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There is a need for a new cardiovascular disease model that includes a wider range of relevant risk factors, in particular lifestyle factors, to aid targeting of interventions and improve population models of the impact of cardiovascular disease and preventive strategies. The model needs to be applicable to a wider population including different ethnic groups, different countries and to those with and without cardiovascular disease. This paper describes the construction of the Cardiovascular Health Improvement Model that aims to meet these requirements.~Background~Background~An odds model is used. Information was taken from 2003 mortality statistics for England and Wales, the Health Survey for England 2003 and published data on relative risk in those with and without CVD and mean blood pressure values in hypertensives. The odds ratios used were taken from the INTERHEART study.~Method~Methods~A worked example is given calculating the 10-year coronary heart disease risk for a 57 year-old non-diabetic male with no personal or family history of cardiovascular disease, who smokes 30 cigarettes a day and has a systolic blood pressure of 137 mmHg, a total cholesterol (TC) of 6.2 mmol/l, a high density lipoprotein (HDL) of 1.3 mol/l, and a body mass index of 21. He neither drinks regularly nor exercises. He can give no reliable information about his mental health or fruit and vegetable intake. His 10-year risk of CHD death is 2.47%.~Results~Results~This paper demonstrates a method for developing a CHD risk model. Further improvements could be made to the model with additional information. The method is applicable to other causes of death.~Conclusion~Conclusions [ABSTRACT FROM AUTHOR]

Objectives: To investigate worry about COVID-19 during the pandemic, and whether worry was associated with phase of the pandemic, COVID-19 death and incidence rates, Government interventions (including lockdown and advertising), age, being clinically at-risk, ethnicity, thinking that the Government had put the right measures in place, perceived risk of COVID-19 to self and the UK, and perceived severity of COVID-19., Design: Secondary analysis of a series of cross-sectional surveys., Setting: 73 online surveys conducted for the English Department of Health and Social Care between 28 January 2020 and 13 April 2022., Participants: Participants were people aged 16 years and over living in the UK (approximately 2000 per wave)., Primary Outcome Measures: Our primary outcome was self-reported worry about COVID-19., Results: Rates of being 'extremely' or 'very' worried changed over time. Worry increased as infection rates increased and fell during lockdowns, but the association became less obvious over time. Respondents aged 60 years and over were less likely to be worried after the launch of the vaccination campaign, while those who were clinically at-risk or from a minoritised ethnic community were more likely to be worried. Higher worry was associated with higher perceived risk, and higher perceived severity of COVID-19. There was no evidence for an association with agreeing that the Government was putting the right measures in place to prevent the spread of COVID-19. The launch of graphic Government advertising campaigns about COVID-19 had no noticeable effect on levels of public worry., Conclusions: In future infectious disease outbreaks, spikes in worry may attenuate over time, although some sections of society may experience higher anxiety than others., Competing Interests: Competing interests: The authors received financial support from NIHR for the submitted work. RA and LES are employees of the UK Health Security Agency; HWWP received additional salary support from Public Health England and NHS England; has a PhD student who works at and has had fees paid by Astra-Zeneca. GJR and LES receive consultancy fees from the Sanofi group of companies. The authors have no other financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work. NTF is a participant of an independent group advising NHS Digital/England on the release of patient data. All authors were participants of the UK’s Scientific Advisory Group for Emergencies or its subgroups., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Wikipedia is the largest free online encyclopedia and the seventh most visited website worldwide, containing >45,000 freely accessible English-language medical articles accessed nearly 1.6 billion times annually. Concerns have been expressed about the balance of content related to biological sex on Wikipedia., Objective: This study aims to categorize the top 1000 most-read (most popular) English-language Wikipedia health articles for June 2019 according to the relevance of the article topic to each sex and quality., Methods: In the first step, Wikipedia articles were identified using WikiProject Medicine Popular Pages. These were analyzed on 13 factors, including total views, article quality, and total number of references. In the second step, 2 general medical textbooks were used as comparators to assess whether Wikipedia's spread of articles was typical compared to the general medical coverage. According to the article's content, we proposed criteria with 5 categories: 1="exclusively female," 2="predominantly female but can also affect male individuals," 3="not sex specific or neutral," 4=predominantly male but can affect female individuals," and 5="exclusively male.", Results: Of the 1000 Wikipedia health articles, 933 (93.3%) were not sex specific and 67 (6.7%) were sex specific. There was no statistically significant difference in the number of reads per month between the sex-specific and non-sex-specific articles (P=.29). Coverage of female topics was higher (50/1000, 5%) than male topics (17/1000, 1.7%; this difference was also observed for the 2 medical textbooks, in which 90.2% (2330/2584) of content was not sex specific, female topics accounted for 8.1% (209/2584), and male topics for accounted for 1.7% (45/2584; statistically significant difference; Fisher exact test P=.03). Female-category articles were ranked higher on the Wikipedia medical topic importance list (top, high, or mid importance) than male-category articles (borderline statistical significance; Fisher exact test P=.05). Female articles had a higher number of total and unique references; a slightly higher number of page watchers, pictures, and available languages; and lower number of edits than male articles (all were statistically nonsignificant)., Conclusions: Across several metrics, a sample of popular Wikipedia health-related articles for both sexes had comparable quality. Wikipedia had a lower number of female articles and a higher number of neutral articles relative to the 2 medical textbooks. These differences were small, but statistically significant. Higher exclusively female coverage, compared to exclusively male coverage, in Wikipedia articles was similar to the 2 medical textbooks and can be explained by inclusion of sections on obstetrics and gynecology. This is unlike the imbalance seen among biographies of living people, in which approximately 77.6% pertain to male individuals. Although this study included a small sample of articles, the spread of Wikipedia articles may reflect the readership and the population's content consumption at a given time. Further study of a larger sample of Wikipedia articles would be valuable., (©Nuša Farič, Henry WW Potts, James M Heilman. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 12.09.2024.)

Objectives: To investigate rates of mpox beliefs, knowledge and intended behaviours in the general population and in gay, bisexual or other men who have sex with men (GBMSM), and factors associated with intended behaviours. To test the impact of motivational messages (vs a factual control) on intended behaviours., Design: Cross-sectional online survey including a nested randomised controlled trial., Setting: Data collected from 5 September 2022 to 6 October 2022., Participants: Participants were aged 18 years or over and lived in the UK (general population). In addition, GBMSM were male, and gay, bisexual or had sex with men. The general population sample was recruited through a market research company. GBMSM were recruited through a market research company, the dating app Grindr and targeted adverts on Meta (Facebook and Instagram)., Main Outcome Measures: Intention to self-isolate, seek medical help, stop all sexual contact, share details of recent sexual contacts and accept vaccination., Results: Sociodemographic characteristics differed by sample. There was no effect of very brief motivational messaging on behavioural intentions. Respondents from Grindr and Meta were more likely to intend to seek help immediately, completely stop sexual behaviour and be vaccinated or intend to be vaccinated, but being less likely to intend to self-isolate (ps<0.001). In the general population sample, intending to carry out protective behaviours was generally associated with being female, older, having less financial hardship, greater worry, higher perceived risk to others and higher perceived susceptibility to and severity of mpox (ps<0.001). There were fewer associations with behaviours in the Grindr sample, possibly due to reduced power., Conclusions: GBMSM were more likely to intend to enact protective behaviours, except for self-isolation. This may reflect targeted public health efforts and engagement with this group. Associations with socioeconomic factors suggest that providing financial support may encourage people to engage with protective behaviours., Competing Interests: Competing interests: HP has received additional salary support from Public Health England and NHS England and receives funding from the National Institute of Health Research. HP receives consultancy fees to his employer from Ipsos MORI and has a PhD student who works at and has fees paid by AstraZeneca. IO and RA are employees of UKHSA., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

