from phase 1 and consisted of interviews with patients and staff, and a workshop to discuss factors affecting PIFU uptake. Compared to phase 1, the purpose was to investigate issues in greater depth and across a wider range of specialties and conditions. We also undertook further quantitative analysis of both local and national data. Finally, we developed an evaluation guide to support ongoing evaluation of local PIFU services. For both phases we adopted a sampling framework for selecting study sites to achieve a balance across a range of variables relating to the type of hospital, and the local geography and population. Staff for interviews were selected through a purposive approach which evolved into convenience sampling due to the availability of staff. Results Scoping review of innovations The scoping review found a variety of innovations in outpatient care that have been evaluated within different health systems. Some of these include changing how appointments are delivered (e.g. teleconsultations), new administration and support systems, specialised support for primary care and personalised follow-up. The purposes of these innovations were grouped into three main areas, for making booking systems more efficient, for optimising use of resources and for improving the clinical value of follow-up appointments. Virtual appointments and administration and scheduling systems are the most evaluated innovations, and only a few studies investigated personalised follow-up. Identifying and investigating innovations using routine hospital data We successfully applied IS modelling to over 20,000 time series of outpatient activity measures. We selected nine services for further investigation and invited relevant staff for interview. Of these, three were interviewed. Two services did not recognise the data findings and had no explanation for the apparent improvements we found. The third recognised the findings and attributed the change to a clinical assessment service. A fourth (not interviewed) identified the change as having been connected to a change in medication use. Evaluation of Patient-Initiated Follow-Up Evidence review We found little evidence on how PIFU is being implemented in the NHS and its impact on staff, patients, and services. Where it had been researched, there was some evidence that PIFU might result in fewer overall outpatient appointments compared with fixed appointment schedules, although results were variable and most studies were of low quality. There was little evidence that PIFU affects patient satisfaction, quality of life, or clinical outcomes. The impact on the wider health services and costs were not well studied. Sites and participants We conducted semistructured interviews with 36 clinical and operational staff based in 5 case study sites and 4 patients. The workshop included 22 staff from a further 13 NHS trusts. Implementation of Patient-Initiated Follow-Up By early 2023, approximately 180,000 patients a month were recorded as being put onto a PIFU pathway. PIFU is most commonly being used in short-term pathways (e.g. physiotherapy or following surgery), although there are examples where it is being used for people with long-term conditions. Models of PIFU vary widely across trusts and clinical area, with a significant degree of variation in patient selection, monitoring, and discharge. The nature of a patient’s condition was a key factor in how it was implemented. Where PIFU had been implemented successfully, enablers included conditions where symptoms and deterioration were easy to identify, clinical engagement, supporting guidance, champions, dedicated staff capacity and flexible recording systems. Barriers to implementation included patients not being aware they were on PIFU, staff resistance, competing priorities and limited capacity to dedicate to PIFU, a lack of engagement with primary care and challenges amending electronic patient record systems to record PIFU activity. Staff saw several opportunities for PIFU, including supporting their service to become more efficient and patient-centred. They also saw opportunities for wider adoption of the innovation, and better use of technology to facilitate delivery. However, staff also pointed to several risks with PIFU, especially where patients do not or cannot access the service when they should. They also raised risks for service capacity within and beyond outpatient departments. Impact of Patient-Initiated Follow-Up on outpatient and emergency department attendance Increasing PIFU rates were associated with less frequent outpatient attendance and rates of patient non-attendance [‘did not attend’ (DNA)], particularly within certain clinical specialties. However, within some specialties increased PIFU rates were associated with more frequent visits. This complemented findings from interviews with staff and from the workshop in that the variety of ways PIFU is implemented can lead to different impacts. We found no practically significant association between PIFU rates and frequency of emergency department (ED) visits overall (results were statistically significant, but of negligible effect size), but a small number of specialties appeared to have increasing PIFU rates associated with less frequent ED visits. Staff at study sites described limitations of their PIFU data for monitoring their outcomes. Moreover, existing data is not currently able to capture wider consequences, such as the impact on primary care. The study’s findings need to be interpreted with the understanding that we used aggregated PIFU data as available data does not currently record which patients are on PIFU pathways. There is also some uncertainty about the completeness of the available PIFU data. Health inequalities There was limited understanding of the impact of PIFU on different patient groups, and staff recognised this as a concern. Digital exclusion, demographic characteristics, socioeconomic status and patient characteristics were all thought to be relevant to how patients engage with or are impacted by PIFU. Some staff were concerned that PIFU could exacerbate inequalities because those with greater individual motivation and ability to advocate for themselves would be more able or willing to initiate contact when they needed. However, some services have used PIFU for engaging with patients who were more likely to miss appointments by enabling them to contact the service at a time that was convenient for them. Staff experiences of Patient-Initiated Follow-Up In most cases, PIFU was viewed by staff as a positive intervention to support patient autonomy and self-management and ensure that time was directed towards those patients with the greatest clinical need. Views on the impact of PIFU on individual staff roles and workload were mixed, and dependent on the extent to which PIFU was used routinely within the service, the nature of the pathway and extent to which PIFU was considered a departure from previous ways of working. Patient experiences of Patient-Initiated Follow-Up Across the case study sites, limited activity had taken place to capture formal feedback from patients, although staff reported that patients were positive about PIFU as an approach and the support they received. Reasons for patients declining PIFU included a preference for regular interaction, a desire to stick to their routine, and a concern that they would be unable to get an appointment when needed. Patients we spoke to were positive about their experiences and liked having the option to contact a specialist when they needed to. Enablers to patient engagement include clear avenues of access and support, communication and ensuring patients do not feel abandoned by the service. Barriers to patient engagement included a lack of awareness and understanding about PIFU, the wider context on access to services and factors related to specific conditions. Evaluation guide We developed a guide to support teams to evaluate the outcomes and impacts of their PIFU services at a specialty level, thus helping address research gaps and encouraging shared learning. Limitations We were unable to develop a reliable methodology to rank time series across multiple outpatient activity measures to identify those most likely to show the impact of a service change. The final selection of changes in performance most likely to be connected to implementation of PIFU required more manual researcher input than anticipated, and the results of a small number of interviews with selected hospitals were variable. Conducting a rapid study of an intervention which was still being rolled out alongside other interventions, where data were limited and when there were significant pressures on NHS staff capacity, introduced considerable challenges. Consequently, the sample sizes for hospital sites, staff and patients were small. Owing to this, the qualitative findings cannot be assumed to be representative of the national picture, although they provide valuable insights into the use of PIFU in outpatient services. Due to the lack of quantitative data on outcomes, we have focused the analyses of the impact of PIFU on changes in outpatient activity and ED attendance and have not been able to use more patient-focused measures. Conclusions With many initiatives being undertaken in NHS hospitals and for different clinical conditions, distinguishing those that provide benefits for outpatient care can be a formidable task. We have found that the implementation of PIFU is associated with significant reductions in the frequency of outpatient attendances and DNAs in some specialties and significant increases in a smaller number of others. However, we do not know if these relationships are all due to PIFU and, because of the available data, have not been able to measure impacts on those specific individuals who are put onto PIFU pathways. Many of the findings have implications for the organisation of outpatient services at a national and local level. These include ensuring PIFU guidance is tailored to specialties or conditions and ensuring communication about PIFU, and its purpose is clear, consistent and accessible to both staff and patients. PIFU is generally perceived as a positive intervention for staff and patients but the impact on individual outcomes, health inequalities, wider patient experience, workload and capacity is still uncertain. Recommendations for research Data collection should include more meaningful patient outcomes and health inequalities alongside patient experiences and impact on staff workload. More research should be conducted on the views and experiences of patients and staff relating to PIFU, particularly with staff in clinical specialties not covered by our own evaluation. More research is needed to understand how PIFU interacts with other outpatient interventions and the wider health and social care system. National data sets could be better used to scan for exceptional changes in relation to outpatient care, combining this with fieldwork to identify whether these correspond to specific innovations. Study registration This study is registered with the Research Registry (UIN: researchregistry8864). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/17) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 38. See the NIHR Funding and Awards website for further award information.