International deployment of remote monitoring and virtual care (RMVC) technologies would efficiently harness their positive impact on outcomes. Since Canada and the United Kingdom have similar populations, health care systems, and digital health landscapes, transferring digital health innovations between them should be relatively straightforward. Yet examples of successful attempts are scarce. In a workshop, we identified 6 differences that may complicate RMVC transfer between Canada and the United Kingdom and provided recommendations for addressing them. These key differences include (1) minority groups, (2) physical geography, (3) clinical pathways, (4) value propositions, (5) governmental priorities and support for digital innovation, and (6) regulatory pathways. We detail 4 broad recommendations to plan for sustainability, including the need to formally consider how highlighted country-specific recommendations may impact RMVC and contingency planning to overcome challenges; the need to map which pathways are available as an innovator to support cross-country transfer; the need to report on and apply learnings from regulatory barriers and facilitators so that everyone may benefit; and the need to explore existing guidance to successfully transfer digital health solutions while developing further guidance (eg, extending the nonadoption, abandonment, scale-up, spread, sustainability framework for cross-country transfer). Finally, we present an ecosystem readiness checklist. Considering these recommendations will contribute to successful international deployment and an increased positive impact of RMVC technologies. Future directions should consider characterizing additional complexities associated with global transfer., (©Quynh Pham, David Wong, Kaylen J Pfisterer, Dionne Aleman, Nick Bansback, Joseph A Cafazzo, Alexander J Casson, Brian Chan, William Dixon, Gerasimos Kakaroumpas, Claudia Lindner, Niels Peek, Henry WW Potts, Barbara Ribeiro, Emily Seto, Charlotte Stockton-Powdrell, Alexander Thompson, Sabine van der Veer. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 01.08.2023.)

Objective: Evidence-based digital health technologies are increasingly important in delivering care to an ageing population with constrained resources. In the United Kingdom, accelerator programmes (APs) have been developed to support the adoption of digital health technologies within the National Health Service. This study aims to explore the perspectives of stakeholders using APs., Methods: Stakeholders representing nine small -and medium-sized enterprises (SMEs) that were engaged with three different APs ( n  = 9). Semi-structured interviews were conducted with key informants between April and September 2018. Framework analysis of the data was performed to explore their perspectives on APs., Results: Four key themes were generated. Informants reported the need to generate evidence before and during the programme, appreciating different types of evidence and their importance. Informants identified several key factors that were a catalyst for success, including involvement in the programme and access to individuals and organisations that were crucial for support. However, several barriers were identified at the programme and system levels. Finally, informants identified key supporting processes that enhanced the adoption of their innovations., Conclusion: SMEs that develop digital health technologies report that, while APs are useful in supporting the adoption of these technologies, some issues remain. These relate to the emphasis on traditional research evidence that remains a challenge for SMEs to generate. Also, several system-level barriers to innovation in healthcare persist. As APs and SMEs continue to create an entrepreneurial ecosystem, there is increased potential for the development of supporting processes and infrastructure to accelerate the efficient and timely adoption of new digital health technologies., Competing Interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CN, SGH and GS declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. HWWP collaborates with DigitalHealth.London, including on their AP. He has a PhD student working at and supported by Patients Know Best, and another working at and supported by BetterPoints Ltd. NP collaborates with DigitalHealth.London and supports their AP as well as others. She is a steering group member at NICE developing updated guidance on evidence for artificial intelligence technologies., (© The Author(s) 2023.)

Ventilating indoor spaces helps prevent COVID-19 transmission. We investigated self-reported rates of opening windows to improve ventilation in the home, perceived effectiveness of opening windows, and confidence that if you wanted to, you could open windows. One in 6 people reported rarely, if ever, opening windows in their home in the last week. Three in 4 people knew that opening windows to improve ventilation was an effective way to prevent the spread of COVID-19 and 5 in 6 were confident that they could open windows in their home. Official messaging should continue to seek to improve knowledge about the effectiveness of ventilation for reducing COVID-19 transmission, and increase the frequency of window opening., Competing Interests: Declaration of Conflicting Interests:The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors had financial support from NIHR for the submitted work; RA is an employee of Public Health England; HWWP receives additional salary support from Public Health England and NHS England; no other financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. NTF is a participant of an independent group advising NHS Digital on the release of patient data. All authors are participants of the UK’s Scientific Advisory Group for Emergencies or its subgroups., (© The Author(s) 2021.)

Background: Behavior change apps can develop iteratively, where the app evolves into a complex, dynamic, or personalized intervention through cycles of research, development, and implementation. Understanding how existing users engage with an app (eg, frequency, amount, depth, and duration of use) can help guide further incremental improvements. We aim to explore how simple visualizations can provide a good understanding of temporal patterns of engagement, as usage data are often longitudinal and rich., Objective: This study aims to visualize behavioral engagement with Drink Less, a behavior change app to help reduce hazardous and harmful alcohol consumption in the general adult population of the United Kingdom., Methods: We explored behavioral engagement among 19,233 existing users of Drink Less. Users were included in the sample if they were from the United Kingdom; were 18 years or older; were interested in reducing their alcohol consumption; had a baseline Alcohol Use Disorders Identification Test score of 8 or above, indicative of excessive drinking; and had downloaded the app between May 17, 2017, and January 22, 2019 (615 days). Measures of when sessions begin, length of sessions, time to disengagement, and patterns of use were visualized with heat maps, timeline plots, k-modes clustering analyses, and Kaplan-Meier plots., Results: The daily 11 AM notification is strongly associated with a change in engagement in the following hour; reduction in behavioral engagement over time, with 50.00% (9617/19,233) of users disengaging (defined as no use for 7 or more consecutive days) 22 days after download; identification of 3 distinct trajectories of use, namely engagers (4651/19,233, 24.18% of users), slow disengagers (3679/19,233, 19.13% of users), and fast disengagers (10,903/19,233, 56.68% of users); and limited depth of engagement with 85.076% (7,095,348/8,340,005) of screen views occurring within the Self-monitoring and Feedback module. In addition, a peak of both frequency and amount of time spent per session was observed in the evenings., Conclusions: Visualizations play an important role in understanding engagement with behavior change apps. Here, we discuss how simple visualizations helped identify important patterns of engagement with Drink Less. Our visualizations of behavioral engagement suggest that the daily notification substantially impacts engagement. Furthermore, the visualizations suggest that a fixed notification policy can be effective for maintaining engagement for some users but ineffective for others. We conclude that optimizing the notification policy to target both effectiveness and engagement is a worthwhile investment. Our future goal is to both understand the causal effect of the notification on engagement and further optimize the notification policy within Drink Less by tailoring to contextual circumstances of individuals over time. Such tailoring will be informed from the findings of our micro-randomized trial (MRT), and these visualizations were useful in both gaining a better understanding of engagement and designing the MRT., (©Lauren Bell, Claire Garnett, Tianchen Qian, Olga Perski, Elizabeth Williamson, Henry WW Potts. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 11.12.2020.)

Background: Novel strategies to promote physical activity (PA) in adolescence are required. The vEngage study aims to test whether a virtual reality (VR) exergaming intervention can engage younger adolescents (aged 13 to 15 years) with PA., Objective: This study aimed to gather adolescents' views of using VR to encourage PA and identify the key features they would like to see in a VR exergaming intervention via interviews., Methods: Participants were recruited through 2 schools in London, United Kingdom. Semistructured interviews were conducted with adolescents about their views on PA and what might work to increase PA, technology, knowledge and experience of VR, and desired features in a VR exergaming intervention. Data were analyzed using Framework Analysis., Results: A total of 31 participants aged between 13 and 15 years (58% female, 62% from nonwhite ethnicities) participated in this interview study. The vast majority had no awareness of government PA recommendations but felt they should be more thoroughly informed. All participants were positive about the use of VR in PA promotion. Rewards, increasing challenges, and a social or multiplayer aspect were identified by participants as crucial aspects to include in a VR exercise game. Barriers were related to cost of high-end systems. Being able to exercise at home was very appealing. VR exergaming was viewed as a way to overcome multiple perceived social and cultural barriers to PA, particularly for girls., Conclusions: Key elements that should be incorporated into a VR game for health intervention were identified and described. These also included the use of rewards, novelty and enjoyment in immersive game play, multiplayer options, and real-world elements, as well as continual updates and new challenge levels. The use of VR to promote PA in adolescents is promising, but some barriers were raised., (©Nuša Farič, Eleanor Yorke, Laura Varnes, Katie Newby, Henry WW Potts, Lee Smith, Adrian Hon, Andrew Steptoe, Abigail Fisher. Originally published in JMIR Serious Games (http://games.jmir.org), 17.06.2019.)

Background: Tests of competence are written and clinical assessments taken by doctors under investigation by the General Medical Council (GMC) who have significant performance concerns. Male doctors on average perform more poorly in clinical assessments than female doctors, and are more likely to be sanctioned. It is unclear why., Aim: To examine sex differences in the tests of competence assessment scores of GPs under investigation by the GMC, compared with GPs not under investigation, and whether scores mediate any relationship between sex and sanction likelihood., Design and Setting: Retrospective cohort study of GPs' administrative tests of competence data., Method: Analysis of variance was undertaken to compare written and clinical tests of competence performance by sex and GP group (under investigation versus volunteers). Path analysis was conducted to explore the relationship between sex, written and clinical tests of competence performance, and investigation outcome., Results: On the written test, female GPs under investigation outperformed male GPs under investigation (Cohen's d = 0.28, P = 0.01); there was no sex difference in the volunteer group (Cohen's d = 0.02, P = 0.93). On the clinical assessment, female GPs outperformed male GPs in both groups (Cohen's d = 0.61, P <0.0001). A higher clinical score predicted remaining on the UK medical register without a warning or sanction, with no independent effect of sex controlling for assessment performance., Conclusion: Female GPs outperform male GPs on clinical assessments, even among GPs with generally very poor performance. Male GPs under investigation may have particularly poor knowledge. Further research is required to understand potential sex differences in doctors who take tests of competence and how these impact on sex differences in investigation outcomes., (© British Journal of General Practice 2019.)

Background: Physical activity (PA) can improve a range of outcomes following a cancer diagnosis. These include an improvement in experience of side effects of treatment (eg, fatigue) and management of comorbid conditions. PA might also increase survival and reduce recurrence. Digital interventions have shown potential for PA promotion among cancer survivors, but most in a previous review were Web-based, and few studies used mobile apps. There are many PA apps available for general public use, but it is unclear whether these are suitable as a PA intervention after a cancer diagnosis., Objective: This study sought posttreatment nonmetastatic breast, prostate, and colorectal cancer survivors' opinions of using smartphone apps to promote PA and gathered their views on existing publicly available PA apps to inform a future intervention., Methods: Each participant was randomly assigned to download 2 of 4 apps (Human, The Walk, The Johnson & Johnson Official 7 Minute Workout, and Gorilla Workout). Participants used each app for 1 week consecutively. In-depth semistructured telephone interviews were then conducted to understand participants' experiences of using the apps and how app-based PA interventions could be developed for cancer survivors. The interviews were analyzed using thematic analysis., Results: Thirty-two participants took part: 50% (16/32) had prostate cancer, 25% (8/32) had breast cancer, and 25% (8/32) had colorectal cancer. Three core themes were identified. The first theme was that multiple factors affect engagement with PA apps and this is highly personalized. Factors affecting engagement included participants' perceptions of (1) the advantages and disadvantages of using apps to support PA, (2) the relevance of the app to the user (eg, in terms of cancer-related factors, their PA goals, the difficulty level of the app, the way in which they interact with their mobile phone, and the extent to which the app fits with their self-identity), (3) the quality of the app (eg, usability, accuracy, quality of production, and scientific evidence-base), and (4) the behavior change techniques used to promote PA. In the second theme, participants recommended that apps that promote walking are most appealing, as walking removes many barriers to PA. Finally, the participants suggested that PA apps should be integrated into cancer care, as they valued guidance and recommendations from health care professionals., Conclusions: This sample of breast, prostate, and colorectal cancer survivors was receptive to the use of apps to promote PA. Although no publicly available PA app was deemed wholly suitable, many suggestions for adaptation and intervention development were provided. The results can inform the development of an app-based PA intervention for cancer survivors. They also highlight the wide-ranging and dynamic influences on engagement with digital interventions, which can be applied to other evaluations of mobile health products in other health conditions and other health behaviors., (©Anna L Roberts, Henry WW Potts, Dimitrios A Koutoukidis, Lee Smith, Abigail Fisher. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 04.01.2019.)

Background: The demographics of doctors working in the UK are changing. The United Kingdom (UK) has voted to leave the European Union (EU) and there is heightened political discourse around the world about the impact of migration on healthcare services. Previous work suggests that foreign trained doctors perform worse than UK graduates in postgraduate medical examinations. We analysed the prevalence by country of primary medical qualification of doctors who were required to take an assessment by the General Medical Council (GMC) because of performance concerns., Methods: This was a retrospective cohort analysis of data routinely collected by the GMC. We compared doctors who had a GMC performance assessment between 1996 and 2013 with the medical register in the same period. The outcome measures were numbers experiencing performance assessments by country or region of medical qualification., Results: The rate of performance assessment varied significantly by place of medical qualification and by year; χ 2 (17) = 188, p < 0.0001, pseudo-R 2  = 15%. Doctors who trained outside of the UK, including those trained in the European Economic Area (EEA), were more likely to have a performance assessment than UK trained doctors, with the exception of South African trained doctors., Conclusions: The rate of performance assessment varies significantly by place of medical qualification. This is the first study to explore the risk of performance assessment by individual places of medical qualification. While concern has largely focused on the competence of non-EEA, International Medical Graduates, we discuss implications for how to ensure European trained doctors are fit to practise before their medical licence in the UK is granted. Further research is needed to investigate whether these country effects hold true when controlling for factors like doctors' sex, age, length of time working in the UK, and English language skills. This will allow evidence-based decisions to be made around the regulatory environment the UK should adopt once it leaves the EU. Patients should be reassured that the vast majority of all doctors working in the UK are competent.

Background: We aimed to compare the performance of EQ-5D-3 L and howRu, which are short generic patient-reported outcome measures (PROMs), in assessing the outcome of hip and knee replacements, using the Oxford Hip Score (OHS) and the Oxford Knee Scores (OKS) for comparison., Methods: Outcome was assessed as the difference between pre-surgery and 6-month post-surgery scores. We used a large sample from the NHS PROMs database, which used EQ-5D-3 L, and a small cohort of patients having the same operations collected by MyClinicalOutcomes (MCO), which used howRu. Both cohorts completed the OHS (hips) or the OKS (knees)., Results: The change (outcome) between pre-op and post-op scores as measured by howRu was greater than that measured by EQ-5D, relative to that measured by OHS or OKS. For hip replacements, the correlation for change measured by howRu and OHS was r = 0.77 (0.66-0.85). The corresponding correlation for change measured by EQ-5D Index and OHS was r = 0.64 (0.63-0.64). For knee replacements the correlation between change in howRu and OKS was r = 0.86 (0.75-0.92); between EQ-5D Index and OKS r = 0.59 (0.58-0.60)., Conclusions: For hip and knee replacement, the outcome measured by howRu was more highly correlated with that measured by the condition-specific Oxford Hip and Knee Scores than were EQ-5D Index or EQ-VAS. The magnitude of change before and after surgery was also greater.