Abstract Introduction Menstrual health in humanitarian contexts is a neglected topic. Its taboo nature presents difficulties for participants in menstrual health projects in these particularly challenging settings. Namely, their experiences may be concealed or overlooked in projects that are typically outcome focused. Realist Evaluation is a useful method to unearth and explore the hidden mechanisms and their causes, which lead to positive or negative participant experiences. The authors have applied this approach to a robust humanitarian menstrual health project to explore how to centre the emotional wellbeing of participants at all stages: prior to, during, and post-participation. Study setting The project studied was led by the International Federation of Red Cross and Red Crescent Societies who piloted their adaptable manual for menstruator–friendly water, sanitation and hygiene (WaSH) facility design in humanitarian contexts. It was conducted by the Lebanese Red Cross in an informal tented settlement hosting Syrian refugees in Qaa, Lebanon. Methods The authors collected interview and focus group data on the contextual factors and processes within the project from nine project staff and 16 settlement inhabitants. They used a realist process of theory development, testing, and consolidation to understand how and under what circumstances the project inputs affected participants’ wellbeing. Results The contextual factors and causal mechanisms promoting participant experience comprised individual (choices influencing and experience during participation), interpersonal (group dynamics and the role of non-menstruators), and organisational (expertise and knowledge, relationship to participants and cultural differences) factors. Implications The research uses a case study from a renowned humanitarian organisation who provided a well-delivered project in a conducive environment to explore the mechanisms and contexts that can promote wider learning and refine understanding and programming in this under-researched and -theorised space. Specifically, it informs which contextual factors and project inputs must be present within a menstrual health project to ensure participant satisfaction whilst efficiently delivering well-designed menstruator-friendly WaSH facilities.

Abstract Background The COVID‐19 pandemic brought rapid and major changes to research, and those wishing to carry out Patient and Public Involvement (PPI) activities faced challenges, such as restrictions on movement and contact, illness, bereavement and risks to potential participants. Some researchers moved PPI to online settings during this time but remote consultations raise, as well as address, a number of challenges. It is important to learn from PPI undertaken in this period as face‐to‐face consultation may no longer be the dominant method for PPI. Methods UK stay‐at‐home measures announced in March 2020 necessitated immediate revisions to the intended face‐to‐face methods of PPI consultation for the ESORT Study, which evaluated emergency surgery for patients with common acute conditions. PPI plans and methods were modified to all components being online. We describe and reflect on: initial plans and adaptation; recruitment; training and preparation; implementation, contextualisation and interpretation. Through first‐hand accounts we show how the PPI processes were developed, experienced and viewed by different partners in the process. Discussion and Conclusions While concerns have been expressed about the possible limiting effects of forgoing face‐to‐face contact with PPI partners, we found important benefits from the altered dynamic of the online PPI environment. There were increased opportunities for participation which might encourage the involvement of a broader demographic, and unexpected benefits in that the online platform seemed to have a ‘democratising’ effect on the meetings, to the benefit of the PPI processes and outcomes. Other studies may however find that their particular research context raises particular challenges for the use of online methods, especially in relation to representation and inclusion, as new barriers to participation may be raised. It is important that methodological challenges are addressed, and researchers provide detailed examples of novel methods for discussion and empirical study. Patient and Public Contribution We report a process which involved people with lived experience of emergency conditions and members of the public. A patient member was involved in the design and implementation, and two patients with lived experience contributed to the manuscript.

Abstract Background There is limited evidence in the literature on the long-term effectiveness and cost-effectiveness of treatments for Acute Severe Ulcerative Colitis (ASUC). The study aimed to perform decision analytic model-based long-term cost-utility analysis (CUA) of infliximab versus ciclosporin for steroid-resistant ASUC investigated in CONSTRUCT pragmatic trial. Methods A decision tree (DT) model was developed using two-year health effect, resource use and costs data from CONSTRUCT trial to estimate relative cost-effectiveness of two competing drugs from the United Kingdom (UK) National Health Services (NHS) perspective. Using short-term trial data, a Markov model (MM) was then developed and evaluated over further 18 years. Both DT and MM were combined to investigate cost-effectiveness of infliximab versus ciclosporin for ASUC patients over 20-year time horizon, with a rigorous multiple deterministic and probabilistic sensitivity analyses to address uncertainty in results. Results The decision tree mirrored trial-based results. Beyond 2-year trial follow-up, Markov model predicted a decrease in colectomy rate, but it remained slightly higher for ciclosporin. NHS costs and quality adjusted life years (QALYs) over base-case 20 year time horizon were £26,793 and 9.816 for ciclosporin and £34,185 and 9.106 for infliximab, suggesting ciclosporin dominates infliximab. Ciclosporin had 95% probability of being cost-effective at a willingness-to-pay (WTP) threshold value up to £20,000. Conclusion Using data from a pragmatic RCT, the cost-effectiveness models produced incremental net health benefit in favour of ciclosporin relative to infliximab. Results from long-term modelling indicated that ciclosporin remains dominant compared with infliximab for the treatment of NHS ASUC patients, however, these need to be interpreted cautiously. Trial registration CONSTRUCT Trial registration number ISRCTN22663589; EudraCT number: 2008- 001968-36 (Date 27/08/2008).

BackgroundAs a response to the COVID-19 pandemic, the Sydney Local Health District in New South Wales, Australia, launched the rpavirtual program, the first full-scale virtual hospital in Australia, to remotely monitor and follow up stable patients with COVID-19. As part of the intervention, a pulse oximeter wearable device was delivered to patients to monitor their oxygen saturation levels, a critical indicator of COVID-19 patient deterioration. Understanding users’ perceptions toward the device is fundamental to assessing its usability and acceptability and contributing to the effectiveness of the intervention, but no research to date has explored the user experience of the pulse oximeter for remote monitoring in this setting. ObjectiveThis study aimed to explore the use, performance, and acceptability of the pulse oximeter by clinicians and patients in rpavirtual during COVID-19. MethodsSemistructured interviews and usability testing were conducted. Stable adult patients with COVID-19 (aged ≥18 years) who used the pulse oximeter and were monitored by rpavirtual, and rpavirtual clinicians monitoring these patients were interviewed. Clinicians could be nurses, doctors, or staff who were part of the team that assisted patients with the use of the pulse oximeter. Usability testing was conducted with patients who had the pulse oximeter when they were contacted. Interviews were coded using the Theoretical Framework of Acceptability. Usability testing was conducted using a think-aloud protocol. Data were collected until saturation was reached. ResultsTwenty-one patients (average age 51, SD 13 years) and 15 clinicians (average age 41, SD 11 years) completed the interview. Eight patients (average age 51, SD 13 years) completed the usability testing. All participants liked the device and thought it was easy to use. They also had a good understanding of how to use the device and the device’s purpose. Patients’ age and device use–related characteristics (eg, the warmth of hands and hand steadiness) were identified by users as factors negatively impacting the accurate use of the pulse oximeter. ConclusionsPatients and clinicians had very positive perceptions of the pulse oximeter for COVID-19 remote monitoring, indicating high acceptability and usability of the device. However, factors that may impact the accuracy of the device should be considered when delivering interventions using the pulse oximeter for remote monitoring. Targeted instructions about the use of the device may be necessary for specific populations (eg, older people and patients unfamiliar with technology). Further research should focus on the integration of the pulse oximeter data into electronic medical records for real-time and secure patient monitoring.

Abstract Background Reducing bullying is a public health priority. KiVa, a school-based anti-bullying programme, is effective in reducing bullying in Finland and requires rigorous testing in other countries, including the UK. This trial aims to test the effectiveness and cost-effectiveness of KiVa in reducing child reported bullying in UK schools compared to usual practice. The trial is currently on-going. Recruitment commenced in October 2019, however due to COVID-19 pandemic and resulting school closures was re-started in October 2020. Methods Design: Two-arm pragmatic multicentre cluster randomised controlled trial with an embedded process and cost-effectiveness evaluation. Participants: 116 primary schools from four areas; North Wales, West Midlands, South East and South West England. Outcomes will be assessed at student level (ages 7–11 years; n = approximately 13,000 students). Intervention: KiVa is a whole school programme with universal actions that places a strong emphasis on changing bystander behaviour alongside indicated actions that provide consistent strategies for dealing with incidents of bullying. KiVa will be implemented over one academic year. Comparator: Usual practice. Primary outcome: Student-level bullying-victimisation assessed through self-report using the extensively used and validated Olweus Bully/Victim questionnaire at baseline and 12-month follow-up. Secondary outcomes: student-level bullying-perpetration; student mental health and emotional well-being; student level of, and roles in, bullying; school related well-being; school attendance and academic attainment; and teachers’ self-efficacy in dealing with bullying, mental well-being, and burnout. Sample size: 116 schools (58 per arm) with an assumed ICC of 0.02 will provide 90% power to identify a relative reduction of 22% with a 5% significance level. Randomisation: recruited schools will be randomised on 1:1 basis stratified by Key-Stage 2 size and free school meal status. Process evaluation: assess implementation fidelity, identify influences on KiVa implementation, and examine intervention mechanisms. Economic evaluation: Self-reported victimisation, Child Health Utility 9D, Client Service Receipt Inventory, frequency of services used, and intervention costs. The health economic analysis will be conducted from a schools and societal perspective. Discussion This two-arm pragmatic multicentre cluster randomised controlled trial will evaluate the KiVa anti-bullying intervention to generate evidence of the effectiveness, cost-effectiveness and scalability of the programme in the UK. Our integrated process evaluation will assess implementation fidelity, identify influences on KiVa implementation across England and Wales and examine intervention mechanisms. The integrated health economic analysis will be conducted from a schools and societal perspective. Our trial will also provide evidence regarding the programme impact on inequalities by testing whether KiVa is effective across the socio-economic gradient. Trial registration Trials ISRCTN 12300853 Date assigned 11/02/2020.