Background: Depression and anxiety are common, often comorbid, conditions, and Internet support groups for them are well used. However, little rigorous research has been conducted on the outcome of these groups., Objective: This study aimed to evaluate the efficacy of an Internet support group in reducing depression and anxiety, and increasing social support and life satisfaction., Methods: A randomized trial compared direction to an existing Internet support group for depression and anxiety with an online expressive writing condition. A total of 863 (628 female) United Kingdom, United States, and Canadian volunteers were recruited via the Internet. Online, self-report measures of depression, anxiety, social support, and satisfaction with life were administered at baseline, 3, and 6 months., Results: All four outcomes - depression, anxiety, social support, and satisfaction with life - improved over the 6 months of the study (all P <.001). There was no difference in outcome between the two conditions: participants responded similarly to the expressive writing and the Internet support group. Engagement with the Internet support group was low, it had high 6-month attrition (692/795, 87%) and low adherence, and it received mixed and often negative feedback. The main problems reported were a lack of comfort and connection with others, negative social comparisons, and the potential for receiving bad advice. Expressive writing had lower attrition (194/295, 65%) and participants reported that it was more acceptable., Conclusions: Until further evidence accumulates, directing people with depression and anxiety to Internet support groups cannot be recommended. On the other hand, online expressive writing seems to have potential, and its use for people with depression and anxiety warrants further investigation., Trial Registration: Clinicaltrials.gov NCT01149265; https://clinicaltrials.gov/ct2/show/NCT01149265 (Archived by WebCite at http://www.webcitation.org/6hYISlNFT).

Objectives: To investigate reasons underlying the low uptake of the influenza A H1N1v vaccination in the UK during the 2009/10 pandemic., Methods: We analysed data from five national telephone surveys conducted in the UK during the latter stages of the pandemic to identify predictors of uptake amongst members of the public offered the vaccine by their primary care physician (n=1320). In addition to demographic variables, participants reported: reasons for declining the vaccination, levels of worry about the risk of catching swine flu, whether too much fuss was being made about the pandemic, whether they or a close friend or relative had had swine flu, how effective they felt the vaccine was, whether they had previously had a seasonal flu vaccination, how well prepared they felt the government was for a pandemic and how satisfied they were with information available about the pandemic. Most participants (n=734, 55.6%) reported being vaccinated against swine flu, compared to 396 who had not been vaccinated and were unlikely to be vaccinated in the future., Results: The main reasons given for declining vaccination were concerns over the vaccine's safety, and being generally healthy. Controlling for demographic variables, risk factors for not being vaccinated were: being female, not having a long-standing infirmity or illness, not having been vaccinated against seasonal flu in previous years, feeling that too much fuss had been made about the pandemic and believing that the vaccine was ineffective., Conclusions: Interventions that target these factors may be effective in improving uptake in a future pandemic., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Members of the public are often sceptical about warnings of an impending public health crisis. Breaking through this scepticism is important if we are to convince people to take urgent protective action. In this paper we explored correlates of perceiving that 'too much fuss' was being made about the 2009/10 influenza A H1N1v ('swine flu') pandemic., Study Design: A secondary analysis of data from 39 nationally representative telephone surveys conducted in the UK during the pandemic., Methods: Each cross-sectional survey (combined n = 42,420) collected data over a three day period and asked participants to state whether they agreed or disagreed that 'too much fuss is being made about the risk of swine flu.', Results: Overall, 55.1% of people agreed or strongly agreed with this sentiment. Perceiving that too much fuss was being made was associated with: being male, being white, being generally healthy, trusting most in a primary care physician to provide advice, not knowing someone who had contracted the illness, believing you know a lot about the outbreak, not wishing to receive additional information about the outbreak and possessing worse factual knowledge about the outbreak than other people., Conclusions: In future disease outbreaks merely providing factual information is unlikely to engage people who are sceptical about the need to take action. Instead, messages which challenge their perceived knowledge and which present case studies of people who have been affected may prove more effective, especially when delivered through trusted channels., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Clinical information systems in the National Health Service do not need to conform to any explicit usability requirements. Poor usability can increase the mental workload experienced by clinicians and cause fatigue, increase error rates and impact the overall patient safety. Mental workload can be used as a measure of usability., Objective: To assess the subjective cognitive workload experienced by general practitioners (GPs) with their systems. To raise awareness of the importance of usability in system design among users, designers, developers and policymakers., Method: We used a modified version of the NASA Task Load Index, adapted for web. We developed a set of common clinical scenarios and computer tasks on an online survey. We emailed the study link to 199 clinical commissioning groups and 1,646 GP practices in England., Results: Sixty-seven responders completed the survey. The respondents had spent an average of 17 years in general practice, had experience of using a mean of 1.5 GP computer systems and had used their current system for a mean time of 6.7 years. The mental workload score was not different among systems. There were significant differences among the task scores, but these differences were not specific to particular systems. The overall score and task scores were related to the length of experience with their present system., Conclusion: Four tasks imposed a higher mental workload on GPs: 'repeat prescribing', 'find episode', 'drug management' and 'overview records'. Further usability studies on GP systems should focus on these tasks. Users, policymakers, designers and developers should remain aware of the importance of usability in system design.What does this study add?• Current GP systems in England do not need to conform to explicit usability requirements. Poor usability can increase the mental workload of clinicians and lead to errors.• Some clinical computer tasks incur more cognitive workload than others and should be considered carefully during the design of a system.• GPs did not report overall very high levels of subjective cognitive workload when undertaking common clinical tasks with their systems.• Further usability studies on GP systems should focus on the tasks incurring higher cognitive workload.• Users, policymakers, and designers and developers should remain aware of the importance of usability in system design.

Background: The relationship between male sex and poor performance in doctors remains unclear, with high profile studies showing conflicting results. Nevertheless, it is an important first step towards understanding the causes of poor performance in doctors. This article aims to establish the robustness of the association between male sex and poor performance in doctors, internationally and over time., Methods: The electronic databases MEDLINE, EMBASE, and PsycINFO were searched from inception to January 2015. Backward and forward citation searching was performed. Journals that yielded the majority of the eligible articles and journals in the medical education field were electronically searched, along with the conference and poster abstracts from two of the largest international medical education conferences. Studies reporting original data, written in English or French, examining the association between sex and medico-legal action against doctors were included. Two reviewers independently extracted study characteristics and outcome data from the full texts of the studies meeting the eligibility criteria. Study quality was assessed using the Newcastle-Ottawa scale. A random effect meta-analysis model was used to summarize and assess the effect of doctors' sex on medico-legal action. Extracted outcomes included disciplinary action by a medical regulatory board, malpractice experience, referral to a medical regulatory body, complaints received by a healthcare complaints body, criminal cases, and medico-legal matter with a medical defence organisation., Results: Overall, 32 reports examining the association between doctors' sex and medico-legal action were included in the systematic review (n=4,054,551), of which 27 found that male doctors were more likely to have experienced medico-legal action. 19 reports were included in the meta-analysis (n=3,794,486, including 20,666 cases). Results showed male doctors had nearly two and a half times the odds of being subject to medico-legal action than female doctors. Heterogeneity was present in all meta-analyses., Conclusion: Male doctors are more likely to have had experienced medico-legal actions compared to female doctors. This finding is robust internationally, across outcomes of varying severity, and over time.

Objective: Healthcare institutions worldwide are moving to electronic health records (EHRs). These transitions are particularly numerous in the US where healthcare systems are purchasing and implementing commercial EHRs to fulfill federal requirements. Despite the central role of EHRs to workflow, the cognitive impact of these transitions on the workforce has not been widely studied. This study assesses the changes in cognitive workload among pediatric nurses during data entry and retrieval tasks during transition from a hybrid electronic and paper information system to a commercial EHR., Materials and Methods: Baseline demographics and computer attitude and skills scores were obtained from 74 pediatric nurses in two wards. They also completed an established and validated instrument, the NASA-TLX, that is designed to measure cognitive workload; this instrument was used to evaluate cognitive workload of data entry and retrieval. The NASA-TLX was administered at baseline (pre-implementation), 1, 5 and 10 shifts and 4 months post-implementation of the new EHR., Results: Most nurse participants experienced significant increases of cognitive workload at 1 and 5 shifts after "go-live". These increases abated at differing rates predicted by participants' computer attitudes scores (p = 0.01)., Conclusions: There is substantially increased cognitive workload for nurses during the early phases (1-5 shifts) of EHR transitions. Health systems should anticipate variability across workers adapting to "meaningful use" EHRs. "One-size-fits-all" training strategies may not be suitable and longer periods of technical support may be necessary for some workers., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Policy initiatives and technological advances enable the use of integrated shared care models of healthcare delivery whereby the focus of care is moved from the hospital to the community, and also of models where patients take increasing responsibility for monitoring and treatment. Such shifts may or may be perceived to change professional roles and responsibilities with implications to the delivery of a professionally and legally acceptable standard of care. We focus on oral anticoagulation and stroke prevention therapy to examine some possible professional and legal implications of the increasing use of shared care., Methods: This paper sought to explore how changes in service delivery influence the discharge of professional responsibilities to patients receiving oral anti-coagulation therapy in the context of clinicians' legal and professional duties. We used a case study of the implementation of a distributed care anti-coagulation service. Qualitative data were collected using complementary methods: participant observation, reflective journaling and legal analysis., Results: Concerns identified by this study included a fear of litigation among both hospital and community-based professionals, a reluctance to embrace an extended role, uncertainty among professionals about the extent of their responsibilities and associated difficulties around adequate exchanges of information. These concerns reflected uncertainty among professionals about the legal and professional scope of the duty of care they owed patients., Conclusion: The findings from this study emphasise the importance of clear role definition, communication and inter-agency cooperation for the successful implementation of a shared care service in which threats to professional and legal standards of care are minimised.

Background: Wikipedia is one of the most accessed sources of health information online. The current English-language Wikipedia contains more than 28,000 articles pertaining to health., Objective: The aim was to characterize individuals' motivations for contributing to health content on the English-language Wikipedia., Methods: A set of health-related articles were randomly selected and recent contributors invited to complete an online questionnaire and follow-up interview (by Skype, by email, or face-to-face). Interviews were transcribed and analyzed using thematic analysis and a realist grounded theory approach., Results: A total of 32 Wikipedians (31 men) completed the questionnaire and 17 were interviewed. Those completing the questionnaire had a mean age of 39 (range 12-59) years; 16 had a postgraduate qualification, 10 had or were currently studying for an undergraduate qualification, 3 had no more than secondary education, and 3 were still in secondary education. In all, 15 were currently working in a health-related field (primarily clinicians). The median period for which they have been an active editing Wikipedia was 3-5 years. Of this group, 12 were in the United States, 6 were in the United Kingdom, 4 were in Canada, and the remainder from another 8 countries. Two-thirds spoke more than 1 language and 90% (29/32) were also active contributors in domains other than health. Wikipedians in this study were identified as health professionals, professionals with specific health interests, students, and individuals with health problems. Based on the interviews, their motivations for editing health-related content were summarized in 5 strongly interrelated categories: education (learning about subjects by editing articles), help (wanting to improve and maintain Wikipedia), responsibility (responsibility, often a professional responsibility, to provide good quality health information to readers), fulfillment (editing Wikipedia as a fun, relaxing, engaging, and rewarding activity), and positive attitude to Wikipedia (belief in the value of Wikipedia). An additional factor, hostility (from other contributors), was identified that negatively affected Wikipedians' motivations., Conclusions: Contributions to Wikipedia's health-related content in this study were made by both health specialists and laypeople of varying editorial skills. Their motivations for contributing stem from an inherent drive based on values, standards, and beliefs. It became apparent that the community who most actively monitor and edit health-related articles is very small. Although some contributors correspond to a model of "knowledge philanthropists," others were focused on maintaining articles (improving spelling and grammar, organization, and handling vandalism). There is a need for more people to be involved in Wikipedia's health-related content.

Background: Patient experience is a key quality outcome for modern health services, but most existing survey methods are long and setting-specific. We identified the need for a short generic questionnaire for tracking patient experience., Methods: We describe the development and validation of the howRwe questionnaire. This has two items relating to clinical care (treat you kindly; listen and explain) and two items relating to the organisation of care (see you promptly; well organised) as perceived by patients. Each item has four responses (excellent, good, fair and poor). The questionnaire was trialled in 828 patients in an orthopaedic pre-operative assessment clinic (PAC)., Results: The howRwe questionnaire is shorter (29 words) and more readable (Flesch-Kincaid grade score 2.2) than other questionnaires with broadly similar objectives. Psychometric properties in this sample are good with Cronbach's α=0.82. Following a change to the appointments system in the clinic, howRwe showed improvement in promptness and organisation, but not in kindness and communication, showing that it can distinguish between the clinical and organisational aspects of patient experience., Conclusions: howRwe meets the criteria for a short generic patient experience questionnaire that is suitable for frequent use. In the validation study of PAC patients, it showed good psychometric properties and concurrent, construct and discriminant validity.

Objectives: While the question of who is likely to be selected for clinical psychology training has been studied, evidence on performance during training is scant. This study explored data from seven consecutive intakes of the UK's largest clinical psychology training course, aiming to identify what factors predict better or poorer outcomes., Design: Longitudinal cross-sectional study using prospective and retrospective data., Method: Characteristics at application were analysed in relation to a range of in-course assessments for 274 trainee clinical psychologists who had completed or were in the final stage of their training., Results: Trainees were diverse in age, pre-training experience, and academic performance at A-level (advanced level certificate required for university admission), but not in gender or ethnicity. Failure rates across the three performance domains (academic, clinical, research) were very low, suggesting that selection was successful in screening out less suitable candidates. Key predictors of good performance on the course were better A-levels and better degree class. Non-white students performed less well on two outcomes. Type and extent of pre-training clinical experience on outcomes had varied effects on outcome. Research supervisor ratings emerged as global indicators and predicted nearly all outcomes, but may have been biased as they were retrospective. Referee ratings predicted only one of the seven outcomes examined, and interview ratings predicted none of the outcomes., Conclusions: Predicting who will do well or poorly in clinical psychology training is complex. Interview and referee ratings may well be successful in screening out unsuitable candidates, but appear to be a poor guide to performance on the course., (© 2013 The Authors. British Journal of Clinical Psychology published by John Wiley & Sons Ltd on behalf of the British Psychological Society.)

Background: To investigate whether factors can be identified that significantly affect hospital length of stay from those available in an electronic patient record system, using primary total knee replacements as an example. To investigate whether a model can be produced to predict the length of stay based on these factors to help resource planning and patient expectations on their length of stay., Methods: Data were extracted from the electronic patient record system for discharges from primary total knee operations from January 2007 to December 2011 (n=2,130) at one UK hospital and analysed for their effect on length of stay using Mann-Whitney and Kruskal-Wallis tests for discrete data and Spearman's correlation coefficient for continuous data. Models for predicting length of stay for primary total knee replacements were tested using the Poisson regression and the negative binomial modelling techniques., Results: Factors found to have a significant effect on length of stay were age, gender, consultant, discharge destination, deprivation and ethnicity. Applying a negative binomial model to these variables was successful. The model predicted the length of stay of those patients who stayed 4-6 days (~50% of admissions) with 75% accuracy within 2 days (model data). Overall, the model predicted the total days stayed over 5 years to be only 88 days more than actual, a 6.9% uplift (test data)., Conclusions: Valuable information can be found about length of stay from the analysis of variables easily extracted from an electronic patient record system. Models can be successfully created to help improve resource planning and from which a simple decision support system can be produced to help patient expectation on their length of stay.