Background: Evidence is required on the clinical effectiveness and cost-effectiveness of emergency surgery compared with non-emergency surgery strategies (including medical management, non-surgical procedures and elective surgery) for patients admitted to hospital with common acute gastrointestinal conditions. Objectives: We aimed to evaluate the relative (1) clinical effectiveness of two strategies (i.e. emergency surgery vs. non-emergency surgery strategies) for five common acute conditions presenting as emergency admissions; (2) cost-effectiveness for five common acute conditions presenting as emergency admissions; and (3) clinical effectiveness and cost-effectiveness of the alternative strategies for specific patient subgroups. Methods: The records of adults admitted as emergencies with acute appendicitis, cholelithiasis, diverticular disease, abdominal wall hernia or intestinal obstruction to 175 acute hospitals in England between 1 April 2010 and 31 December 2019 were extracted from Hospital Episode Statistics and linked to mortality data from the Office for National Statistics. Eligibility was determined using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis codes, which were agreed by clinical panel consensus. Patients having emergency surgery were identified from Office of Population Censuses and Surveys procedure codes. The study addressed the potential for unmeasured confounding with an instrumental variable design. The instrumental variable was each hospital’s propensity to use emergency surgery compared with non-emergency surgery strategies. The primary outcome was the ‘number of days alive and out of hospital’ at 90 days. We reported the relative effectiveness of the alternative strategies overall, and for prespecified subgroups (i.e. age, number of comorbidities and frailty level). The cost-effectiveness analyses used resource use and mortality from the linked data to derive estimates of incremental costs, quality-adjusted life-years and incremental net monetary benefits at 1 year. Results: Cohort sizes were as follows: 268,144 admissions with appendicitis, 240,977 admissions with cholelithiasis, 138,869 admissions with diverticular disease, 106,432 admissions with a hernia and 133,073 admissions with an intestinal obstruction. Overall, at 1 year, the average number of days alive and out of hospitals at 90 days, costs and quality-adjusted life-years were similar following either strategy, after adjusting for confounding. For each of the five conditions, overall, the 95% confidence intervals (CIs) around the incremental net monetary benefit estimates all included zero. For patients with severe frailty, emergency surgery led to a reduced number of days alive and out of hospital and was not cost-effective compared with non-emergency surgery, with incremental net monetary benefit estimates of –£18,727 (95% CI –£23,900 to –£13,600) for appendicitis, –£7700 (95% CI –£13,000 to –£2370) for cholelithiasis, –£9230 (95% CI –£24,300 to £5860) for diverticular disease, –£16,600 (95% CI –£21,100 to –£12,000) for hernias and –£19,300 (95% CI –£25,600 to –£13,000) for intestinal obstructions. For patients who were ‘fit’, emergency surgery was relatively cost-effective, with estimated incremental net monetary benefit estimates of £5180 (95% CI £684 to £9680) for diverticular disease, £2040 (95% CI £996 to £3090) for hernias, £7850 (95% CI £5020 to £10,700) for intestinal obstructions, £369 (95% CI –£728 to £1460) for appendicitis and £718 (95% CI £294 to £1140) for cholelithiasis. Public and patient involvement translation workshop participants emphasised that these findings should be made widely available to inform future decisions about surgery. Limitations: The instrumental variable approach did not eliminate the risk of confounding, and the acute hospital perspective excluded costs to other providers. Conclusions: Neither strategy was more cost-effective overall. For patients with severe frailty, non-emergency surgery strategies were relatively cost-effective. For patients who were fit, emergency surgery was more cost-effective. Future work: For patients with multiple long-term conditions, further research is required to assess the benefits and costs of emergency surgery. Study registration: This study is registered as reviewregistry784. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 1. See the NIHR Journals Library website for further project information.

Purpose: Rural hospital closures result in the loss of lifesaving acute care for rural residents and threaten the health of rural communities significantly. Understanding short- and longer-term effects nurses experiences related to a rural hospital closure can pose a unique challenge, as nurses may relocate and become difficult to identify. In this paper, the authors describe the strategies used during a pandemic to recruit and retain rural nurse research participants who experienced a rural hospital closure. Strategies presented may help nurse researchers recruit a unique and difficult-to-reach rural nurse population during a pandemic. Sample: The sample consisted of nurses who worked in a rural hospital that closed between 2014 to 2020 in one Southwestern state. Method: The authors describe multiple strategies used to recruit rural nurses such as public outreach, social media outreach, and personal outreach. Public outreach was used through professional organization email listservs and printed newspaper advertisements. Social media outreach included public posts online. Personal outreach to former rural hospital employees who were existing contacts was through personal social media messages, phone calls, and texts. Findings: The most effective method for recruitment and retention was personal outreach through rural hospital champions who sent personal messages using social media. The final sample included 10 nurses from two rural hospitals that closed. Five nurses reported about a hospital that closed in 2014, while five nurses reported about a hospital that closed in 2015. Conclusion: For successful recruitment, future researchers should use a direct, personal recruitment strategy to recruit and retain rural nurse research participants for studies about rural hospital closures. Other strategies for successful rural nurse recruitment for research include planning for an extended recruitment timeline, being flexible with participants regarding data collection procedures, cultivating research interest among rural nurses, and building a culture of research in rural settings. Keywords: rural, nursing, research, sampling, recruitment, hospital closure, COVID-19 DOI: https://doi.org/10.14574/ojrnhc.v21i2.682 Acknowledgements: Our study was supported by the Excellence in Research Award sponsored by the Texas Organization of Baccalaureate and Graduate Nursing Education (TOBGNE)

Abstract Background Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. If patients are not rescued and suffer a cardiac arrest as a result then only around 15% will survive. Track and Trigger systems have been introduced into the NHS to improve both identification and response to such patients. This study examines the association between the type of Track & Trigger System (TTS) (National Early Warning Score (NEWS) versus non-NEWS) and the mode of TTS (paper TTS versus electronic TTS) and incidence of in-hospital ward-based cardiac arrests (IHCA) attended by a resuscitation team. Methods TTS type and mode was retrospectively collected at hospital level from 106 NHS acute hospitals in England between 2009 to 2015 via an organisational survey. Poisson regression and logistic regression models, adjusted for case-mix, temporal trends and seasonality were used to determine the association between TTS and hospital-level ward-based IHCA and survival rates. Results The NEWS was introduced in England in 2012 and by 2015, three-fifths of hospitals had adopted it. One fifth of hospitals had instituted an electronic TTS by 2015. Between 2009 and 2015 the incidence of IHCA fell. Introduction or use of NEWS in a hospital was associated with a reduction of 9.4% in the rate of ward-based IHCA compared to non-NEWS systems (incidence rate ratio 0.906, p

A vast majority of COVID-19 cases present with mild or moderate symptoms. The study region is in an urban and well-defined environment in a low-incidence region in Northern Germany. In the present study, we explored the dynamics of the antibody response with respect to onset, level and duration in patients with confirmed SARS-CoV-2 infection. Anti-SARS-CoV-2 IgG and IgA were detected by automated enzyme-linked immunosorbent assay (ELISA) of SARS-CoV-2 infected patients monitored by the Health Protection Authority. This explorative monocentric study shows IgA and IgG antibody profiles from 118 patients with self-reported mild to moderate, or no COVID-19 related symptoms after laboratory-confirmed infection with SARS-CoV-2. We found that 21.7% and 18.1% of patients were seronegative for IgA or IgG, respectively. Clinically, most of the seronegative patients showed no to only moderate symptoms. With regard to antibody profiling 82% of all patients developed sustainable antibodies (IgG) and 78% (IgA) 3 weeks or later after the infection. Our data indicate that antibody-positivity is a useful indicator of a previous SARS-CoV-2 infection. Negative antibodies do not rule out SARS-CoV-2 infection. Future studies are needed to determine the functionality of the antibodies in terms of neutralization capacity leading to personal protection and prevention ability to transmit the virus as well as to protect after vaccination.

Background: Hunger can influence healthy development of children and has been shown to be associated with other determinants of child health, such as violence within the family and maternal (mental) health problems. Whilst the majority of research has been conducted in high-income countries with vulnerable populations, less is known about the circumstances in low-and-middle-income countries. This study explored the experience of hunger in vulnerable families in three Southeastern European countries, and simultaneously examined relationships with four sets of risk factors—lack of financial, mental, familial, and social resources.Methods: Families (N = 140) were recruited for a parenting intervention targeting child behavioral problems. Baseline data was collected on hunger, socioeconomic characteristics, mental health and wellbeing, family violence (i.e., child maltreatment and intimate partner violence), and social and emotional support. Univariate and multivariable risk factors of hunger were examined cross-sectionally with regression models.Results: Overall, 31% of families experienced at least one form of hunger in the last month. Worse family functioning, current intimate partner violence, and more instances of child neglect showed univariate associations with family hunger. In hierarchical analysis, five risk factors remained significantly associated with the experience of hunger: lower adult educational, literacy level, emotional support, more children in the household and higher scores on parental depression, anxiety, and stress.Conclusions: Hunger in Southeastern European families, among families with children showing elevated behavioral problems, was associated with more family violence, but specifically poorer mental health and less emotional support above and beyond socio-structural strains. Adapting parenting interventions to support the primary caregiver in getting more access to emotional support may potentially also change hunger and its association with health and violence. However, this hypothetical pathway of change needs explicit testing.

Abstract Background Variation in access to joint replacement surgery has been widely reported but less attention has been given to the impact of comorbidities on the patient journey to joint replacement surgery. There is a lack of consensus amongst healthcare professionals and commissioners about how patients with comorbidities should be referred or selected for joint replacement surgery. It is therefore important to understand the views of healthcare professionals on the management, referral and selection of patients with comorbidities for joint replacement surgery. Methods An exploratory qualitative study involving semi-structured interviews with 20 healthcare professionals in England across the referral pathway to joint replacement surgery. They were asked to talk about their experiences of referring and selecting patients with comorbidities for joint replacement surgery. The interviews were audio-recorded and transcribed verbatim. Data analysis followed a thematic analysis approach based on the principles of grounded theory. Results In general, the presence of comorbidities was not seen as a barrier to being referred or selected for joint replacement but was seen as a challenge to manage the patients’ journey across the referral pathway. Each professional group, concentrated on different aspects of the patients’ condition which appeared to affect how they managed patients with comorbidities. This implied there was a disagreement about roles and responsibilities in the management of patients with comorbidities. None of the professionals believed it was their responsibility to address comorbidities in preparation for surgery. This disagreement was identified as a reason why some patients seem to ‘get lost’ in the referral system when they were considered to be unprepared for surgery. Patients were then potentially left to manage their own comorbidities before being reconsidered for joint replacement. Conclusions At the clinician-level, comorbidities were not perceived as a barrier to accessing joint replacement surgery but at the pathway-level, it may create an implicit barrier such that patients with comorbidities may get ‘lost’ to the system. Further study is needed to explore the roles and responsibilities of professionals across the current orthopaedic referral pathway which may be less suitable for patients with comorbidities.

Background: Unchecked patient deterioration can lead to in-hospital cardiac arrest (IHCA) and avoidable death. The National Cardiac Arrest Audit (NCAA) has found fourfold variation in IHCA rates and survival between English hospitals. Key to reducing IHCA is both the identification of patients at risk of deterioration and prompt response. A range of targeted interventions have been introduced but implementation varies between hospitals. These differences are likely to contribute to the observed variation between and within hospitals over time. Objective: To determine how interventions aimed at identification and management of deteriorating patients are associated with IHCA rates and outcomes. Design: A mixed-methods study involving a systematic literature review, semistructured interviews with 60 NHS staff, an organisational survey in 171 hospitals and interrupted time series and difference-in-difference analyses (106 hospitals). Setting: English hospitals participating in the NCAA audit. Participants: NHS staff (approximately 300) and patients (13 million). Interventions: Education, track-and-trigger systems (TTSs), standardised handover tools and outreach teams. Main outcome measures: IHCA rates, survival and hospital-wide mortality. Data sources: NCAA, Hospital Episode Statistics, Office for National Statistics Mortality Statistics. Methods: A literature review and qualitative interviews were used to design an organisational survey that determined how interventions have been implemented in practice and across time. Associations between variations in services and IHCA rates and survival were determined using cross-sectional, interrupted time series and difference-in-difference analyses over the index study period (2009/10 to 2014/15). Results: Across NCAA hospitals, IHCAs fell by 6.4% per year and survival increased by 5% per year, with hospital mortality decreasing by a similar amount. A national, standard TTS [the National Early Warning Score (NEWS)], introduced in 2012, was adopted by 70% of hospitals by 2015. By 2015, one-third of hospitals had converted from paper-based TTSs to electronic TTSs, and there had been an increase in the number of hospitals with an outreach team and an increase in the number with a team available at all times. The extent of variation in the uses of educational courses and structured handover tools was limited, with 90% of hospitals reporting use of standardised communication tools, such as situation, background, assessment and recommendation, in 2015. Introduction of the NEWS was associated with an additional 8.4% decrease in IHCA rates and, separately, a conversion from paper to electronic TTS use was associated with an additional 7.6% decrease. However, there was no associated change in IHCA survival or hospital mortality. Outreach teams were not associated with a change in IHCA rates, survival or hospital mortality. A sensitivity analysis restricted to ward-based IHCAs did not alter the findings but did identify an association between increased outreach team intensity in 2015 and IHCA survival. Limitations: The organisational survey was not able to explore all aspects of the interventions and the contextual factors that influenced them. Changes over time were dependent on respondents’ recall. Conclusions: Standardisation of TTSs and introduction of electronic TTSs are associated with a reduction in IHCAs. The apparent lack of impact of outreach teams may reflect their mode of introduction, that their effect is through providing support for implementation of TTS or that the organisation of the response to deterioration is not critical, as long as it is timely. Their role in end-of-life decision-making may account for the observed association with IHCA survival. Future work: To assess the potential impact of outreach teams at hospital level and patient level, and to establish which component of the TTS has the greatest effect on outcomes. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Abstract Background Estimates of the burden of disease caused by a particular agent are used to assist in making policy and prioritizing actions. Most estimations have employed the attributable fraction approach, which estimates the proportion of disease cases or deaths in a specific year which are attributable to past exposure to a particular agent. While this approach has proven extremely useful in quantifying health effects, it requires historical data on exposures which are not always available. Methods We present an alternative method, the future excess fraction method, which is based on the lifetime risk approach, and which requires current rather than historical exposure data. This method estimates the future number of exposure-related disease cases or deaths occurring in the subgroup of the population who were exposed to the particular agent in a specific year. We explain this method and use publically-available data on current asbestos exposure and mesothelioma incidence to demonstrate the use of the method. Conclusions Our approach to modelling burden of disease is useful when there are no historical measures of exposure and where future disease rates can be projected on person years at risk.