Background: Prospective Hazard Analysis techniques such as Healthcare Failure Modes and Effects Analysis (HFMEA) and Structured What If Technique (SWIFT) have the potential to increase safety by identifying risks before an adverse event occurs. Published accounts of their application in healthcare have identified benefits, but the reliability of some methods has been found to be low. The aim of this study was to examine the validity of SWIFT and HFMEA by comparing their outputs in the process of risk assessment, and comparing the results with risks identified by retrospective methods., Methods: The setting was a community-based anticoagulation clinic, in which risk assessment activities had been previously performed and were available. A SWIFT and an HFMEA workshop were conducted consecutively on the same day by experienced experts. Participants were a mixture of pharmacists, administrative staff and software developers. Both methods produced lists of risks scored according to the method's procedure. Participants' views about the value of the workshops were elicited with a questionnaire., Results: SWIFT identified 61 risks and HFMEA identified 72 risks. For both methods less than half the hazards were identified by the other method. There was also little overlap between the results of the workshops and risks identified by prior root cause analysis, staff interviews or clinical governance board discussions. Participants' feedback indicated that the workshops were viewed as useful., Conclusions: Although there was limited overlap, both methods raised important hazards. Scoping the problem area had a considerable influence on the outputs. The opportunity for teams to discuss their work from a risk perspective is valuable, but these methods cannot be relied upon in isolation to provide a comprehensive description. Multiple methods for identifying hazards should be used and data from different sources should be integrated to give a comprehensive view of risk in a system.

Background: Measures used for medical student selection should predict future performance during training. A problem for any selection study is that predictor-outcome correlations are known only in those who have been selected, whereas selectors need to know how measures would predict in the entire pool of applicants. That problem of interpretation can be solved by calculating construct-level predictive validity, an estimate of true predictor-outcome correlation across the range of applicant abilities., Methods: Construct-level predictive validities were calculated in six cohort studies of medical student selection and training (student entry, 1972 to 2009) for a range of predictors, including A-levels, General Certificates of Secondary Education (GCSEs)/O-levels, and aptitude tests (AH5 and UK Clinical Aptitude Test (UKCAT)). Outcomes included undergraduate basic medical science and finals assessments, as well as postgraduate measures of Membership of the Royal Colleges of Physicians of the United Kingdom (MRCP(UK)) performance and entry in the Specialist Register. Construct-level predictive validity was calculated with the method of Hunter, Schmidt and Le (2006), adapted to correct for right-censorship of examination results due to grade inflation., Results: Meta-regression analyzed 57 separate predictor-outcome correlations (POCs) and construct-level predictive validities (CLPVs). Mean CLPVs are substantially higher (.450) than mean POCs (.171). Mean CLPVs for first-year examinations, were high for A-levels (.809; CI: .501 to .935), and lower for GCSEs/O-levels (.332; CI: .024 to .583) and UKCAT (mean = .245; CI: .207 to .276). A-levels had higher CLPVs for all undergraduate and postgraduate assessments than did GCSEs/O-levels and intellectual aptitude tests. CLPVs of educational attainment measures decline somewhat during training, but continue to predict postgraduate performance. Intellectual aptitude tests have lower CLPVs than A-levels or GCSEs/O-levels., Conclusions: Educational attainment has strong CLPVs for undergraduate and postgraduate performance, accounting for perhaps 65% of true variance in first year performance. Such CLPVs justify the use of educational attainment measure in selection, but also raise a key theoretical question concerning the remaining 35% of variance (and measurement error, range restriction and right-censorship have been taken into account). Just as in astrophysics, 'dark matter' and 'dark energy' are posited to balance various theoretical equations, so medical student selection must also have its 'dark variance', whose nature is not yet properly characterized, but explains a third of the variation in performance during training. Some variance probably relates to factors which are unpredictable at selection, such as illness or other life events, but some is probably also associated with factors such as personality, motivation or study skills.

This article presents a systematic review of the literature on information visualization for making sense of personal health information. Based on this review, five application themes were identified: treatment planning, examination of patients' medical records, representation of pedigrees and family history, communication and shared decision making, and life management and health monitoring. While there are recognized design challenges associated with each of these themes, such as how best to represent data visually and integrate qualitative and quantitative information, other challenges and opportunities have received little attention to date. In this article, we highlight, in particular, the opportunities for supporting people in better understanding their own illnesses and making sense of their health conditions in order to manage them more effectively.

Research has examined the public's understanding of mental illness and stigma, but there is scant evidence on intellectual disabilities. This study investigated whether the public from different ethnic groups can recognise symptoms of schizophrenia and intellectual disability depicted in a vignette, and what factors predict recognition and social distance. A survey of lay people of working age was completed in the UK (N=1002). The sample was ethnically mixed, with the largest groups consisting of white UK residents, and people from Asian and black African/Caribbean backgrounds. Regression analyses were performed to identify predictors of recognition and social distance. Across the whole sample, 25.7% recognised schizophrenia and 28.0% intellectual disability. Ethnicity, gender, education and prior contact predicted recognition of both vignettes. Social distance was higher for schizophrenia than intellectual disability, but overall participants were ambivalent to mildly negative about social contact with individuals with either symptomatology. Familiarity was associated with lower social distance for both conditions. Symptom recognition predicted reduced social distance for intellectual disability, but not for schizophrenia. The low levels of awareness of symptoms and high levels of stigma among some ethnic groups indicate a need for targeted public education efforts and further research., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: UK-trained medical students and doctors from minority ethnic groups underperform academically. It is unclear why this problem exists, which makes it difficult to know how to address it., Aim: To investigate whether demographic and psychological factors mediate the relationship between ethnicity and final examination scores., Sample: Two consecutive cohorts of Year 5 (final year) UCL Medical School students (n= 703; 51% minority ethnic). A total of 587 (83%) had previously completed a questionnaire in Year 3., Methods: Participants were administered a questionnaire in 2005 and 2006 that included a short version of the NEO-PI-R, the Study Process Questionnaire, and the General Health Questionnaire (GHQ) as well as socio-demographic measures. Participants were then followed up to final year (2007-2010). White and minority ethnic students' questionnaire responses and final examination grades were compared using univariate tests. The effect of ethnicity on final year grades after taking into account the questionnaire variables was calculated using hierarchical multiple linear regression., Results: Univariate ethnic differences were found on age, personality, learning styles, living at home, first language, parental factors, and prior education. Minority ethnic students had lower final exam scores, were more likely to fail, and less likely to achieve a merit or distinction in finals. Multivariate analyses showed ethnicity predicted final exam scores even after taking into account questionnaire factors., Conclusions: Ethnic differences in the final year performance of two cohorts of UCL medical students were not due to differences in psychological or demographic factors, which suggests alternative explanations are responsible for the ethnic attainment gap in medicine., (© 2011 The British Psychological Society.)