Background: With a higher proportion of older people in the UK population, new approaches are needed to reduce emergency hospital admissions, thereby shifting care delivery out of hospital when possible and safe. Study aim: To evaluate the introduction of predictive risk stratification in primary care. Objectives: To (1) measure the effects on service usage, particularly emergency admissions to hospital; (2) assess the effects of the Predictive RIsk Stratification Model (PRISM) on quality of life and satisfaction; (3) assess the technical performance of PRISM; (4) estimate the costs of PRISM implementation and its effects; and (5) describe the processes of change associated with PRISM. Design: Randomised stepped-wedge trial with economic and qualitative components. Setting: Abertawe Bro Morgannwg University Health Board, south Wales. Participants: Patients registered with 32 participating general practices. Intervention: PRISM software, which stratifies patients into four (emergency admission) risk groups; practice-based training; and clinical support. Main outcome measures: Primary outcome – emergency hospital admissions. Secondary outcomes – emergency department (ED) and outpatient attendances, general practitioner (GP) activity, time in hospital, quality of life, satisfaction and costs. Data sources: Routine anonymised linked health service use data, self-completed questionnaires and staff focus groups and interviews. Results: Across 230,099 participants, PRISM implementation led to increased emergency admissions to hospital [ΔL = 0.011, 95% confidence interval (CI) 0.010 to 0.013], ED attendances (ΔL = 0.030, 95% CI 0.028 to 0.032), GP event-days (ΔL = 0.011, 95% CI 0.007 to 0.014), outpatient visits (ΔL = 0.055, 95% CI 0.051 to 0.058) and time spent in hospital (ΔL = 0.029, 95% CI 0.026 to 0.031). Quality-of-life scores related to mental health were similar between phases (Δ = –0.720, 95% CI –1.469 to 0.030); physical health scores improved in the intervention phase (Δ = 1.465, 95% CI 0.774 to 2.157); and satisfaction levels were lower (Δ = –0.074, 95% CI – 0.133 to –0.015). PRISM implementation cost £0.12 per patient per year and costs of health-care use per patient were higher in the intervention phase (Δ = £76, 95% CI £46 to £106). There was no evidence of any significant difference in deaths between phases (9.58 per 1000 patients per year in the control phase and 9.25 per 1000 patients per year in the intervention phase). PRISM showed good general technical performance, comparable with existing risk prediction tools (c-statistic of 0.749). Qualitative data showed low use by GPs and practice staff, although they all reported using PRISM to generate lists of patients to target for prioritised care to meet Quality and Outcomes Framework (QOF) targets. Limitations: In Wales during the study period, QOF targets were introduced into general practice to encourage targeting care to those at highest risk of emergency admission to hospital. Within this dynamic context, we therefore evaluated the combined effects of PRISM and this contemporaneous policy initiative. Conclusions: Introduction of PRISM increased emergency episodes, hospitalisation and costs across, and within, risk levels without clear evidence of benefits to patients. Future research: (1) Evaluation of targeting of different services to different levels of risk; (2) investigation of effects on vulnerable populations and health inequalities; (3) secondary analysis of the Predictive Risk Stratification: A Trial in Chronic Conditions Management data set by health condition type; and (4) acceptability of predictive risk stratification to patients and practitioners. Trial and study registration: Current Controlled Trials ISRCTN55538212 and PROSPERO CRD42015016874. Funding: The National Institute for Health Research Health Services Delivery and Research programme.

Background: Child disruptive behavioural problems are a large and costly public health problem. The Incredible Years® (IY) parenting programme has been disseminated across the UK to prevent this problem and shown to be effective in several trials. It is vital for policy to know for which families IY is most effective, to be sure that it helps reduce, rather than widen, socioeconomic inequalities. Individual trials lack power and generalisability to examine differential effects; conventional meta-analysis lacks information about within-trial variability in effects. Objectives: To overcome these limitations by pooling individual-level data from the IY parenting trials in Europe to examine to what extent it benefits socially disadvantaged families. Secondary objectives examine (1) additional moderators of effects on child behaviour, (2) wider health benefits and potential harms and (3) costs, cost-effectiveness and potential long-term savings. Design: Individual participant data meta-analysis of 14 randomised trials of the IY parenting intervention. Settings: UK (eight trials), the Netherlands, Ireland, Norway, Sweden and Portugal. Participants: Data were from 1799 families, with children aged 2–10 years (mean 5.1 years; 63% boys). Interventions: IY Basic parenting programme. Main outcome measures: Primary outcome was disruptive child behaviour, determined by the Eyberg Child Behavior Inventory Intensity scale (ECBI-I). Secondary outcomes included self-reported parenting practices, parenting stress, mental health, children’s attention deficit hyperactivity disorder (ADHD) and emotional symptoms. Results: There were no differential effects of IY on disruptive behaviour in families with different levels of social/socioeconomic disadvantage or differential effects for ethnic minority families, families with different parenting styles, or for children with comorbid ADHD or emotional problems or of different ages. Some moderators were found: intervention effects were strongest in children with more severe baseline disruptive behaviour, in boys, and in children with parents who were more depressed. Wider health benefits included reduced child ADHD symptoms, greater parental use of praise, and reduced harsh and inconsistent discipline. The intervention did not improve parental depression, stress, self-efficacy or children’s emotional problems. Economic data were available for five UK and Ireland trials (maximum n = 608). The average cost per person of the IY intervention was £2414. The probability that the IY intervention is considered cost-effective is 99% at a willingness to pay of £145 per 1-point improvement on the ECBI-I. Estimated longer-term savings over 20 years range from £1000 to £8400 per child, probably offsetting the cost of the intervention. Limitations: Limitations include a focus on one parenting programme; the need to make assumptions in harmonising data; and the fact that data addressed equalities in the effectiveness of, not access to, the intervention. Conclusions: There is no evidence that the benefits of the IY parenting intervention are reduced in disadvantaged or minority families; benefits are greater in the most distressed families, including parents who are depressed. Thus, the intervention is unlikely to widen socioeconomic inequalities in disruptive behaviour and may have effects in narrowing inequalities due to parent depression. It was as likely to be effective for older as for younger children. It has wider benefits for ADHD and parenting and is likely to be considered to be cost-effective. Researchers/funders should encourage data sharing to test equity and other moderator questions for other interventions; further research is needed on enhancing equality of access to interventions. Funding: The National Institute for Health Research Public Health Research programme.

BACKGROUNDZika virus transmission dynamics in urban environments follow a complex spatiotemporal pattern that appears unpredictable and barely related to high mosquito density areas. In this context, human activity patterns likely have a major role in Zika transmission dynamics. This paper examines the effect of host variability in the amount of time spent outdoors on Zika epidemiology in an urban environment.METHODOLOGY/PRINCIPAL FINDINGSFirst, we performed a survey on time spent outdoors by residents of Miami-Dade County, Florida. Second, we analyzed both the survey and previously published national data on outdoors time in the U.S. to provide estimates of the distribution of the time spent outdoors. Third, we performed a computational modeling evaluation of Zika transmission dynamics, based on the time spent outdoors by each person. Our analysis reveals a strong heterogeneity of the host population in terms of time spent outdoors-data are well captured by skewed gamma distributions. Our model-based evaluation shows that in a heterogeneous population, Zika would cause a lower number of infections than in a more homogenous host population (up to 4-fold differences), but, at the same time, the epidemic would spread much faster. We estimated that in highly heterogeneous host populations the timing of the implementation of vector control measures is the major factor for limiting the number of Zika infections.CONCLUSIONS/SIGNIFICANCEOur findings highlight the need of considering host variability in exposure time for managing mosquito-borne infections and call for the revision of the triggers for vector control strategies, which should integrate mosquito density data and human outdoor activity patterns in specific areas.

Background: COPING parent (Confident Parent Internet Guide) is an online universal parenting programme designed for parents of children aged 3-8 who are interested in learning positive parenting strategies to address everyday parenting challenges. Most people now have access to the internet and many parents seek online parenting advice, so it is important to ensure that advice is both evidence-based and freely available. The 10-week online COPING parent programme presents information and activities based on core social learning theory principles. The programme provides information and video examples of parenting skills, uses quizzes to test knowledge and suggests home practice activities. This study was undertaken to obtain feedback on the usefulness and acceptability of the programme to inform its further development. Design and Methods: The programme was created using the LifeGuide software and participants (n=20) were asked to complete one chapter of the programme each week and provide feedback. This feasibility study was undertaken to highlight any technical issues and suggest modifications prior to a more rigorous evaluation. Results: Both participant feedback and programme usage data are reported. Thirteen feedback forms were returned and programme usage data was downloaded for all participants. Feedback suggested modifications that included adaptations to enable the programme to be accessed by tablet users, an option to look back over previously completed chapters, the inclusion of more video examples of positive parenting and text message prompting to address attrition challenges.

Background: Assessing severity and spread of a novel influenza strain at the start of a pandemic is critical for informing a targeted and proportional response. It requires community-level studies to estimate the burden of infection and disease. Rapidly initiating such studies in a pandemic is difficult. The study aims to establish an efficient system allowing real-time assessment of population susceptibility, spread of infection and clinical attack rates in the event of a pandemic. Methods: We developed and appended additional survey questions and specimen collection to the Health Survey for England (HSE) – a large, annual, rolling nationally representative general population survey recruiting throughout the year – to enable rapid population-based surveys of influenza infection and disease during a pandemic. Using these surveys we can assess the spread of the virus geographically, by age and through time. The data generated can also provide denominators for national estimates of case fatality and hospitalisation rates. Phase 1: we compared retrospectively collected HSE illness rates during the first two infection waves of the 2009 pandemic with the Flu Watch study (a prospective community cohort). Monthly and seasonal age-specific rates of illness and proportion vaccinated were compared. Phase 2: we piloted blood specimen and data collection alongside the 2012–13 HSE. We are developing laboratory methods and protocols for real-time serological assays of a novel pandemic influenza virus using these specimens, and automated programmes for analysing and reporting illness and infection rates. Phase 3: during inter-pandemic years, the study enters a holding phase, where it is included in the yearly HSE ethics application and planning procedures, allowing rapid triggering in a pandemic. Phase 4: once retriggered, the study will utilise the methods developed in phase 2 to monitor the severity and spread of the pandemic in real time. Results: Phase 1: the rates of reported illness during the first two waves in the HSE underestimated the community burden as measured by Flu Watch, but the patterns of illness by age and time were broadly comparable. The extent of underestimation was greatest for HSE participants interviewed later in the year compared with those interviewed closer to the pandemic. Vaccine uptake in the HSE study was comparable to independent national estimates and the Flu Watch study. Phases 2 and 3: illness data and serological samples from 2018 participants were collected in the 2012–13 HSE and transferred to the University College London Hospital. In the 2013 HSE and onwards, this project was included in the annual HSE ethics and planning rounds. Conclusions: The HSE’s underestimation of illness rates during the first two waves of the pandemic is probably due to recall bias and the limitation of being able to report only one illness when multiple illnesses per season can occur. Changes to the illness questions (reporting only recent illnesses) should help minimise these issues. Additional prospective follow-up could improve measurement of disease incidence. The representative nature of the HSE allows accurate measurements of vaccine uptake. Study registration: This study is registered as ISRCTN80214280. Funding: This project was funded by the NIHR Public Health Research programme and will be published in full in Public Health Research; Vol. 3, No. 6. See the NIHR Journals Library website for further project information.

Abstract Background The availability of routinely collected service-related endoscopy data from NHS endoscopy units has never been quantified. Methods This retrospective observational study asked 19 endoscopy units to submit copies of all in-house, service-related endoscopy data that had been routinely collected by the unit – Referral numbers, Activity, Number of patients waiting and Number of lost slots. Nine of the endoscopy units had previously participated in the Modernising Endoscopy Services (MES) project during 2003 to redesign their endoscopy services. These MES sites had access to additional funding and data collection software. The other ten (Control sites) had modernised independently. All data was requested in two phases and corresponded to eight specific time points between January 2003 and April 2006. Results Only eight of 19 endoscopy units submitted routinely collected, service-related data. Another site's data was collected specifically for the study. A further two units claimed to routinely collect service-related data but did not submit any to the study. The remaining eight did not collect any service-related endoscopy data routinely and liaised with their Trust for data. Of the eight sites submitting service-related data, only three were MES project sites. Of these three, the data variables collected were limited and none collected the complete set of endoscopy data variables requested. Of the other five sites, two collected all four endoscopy data types. Data for the three MES project sites went back as far as January 2003, whilst the five Control sites were only able to submit data from December 2003 onwards. Conclusion There was a lack of service-related endoscopy data routinely collected by the study sites, especially those who had participated in the MES project. Without this data, NHS endoscopy services cannot have a true understanding of their services, cannot identify problems and cannot measure the impact of any changes. With the increasing pressures placed on NHS endoscopy services, the need to effectively inform redesign plans is paramount. We recommend the compulsory collection of service-related endoscopy data by all NHS endoscopy units using a standardised format with rigorous guidelines.

Abstract Background The Two-Week Rule (TWR) was introduced to ensure that all patients with a suspected colorectal cancer (CRC) saw a hospital specialist within 14 days of an urgent GP referral. Guidelines were available to GPs to facilitate the appropriate TWR referral of patients exhibiting high-risk CRC symptoms. Methods We aimed to evaluate the TWR and its CRC detection rate on NHS CRC diagnostic services by performing a literature search and critically appraising the peer-reviewed studies. Only 12 studies were eligible for inclusion. Data was collected and overall results were given as weighted averages. Results The studies identified indicated that only 10.3% of patients referred by the TWR were eventually diagnosed with CRC. When examining the referral origin of all CRC patients diagnosed during the time of the studies, 24% had been referred using the TWR, 24.1% were referred as emergency cases, and 52.4% were referred using alternative routes. No evidence was found to indicate that the TWR had resulted in identifying CRC patients at an earlier, more treatable stage of their disease. Conclusion The TWR referral system needs to be improved to increase the number of CRC patients referred using this fast track method as they present to their GP. The TWR and new NICE Guidelines for the referral of patients with suspected cancer should be independently evaluated.

Abstract Background Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity. Methods We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data. Results The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse. Conclusions In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.

Abstract Background The first COVID-19 cases were diagnosed in Australia on 25 January 2020. Initial epidiemiology showed that the majority of cases were in returned travellers from overseas. One aspect of Public Health response was to introduce compulsory 14 day quarantine for all travellers returning to New South Wales (NSW) by air or sea in Special Health Accommodation (SHA). We aim to outline the establishment of a specialised health quarantine accommodation service in the context of the COVID-19 pandemic, and describe the first month of COVID-19 screening. Methods The SHA was established with a comprehensive governance structure, remote clinical management through Royal Prince Alfred Virtual Hospital (rpavirtual) and site management with health care workers, NSW Police and accommodation staff. Results From 29 March to 29 April 2020, 373 returning travellers were admitted to the SHA from Sydney Airport. 88 (26.1%) of those swabbed were positive for SARS-CoV 2. The day of diagnosis of COVID-19 varied from Day 1 to Day 13, with 63.6% (n = 56) of these in the first week of quarantine. 50% of the people in the SHA were referred to rpavirtual for ongoing clinical management. Seven people required admission to hospital for ongoing clinical care. Conclusion The Public Health response to COVID-19 in Australia included early and increased case detection through testing, tracing of contacts of confirmed cases, social distancing and prohibition of gatherings. In addition to these measures, the introduction of mandated quarantine for travellers to Australia was integral to the successful containment of COVID-19 in NSW and Australia through the prevention of transmission locally and interstate from returning travellers.

Abstract Background An increasing number of patients undergoing hip or knee replacement have chronic diseases. It has been suggested that the presence of chronic diseases may affect access to this type of surgery in the English National Health Service (NHS). We examined the access to hip and knee replacement surgery in patients with and without chronic diseases according to preoperative patient-reported pain, functional status and symptom duration. Methods We analysed data of 640,832 patients who had hip or knee surgery between 2009 and 2016 in England. Multivariable regression was used to estimate the impact of 11 chronic diseases on severity of joint problems as measured on a scale from 0 to 48 by Oxford Hip (OHS) and Knee Scores (OKS) just before surgery and on likelihood of long-standing joint problems (> 5 years pre-operatively). Results Patients with chronic diseases reported more severe joint problems than patients without (OHS differences ranged from 1.1 [95% CI 0.93, 1.2] to 2.5 [95% CI 2.3, 2.7] and OKS differences from 0.5 [95% CI 0.3, 0.7] to 2.6 [95% CI 2.4, 2.7] for the 11 chronic diseases) but the differences remain small. When analysed separately, patients with chronic diseases reported both more severe pain and poorer functional status. Six chronic diseases in hip patients and two in knee patients increased the likelihood that they had long-standing joint problems. The severity of joint problems just before surgery increased with the number of chronic diseases (OHS differences; one chronic disease (1.5 [95% CI 1.4, 1.5]) to four or more (5.8 [95% CI 5.6, 6.0])). Conclusions Patients with chronic diseases reported more severe joint problems immediately before hip or knee replacement surgery suggesting they have hip or knee replacement later in the course of their joint disease.