This paper reports on a head-to-head study of howRU and EQ-5D on patients with cardiovascular disease. howRU is a short generic measure of health-related quality of life comprising 39 words, designed for routine use, which we compare with EQ-5D (230 words). Patients attending a clinic completed both instruments. Completed data were available for 116 patients, 51% female, mean age 56 and SD 20. howRU is shorter, has better readability statistics, a higher completion rate, a wider range of states used and a smaller ceiling effect than EQ-5D. The correlations of howRU with EQ-5D are similar to those of EQ-5D with other validated instruments.

Background: UK medical schools typically have over 300 students per year, making it impossible for students to know all the others well., Aims: This longitudinal cohort study measured the formation of medical student social networks and their relationship to grades., Method: In November 2009, 215/317 (68%) Year 2 UCL medical students reported their friendships with others in their year, by questionnaire. Multiple regression assessed the relationship between friendships, exam results and background variables (obtained from student records), with permutation testing to assess statistical significance., Results: Students of the same sex, the same ethnic group, and in the same tutor and small groups (to which they were randomly assigned at the start of medical school) were socially closer. Taking into account absolute difference in Year 1 grades, Year 2 pairs who were socially closer in November 2009 had more similar May 2010 grades. Individual student variables did not predict similarity in 2010 grades after taking friendships into account., Conclusions: The results suggest that medical students chose friends of the same sex and ethnic group as themselves; but random allocation of students to tutor groups also influenced friendships. Most importantly, friendships related to subsequent exam performance, suggesting friendship may influence learning.

Background: This study investigated whether the introduction of professional development teaching in the first two years of a medical course improved students' observed communication skills with simulated patients. Students' observed communication skills were related to patient-centred attitudes, confidence in communicating with patients and performance in later clinical examinations., Methods: Eighty-two medical students from two consecutive cohorts at a UK medical school completed two videoed consultations with a simulated patient: one at the beginning of year 1 and one at the end of year 2. Group 1 (n = 35) received a traditional pre-clinical curriculum. Group 2 (n = 47) received a curriculum that included communication skills training integrated into a 'professional development' vertical module. Videoed consultations were rated using the Evans Interview Rating Scale by communication skills tutors. A subset of 27% were double-coded. Inter-rater reliability is reported., Results: Students who had received the professional development teaching achieved higher ratings for use of silence, not interrupting the patient, and keeping the discussion relevant compared to students receiving the traditional curriculum. Patient-centred attitudes were not related to observed communication. Students who were less nervous and felt they knew how to listen were rated as better communicators. Students receiving the traditional curriculum and who had been rated as better communicators when they entered medical school performed less well in the final year clinical examination., Conclusions: Students receiving the professional development training showed significant improvements in certain communication skills, but students in both cohorts improved over time. The lack of a relationship between observed communication skills and patient-centred attitudes may be a reflection of students' inexperience in working with patients, resulting in 'patient-centredness' being an abstract concept. Students in the early years of their medical course may benefit from further opportunities to practise basic communication skills on a one-to-one basis with patients.

During the 2009 flu pandemic, all frontline UK healthcare workers were encouraged to have both the seasonal and swine flu vaccines. Analysis of six national telephone surveys conducted in the run-up to the UK's swine flu vaccination campaign showed that NHS workers were no more likely to accept the swine flu vaccine than non-NHS workers (55.6% versus 52.4% respectively), although they were more likely to accept the seasonal flu vaccine (38.8% versus 22.6%). Reasons for non-acceptance were similar for both vaccines: low perceived personal benefits together with safety and efficacy concerns. Addressing these factors may improve uptake in future vaccination campaigns., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To determine whether the ethnicity of UK trained doctors and medical students is related to their academic performance., Design: Systematic review and meta-analysis., Data Sources: Online databases PubMed, Scopus, and ERIC; Google and Google Scholar; personal knowledge; backwards and forwards citations; specific searches of medical education journals and medical education conference abstracts., Study Selection: The included quantitative reports measured the performance of medical students or UK trained doctors from different ethnic groups in undergraduate or postgraduate assessments. Exclusions were non-UK assessments, only non-UK trained candidates, only self reported assessment data, only dropouts or another non-academic variable, obvious sampling bias, or insufficient details of ethnicity or outcomes. Results 23 reports comparing the academic performance of medical students and doctors from different ethnic groups were included. Meta-analyses of effects from 22 reports (n = 23,742) indicated candidates of "non-white" ethnicity underperformed compared with white candidates (Cohen's d = -0.42, 95% confidence interval -0.50 to -0.34; P<0.001). Effects in the same direction and of similar magnitude were found in meta-analyses of undergraduate assessments only, postgraduate assessments only, machine marked written assessments only, practical clinical assessments only, assessments with pass/fail outcomes only, assessments with continuous outcomes only, and in a meta-analysis of white v Asian candidates only. Heterogeneity was present in all meta-analyses., Conclusion: Ethnic differences in academic performance are widespread across different medical schools, different types of exam, and in undergraduates and postgraduates. They have persisted for many years and cannot be dismissed as atypical or local problems. We need to recognise this as an issue that probably affects all of UK medical and higher education. More detailed information to track the problem as well as further research into its causes is required. Such actions are necessary to ensure a fair and just method of training and of assessing current and future doctors.

Background: User-generated content in an online environment has significant implications in both education and health. Instead of a model of knowledge being something transferred from the expert to the student or to the patient, Web 2.0 technologies offer the hope of making learning, and healthcare delivery, a more collaborative and participative process. However, some evidence suggests that this supposed democratisation of production is not entirely democratic and, in an educational context, many students are uncomfortable about sharing material they create with their peers., Aim: To understand students' affective and other experiences of generating content to be shared online with peers (e.g. in online discussions)., Methods: Online interviews, face-to-face focus groups and further methods with two student groups in medical education, one undergraduate and one postgraduate., Results: Students were broadly positive about creating and sharing material online, but were also quite anxious about doing so. Many practical issues, including around course design, student workload and assessment pressures, were barriers to students creating and sharing material. Group size is also important, with self-sustaining activity less likely in small groups., Conclusion: Successfully introducing user-generated content into medical education requires attention to practical details and an awareness of the student anxiety that can arise.

Objectives: To assess the association between levels of worry about the possibility of catching swine flu and the volume of media reporting about it; the role of psychological factors in predicting likely uptake of the swine flu vaccine; and the role of media coverage and advertising in predicting other swine flu-related behaviours., Design: Data from a series of random-digit-dial telephone surveys were analysed. A time series analysis tested the association between levels of worry and the volume of media reporting on the start day of each survey. Cross-sectional regression analyses assessed the relationships between likely vaccine uptake or behaviour and predictor variables., Setting: Thirty-six surveys were run at, on average, weekly intervals across the UK between 1 May 2009 and 10 January 2010. Five surveys (run between 14 August and 13 September) were used to assess likely vaccine uptake. Five surveys (1-17 May) provided data relating to other behaviours., Participants: Between 1047 and 1173 people aged 16 years or over took part in each survey: 5175 participants provided data about their likely uptake of the swine flu vaccine; 5419 participants provided data relating to other behaviours., Main Outcome Measures: All participants were asked to state how worried they were about the possibility of personally catching swine flu. Subsets were asked how likely they were to take up a swine flu vaccination if offered it and whether they had recently carried tissues with them, bought sanitising hand gel, avoided using public transport or had been to see a general practitioner, visited a hospital or called NHS Direct for a flu-related reason., Results: The percentage of 'very' or 'fairly' worried participants fluctuated between 9.6% and 32.9%. This figure was associated with the volume of media reporting, even after adjusting for the changing severity of the outbreak [chi2(1) = 6.6, p = 0.010, coefficient for log-transformed data = 2.6]. However, this effect only occurred during the UK's first summer wave of swine flu. In total, 56.1% of respondents were very or fairly likely to accept the swine flu vaccine. The strongest predictors were being very worried about the possibility of oneself [adjusted odds ratio (aOR) 4.7, 95% confidence interval (CI) 3.2 to 7.0] or one's child (aOR 8.0, 95% CI 4.6 to 13.9) catching swine flu. Overall, 33.1% of participants reporting carrying tissues with them, 9.5% had bought sanitising gel, 2.0% had avoided public transport and 1.6% had sought medical advice. Exposure to media coverage or advertising about swine flu increased tissue carrying or buying of sanitising hand gel, and reduced avoidance of public transport or consultation with health services during early May 2009. Path analyses showed that media coverage and advertising had these differential effects because they raised the perceived efficacy of hygiene behaviours but decreased the perceived efficacy of avoidance behaviours., Conclusions: During the swine flu outbreak, uptake rates for protective behaviours and likely acceptance rates for vaccination were low. One reason for this may in part be explained by was the low level of public worry about the possibility of catching swine flu. When levels of worry are generally low, acting to increase the volume of mass media and advertising coverage is likely to increase the perceived efficacy of recommended behaviours, which, in turn, is likely to increase their uptake.