Background: Parenting interventions and conditional cash transfer (CCT) programmes are promising strategies to reduce the risk of violence against children, but evidence of the effectiveness of combining such programmes is lacking for families in low- and middle-income countries with children over two years of age. This study examined the effectiveness of a locally adapted parenting programme delivered as part of a government CCT system to low-income families with children aged two to six years in Metro Manila, Philippines. Methods: Participants were randomly assigned (1:1) to either a 12-session group-based parenting programme or treatment-as-usual services (N = 120). Participation in either service was required among the conditions for receiving cash grants. Baseline assessments were conducted in July 2017 with one-month post-intervention assessments in January-February 2018 and 12-month follow-up in January-February 2019. All assessments were parent-report (ClinicalTrials.gov: NCT03205449). Findings: One-month post-intervention assessments indicated moderate intervention effects for primary outcomes of reduced overall child maltreatment (d = -0.50 [-0.86, -0.13]), emotional abuse (d = -0.59 [-0.95; -0.22]), physical abuse (IRR = 0.51 [0.27; 0.74]), and neglect (IRR = 0.52 [0.18; 0.85]). There were also significant effects for reduced dysfunctional parenting, child behaviour problems, and intimate partner violence, and increased parental efficacy and positive parenting. Reduced overall maltreatment, emotional abuse, and neglect effects were sustained at one-year follow-up. Interpretation: Findings suggest that a culturally adapted parenting intervention delivered as part of a CCT programme may be effective in sustaining reductions in violence against children in low- and middle-income countries. Funding: This research was supported by UBS Optimus Foundation and UNICEF Philippines, and by the Complexity and Relationships in Health Improvement Programmes of the Medical Research Council MRC UK and Chief Scientist Office (Grant: MC_UU_00022/1 and CSO SPHSU16, MC_UU_00022/3 and CSO SPHSU18).

Background: People with cystic fibrosis frequently have low levels of adherence to inhaled medications. Objectives: The objectives were to develop and evaluate an intervention for adults with cystic fibrosis to improve adherence to their inhaled medication. Design: We used agile software methods to develop an online platform. We used mixed methods to develop a behaviour change intervention for delivery by an interventionist. These were integrated to become the CFHealthHub intervention. We undertook a feasibility study consisting of a pilot randomised controlled trial and process evaluation in two cystic fibrosis centres. We evaluated the intervention using an open-label, parallel-group randomised controlled trial with usual care as the control. Participants were randomised in a 1 : 1 ratio to intervention or usual care. Usual care consisted of clinic visits every 3 months. We undertook a process evaluation alongside the randomised controlled trial, including a fidelity study, a qualitative interview study and a mediation analysis. We undertook a health economic analysis using both a within-trial and model-based analysis. Setting: The randomised controlled trial took place in 19 UK cystic fibrosis centres. Participants: Participants were people aged ≥ 16 years with cystic fibrosis, on the cystic fibrosis registry, not post lung transplant or on the active transplant list, who were able to consent and not using dry-powder inhalers. Intervention: People with cystic fibrosis used a nebuliser with electronic monitoring capabilities. This transferred data automatically to a digital platform. People with cystic fibrosis and clinicians could monitor adherence using these data, including through a mobile application (app). CFHealthHub displayed graphs of adherence data as well as educational and problem-solving information. A trained interventionist helped people with cystic fibrosis to address their adherence. Main outcome measures: Randomised controlled trial – adjusted incidence rate ratio of pulmonary exacerbations meeting the modified Fuchs criteria over a 12-month follow-up period (primary outcome); change in percentage adherence; and per cent predicted forced expiratory volume in 1 second (key secondary outcomes). Process evaluation – percentage fidelity to intervention delivery, and participant and interventionist perceptions of the intervention. Economic modelling – incremental cost per quality-adjusted life-year gained. Results: Randomised controlled trial – 608 participants were randomised to the intervention (n = 305) or usual care (n = 303). To our knowledge, this was the largest randomised controlled trial in cystic fibrosis undertaken in the UK. The adjusted rate of exacerbations per year (primary outcome) was 1.63 in the intervention and 1.77 in the usual-care arm (incidence rate ratio 0.96, 95% confidence interval 0.83 to 1.12; p = 0.638) after adjustment for covariates. The adjusted difference in mean weekly normative adherence was 9.5% (95% confidence interval 8.6% to 10.4%) across 1 year, favouring the intervention. Adjusted mean difference in forced expiratory volume in 1 second (per cent) predicted at 12 months was 1.4% (95% confidence interval –0.2% to 3.0%). No adverse events were related to the intervention. Process evaluation – fidelity of intervention delivery was high, the intervention was acceptable to people with cystic fibrosis, participants engaged with the intervention [287/305 (94%) attended the first intervention visit], expected mechanisms of action were identified and contextual factors varied between randomised controlled trial sites. Qualitative interviews with 22 people with cystic fibrosis and 26 interventionists identified that people with cystic fibrosis welcomed the objective adherence data as proof of actions to self and others, and valued the relationship that they built with the interventionists. Economic modelling – the within-trial analysis suggests that the intervention generated 0.01 additional quality-adjusted life-years at an additional cost of £865.91 per patient, leading to an incremental cost-effectiveness ratio of £71,136 per quality-adjusted life-year gained. This should be interpreted with caution owing to the short time horizon. The health economic model suggests that the intervention is expected to generate 0.17 additional quality-adjusted life-years and cost savings of £1790 over a lifetime (70-year) horizon; hence, the intervention is expected to dominate usual care. Assuming a willingness-to-pay threshold of £20,000 per quality-adjusted life-year gained, the probability that the intervention generates more net benefit than usual care is 0.89. The model results are dependent on assumptions regarding the duration over which costs and effects of the intervention apply, the impact of the intervention on forced expiratory volume in 1 second (per cent) predicted and the relationship between increased adherence and drug-prescribing levels. Limitations: Number of exacerbations is a sensitive and valid measure of clinical change used in many trials. However, data collection of this outcome in this context was challenging and could have been subject to bias. It was not possible to measure baseline adherence accurately. It was not possible to quantify the impact of the intervention on the number of packs of medicines prescribed. Conclusions: We developed a feasible and acceptable intervention that was delivered to fidelity in the randomised controlled trial. We observed no statistically significant difference in the primary outcome of exacerbation rates over 12 months. We observed an increase in normative adherence levels in a disease where adherence levels are low. The magnitude of the increase in adherence may not have been large enough to affect exacerbations. Future work: Given the non-significant difference in the primary outcome, further research is required to explore why an increase in objective normative adherence did not reduce exacerbations and to develop interventions that reduce exacerbations. Trial registration: Work package 3.1: Current Controlled Trials ISRCTN13076797. Work packages 3.2 and 3.3: Current Controlled Trials ISRCTN55504164. Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

BackgroundWater, sanitation and hygiene (WASH) interventions should support infant growth but trial results are inconsistent. Frequently, interventions do not consider behaviours or transmission pathways specific to age. A household playspace (HPS) is one intervention component which may block faecal-oral transmission. This study was a two-armed, parallel-group, randomised, controlled feasibility trial of a HPS in rural Ethiopia. It aimed to recommend proceeding to a definitive trial. Secondary outcomes included effects on infant health, injury prevention and women's time.MethodsNovember 2019-January 2020 106 households were identified and assessed for eligibility. Recruited households (N = 100) were randomised (blinded prior to the trial start) to intervention or control (both n = 50). Outcomes included recruitment, attrition, adherence, and acceptability. Data were collected at baseline, two and four weeks.FindingsRecruitment met a priori criteria (≥80%). There was no loss to follow-up, and no non-use, meeting adherence criteria (both ≤10%). Further, 48.0% (95% CI 33.7-62.6; n = 24) of households appropriately used and 56.0% (41.3-70.0; n = 28) cleaned the HPS over four weeks, partly meeting adherence criteria (≥50%). For acceptability, 41.0% (31.3-51.3; n = 41) of infants were in the HPS during random visits, failing criteria (≥50%). Further, the proportion of HPS use decreased during some activities, failing criteria (no decrease in use). A modified Barrier Analysis described good acceptability and multiple secondary benefits, including on women's time burden and infant injury prevention.InterpretationDespite failing some a priori criteria, the trial demonstrated mixed adherence and good acceptability among intervention households. A definitive trial to determine efficacy is warranted if recommended adjustments are made.FundingPeople In Need; Czech Development Agency.Trial registrationRIDIE-ID-5de0b6938afb8.

Summary: Background: The SARS-CoV-2 variant B.1.1.7 was first identified in December, 2020, in England. We aimed to investigate whether increases in the proportion of infections with this variant are associated with differences in symptoms or disease course, reinfection rates, or transmissibility. Methods: We did an ecological study to examine the association between the regional proportion of infections with the SARS-CoV-2 B.1.1.7 variant and reported symptoms, disease course, rates of reinfection, and transmissibility. Data on types and duration of symptoms were obtained from longitudinal reports from users of the COVID Symptom Study app who reported a positive test for COVID-19 between Sept 28 and Dec 27, 2020 (during which the prevalence of B.1.1.7 increased most notably in parts of the UK). From this dataset, we also estimated the frequency of possible reinfection, defined as the presence of two reported positive tests separated by more than 90 days with a period of reporting no symptoms for more than 7 days before the second positive test. The proportion of SARS-CoV-2 infections with the B.1.1.7 variant across the UK was estimated with use of genomic data from the COVID-19 Genomics UK Consortium and data from Public Health England on spike-gene target failure (a non-specific indicator of the B.1.1.7 variant) in community cases in England. We used linear regression to examine the association between reported symptoms and proportion of B.1.1.7. We assessed the Spearman correlation between the proportion of B.1.1.7 cases and number of reinfections over time, and between the number of positive tests and reinfections. We estimated incidence for B.1.1.7 and previous variants, and compared the effective reproduction number, Rt, for the two incidence estimates. Findings: From Sept 28 to Dec 27, 2020, positive COVID-19 tests were reported by 36 920 COVID Symptom Study app users whose region was known and who reported as healthy on app sign-up. We found no changes in reported symptoms or disease duration associated with B.1.1.7. For the same period, possible reinfections were identified in 249 (0·7% [95% CI 0·6–0·8]) of 36 509 app users who reported a positive swab test before Oct 1, 2020, but there was no evidence that the frequency of reinfections was higher for the B.1.1.7 variant than for pre-existing variants. Reinfection occurrences were more positively correlated with the overall regional rise in cases (Spearman correlation 0·56–0·69 for South East, London, and East of England) than with the regional increase in the proportion of infections with the B.1.1.7 variant (Spearman correlation 0·38–0·56 in the same regions), suggesting B.1.1.7 does not substantially alter the risk of reinfection. We found a multiplicative increase in the Rt of B.1.1.7 by a factor of 1·35 (95% CI 1·02–1·69) relative to pre-existing variants. However, Rt fell below 1 during regional and national lockdowns, even in regions with high proportions of infections with the B.1.1.7 variant. Interpretation: The lack of change in symptoms identified in this study indicates that existing testing and surveillance infrastructure do not need to change specifically for the B.1.1.7 variant. In addition, given that there was no apparent increase in the reinfection rate, vaccines are likely to remain effective against the B.1.1.7 variant. Funding: Zoe Global, Department of Health (UK), Wellcome Trust, Engineering and Physical Sciences Research Council (UK), National Institute for Health Research (UK), Medical Research Council (UK), Alzheimer's Society.

Ending all violence against children by 2030 is a core part of Sustainable Development Goals 5 and 16. A number of promising violence reduction strategies have been identified in research studies. However, we lack an understanding of the implementation and impact of these programs in respect to their delivery at a large scale or within existing service systems, particularly in low- and middle-income countries (LMICs). We advocate for greater collaboration between researchers, policymakers, donors, governments, non-governmental organizations, and program managers and staff to study how violence prevention programs operate on a large scale. We describe a new initiative aiming to foster such collaborations in the field of family strengthening programs.

BackgroundAustralia has successfully controlled the COVID-19 pandemic. Similar to other high-income countries, Australia has extensively used telehealth services. Virtual health care, including telemedicine in combination with remote patient monitoring, has been implemented in certain settings as part of new models of care that are aimed at managing patients with COVID-19 outside the hospital setting. ObjectiveThis study aimed to describe the implementation of and early experience with virtual health care for community management of patients with COVID-19. MethodsThis observational cohort study was conducted with patients with COVID-19 who availed of a large Australian metropolitan health service with an established virtual health care program capable of monitoring patients remotely. We included patients with COVID-19 who received the health service, could self-isolate safely, did not require immediate admission to an in-patient setting, had no major active comorbid illness, and could be managed at home or at other suitable sites. Skin temperature, pulse rate, and blood oxygen saturation were remotely monitored. The primary outcome measures were care escalation rates, including emergency department presentation, and hospital admission. ResultsDuring March 11-29, 2020, a total of 162 of 173 (93.6%) patients with COVID-19 (median age 38 years, range 11-79 years), who were diagnosed locally, were enrolled in the virtual health care program. For 62 of 162 (38.3%) patients discharged during this period, the median length of stay was 8 (range 1-17) days. The peak of 100 prevalent patients equated to approximately 25 patients per registered nurse per shift. Patients were contacted a median of 16 (range 1-30) times during this period. Video consultations (n=1902, 66.3%) comprised most of the patient contacts, and 132 (81.5%) patients were monitored remotely. Care escalation rates were low, with an ambulance attendance rate of 3% (n=5), emergency department attendance rate of 2.5% (n=4), and hospital admission rate of 1.9% (n=3). No deaths were recorded. ConclusionsCommunity-based virtual health care is safe for managing most patients with COVID-19 and can be rapidly implemented in an urban Australian setting for pandemic management. Health services implementing virtual health care should anticipate challenges associated with rapid technology deployments and provide adequate support to resolve them, including strategies to support the use of health information technologies among consumers.

When waste management infrastructure is built, there can be resistance from the local affected populations, often termed the Not in My Backyard (NIMBY) phenomenon. This study aims to understand the forms of resistance that may develop in such contexts, focusing on 2 solid waste and 1 liquid waste management site within Mzuzu City, Malawi. At the newest solid waste site, community resistance had grown to the extent that the site was reportedly destroyed by the local community. Interviews and observations of the sites are complemented by examining historic and recent satellite images. It was found that, at the new solid waste site, community engagement had not been conducted effectively prior to construction and as part of ongoing site operations. This was compounded by poor site management and the non-delivery of the promised benefits to the community. In contrast, at the liquid waste site, the community could access untreated sludge for use as fertilizer and were happier to live within its vicinity. While NIMBYism is a frustrating phenomenon for city planners, it is understandable that communities want to protect their health and well-being when there is a history of mismanagement of waste sites which is sadly common in low-income settings. It is difficult for government agencies to deliver these services and broader waste management. In this study, an unsuccessful attempt to do something better with a legitimate goal is not necessarily a failure, but part of a natural learning process for getting things right.

BackgroundAdherence to nebulizer treatments in adults with cystic fibrosis (CF) is often low. A new complex intervention to help adults with CF increase their adherence to nebulizer treatments was tested in a pilot randomized controlled trial (RCT) in 2 UK CF centers. Patients used a nebulizer with electronic monitoring capabilities that transferred data automatically to a digital platform (CFHealthHub) to monitor adherence over time and to a tailored website to display graphs of adherence data and educational and problem-solving information about adherence. A trained interventionist helped patients identify ways to increase their adherence. ObjectiveThis study aims to explore the mechanisms of action underpinning the intervention. MethodsA qualitative interview study was conducted concurrently with a pilot RCT. In total, 25 semistructured interviews were conducted with 3 interventionists at 2 time points, 14 patients in the intervention arm of the trial, and 5 members of the multidisciplinary teams offering wider care to patients. A framework approach was used for the analysis. ResultsThe intervention was informed by a theoretical framework of behavior change. There was evidence of the expected behavior change mechanisms of action. There was also evidence of additional mechanisms of action associated with effective telehealth interventions for self-management support: relationships, visibility, and fit. Patients described how building a relationship with the interventionist through face-to-face visits with someone who cared about them and their progress helped them to consider ways of increasing adherence to medication. Rather than seeing the visibility of adherence data to clinicians as problematic, patients found this motivating, particularly if they received praise about progress made. The intervention was tailored to individuals, but there were challenges in how the intervention fitted into some patients’ busy lives when delivered through a desktop computer. ConclusionsThe mechanisms of action associated with effective telehealth interventions for self-management operated within this new intervention. The intervention was modified to strengthen mechanisms of action based on these findings, for example, delivery through an app accessed via mobile phones and then tested in an RCT in 19 UK CF centers. Trial RegistrationInternational Standard Randomized Controlled Trial Number 13076797; http://www.isrctn.com/ISRCTN13076797

OBJECTIVE: Many doctors report working excessively demanding schedules that comply with the European Working Time Directive (EWTD). We compared groups of junior doctors working on different schedules in order to identify which features of schedule design most negatively affected their fatigue and well-being in recent weeks. METHODS: Completed by 336 doctors, the questionnaires focused on the respondents’ personal circumstances, work situation, work schedules, sleep, and perceptions of fatigue, work–life balance and psychological strain. RESULTS: Working 7 consecutive nights was associated with greater accumulated fatigue and greater work–life interference, compared with working just 3 or 4 nights. Having only 1 rest day after working nights was associated with increased fatigue. Working a weekend on-call between 2 consecutive working weeks was associated with increased work–life interference. Working frequent on-calls (either on weekends or during the week) was associated with increased work–life interference and psychological strain. Inter-shift intervals of