Objective: To evaluate a national programme to develop and implement centrally stored electronic summaries of patients' medical records., Design: Mixed-method, multilevel case study., Setting: English National Health Service 2007-10. The summary care record (SCR) was introduced as part of the National Programme for Information Technology. This evaluation of the SCR considered it in the context of national policy and its frontline implementation and use in three districts. Participants and methods Quantitative data (cumulative records created nationally plus a dataset of 416 325 encounters in participating primary care out-of-hours and walk-in centres) were analysed statistically. Qualitative data (140 interviews including policy makers, managers, clinicians, and software suppliers; 2000 pages of ethnographic field notes including observation of 214 clinical consultations; and 3000 pages of documents) were analysed thematically and interpretively., Results: Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme's fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort., Conclusions: Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale.

Background: Many quality and safety improvement methods in healthcare rely on a complete and accurate map of the process. Process mapping in healthcare is often achieved using a sequential flow diagram, but there is little guidance available in the literature about the most effective type of process map to use. Moreover there is evidence that the organisation of information in an external representation affects reasoning and decision making. This exploratory study examined whether the type of process map - sequential or hierarchical - affects healthcare practitioners' judgments., Methods: A sequential and a hierarchical process map of a community-based anti coagulation clinic were produced based on data obtained from interviews, talk-throughs, attendance at a training session and examination of protocols and policies. Clinic practitioners were asked to specify the parts of the process that they judged to contain quality and safety concerns. The process maps were then shown to them in counter-balanced order and they were asked to circle on the diagrams the parts of the process where they had the greatest quality and safety concerns. A structured interview was then conducted, in which they were asked about various aspects of the diagrams., Results: Quality and safety concerns cited by practitioners differed depending on whether they were or were not looking at a process map, and whether they were looking at a sequential diagram or a hierarchical diagram. More concerns were identified using the hierarchical diagram compared with the sequential diagram and more concerns were identified in relation to clinical work than administrative work. Participants' preference for the sequential or hierarchical diagram depended on the context in which they would be using it. The difficulties of determining the boundaries for the analysis and the granularity required were highlighted., Conclusions: The results indicated that the layout of a process map does influence perceptions of quality and safety problems in a process. In quality improvement work it is important to carefully consider the type of process map to be used and to consider using more than one map to ensure that different aspects of the process are captured.

Context: The extensive research literature on electronic patient records (EPRs) presents challenges to systematic reviewers because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches., Methods: Using the meta-narrative method and searching beyond the Medline-indexed literature, this review used "conflicting" findings to address higher-order questions about how researchers had differently conceptualized and studied the EPR and its implementation., Findings: Twenty-four previous systematic reviews and ninety-four further primary studies were considered. Key tensions in the literature centered on (1) the EPR ("container" or "itinerary"); (2) the EPR user ("information-processer" or "member of socio-technical network"); (3) organizational context ("the setting within which the EPR is implemented" or "the EPR-in-use"); (4) clinical work ("decision making" or "situated practice"); (5) the process of change ("the logic of determinism" or "the logic of opposition"); (6) implementation success ("objectively defined" or "socially negotiated"); and (7) complexity and scale ("the bigger the better" or "small is beautiful")., Conclusions: The findings suggest that EPR use will always require human input to recontextualize knowledge; that even though secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper may offer a unique degree of ecological flexibility; and that smaller EPR systems may sometimes be more efficient and effective than larger ones. We suggest an agenda for further research.

The practice of clinical medicine is becoming increasingly specialized, and this change has increased the challenge of developing fair, valid, and reliable tests of knowledge, particularly for single candidates or small groups of candidates. The problem is particularly relevant to the UK's General Medical Council's Fitness to Practice procedures, which investigate individual doctors. In such cases, there is a need for an alternative to the conventional approach to reliability estimation that will still allow the delivery of reproducible and standardized tests. This report describes the three-year process (starting in 2005) of developing a knowledge test that can be tailored for individual doctors practicing in narrowly specialized fields or at various stages in their training. The process of test development for this study consisted of five stages: item writing, to create individual questions; blueprinting, to establish the content and context that each item might test; standard setting, to calculate for each question a theoretical probability that a doctor of just-adequate capability would answer the question correctly; reference data collection, to determine for each item the distribution of scores to be expected from a large population of doctors in good standing; and test assembly, to select sets of questions that together formed complete and balanced tests. Tailored testing is a valid, feasible, and reproducible method of assessing the knowledge of one doctor or small groups of doctors who are practicing in narrow or subspecialty areas.

It is a tenet of cognitive behavioral treatment of persistent pain problems that ex-patients should adhere to treatment methods over the longer term, in order to maintain and to extend treatment gains. However, no research has quantified the causal influence of adherence on short-term outcome in this field. The aims of this study are to assess determinants of adherence to treatment recommendations in several domains, and to examine the extent to which cognitive and behavioral adherence predicts better outcome of cognitive behavioral treatment for persistent pain. Longitudinal data from a sample of 2345 persistent pain patients who attended a multicomponent treatment programme were subjected to structural equation modeling. Adherence emerged as a mediating factor linking post-treatment and follow-up treatment outcome, but contributed only 3% unique variance to follow-up outcomes. Combined end-of-treatment outcomes and adherence factors accounted for 72% of the variance in outcome at one-month follow-up. Notwithstanding shortcomings in the measurement of adherence, these findings question the emphasis normally given to adherence in the maintenance of behavioral and cognitive change, and clinical implications are discussed.

Background: Choose and Book is a central part of the UK Government patient choice agenda that seeks to provide patients with a choice over the time, date and place of their first outpatient appointment. This is done through the use of a computerised booking system. After a 2004 pilot study, Choose and Book was formally launched in January 2006. This is the first study of patient experience of Choose and Book since then., Methods: A questionnaire survey of reported experience of choice over the time, data and place of appointment, carried out in a National Health Service hospital in London. 104 patients at their first outpatient appointment completed the questionnaire, consisting of a consecutive series of patients referred through Choose and Book and a sample referred through the conventional booking system., Results: Among the Choose and Book patients, 66% (31/47; 95% CI 52 to 78%) reported not being given a choice of appointment date, 66% (31/47; 95% CI 52 to 78%) reported not being given a choice of appointment time, 86% (37/43; 95% CI 74 to 94%) reported being given a choice of fewer than four hospitals in total and 32% (15/47; 95% CI 20 to 46%) reported not being given any choice of hospital., Conclusion: In this study, patients did not experience the degree of choice that Choose and Book was designed to deliver.

Background: There are two competing methods for improving the accuracy of a radiologist interpreting screening mammograms: computer aids (CAD) or independent second reading., Methods: Bibliographic databases were searched for clinical trials. Meta-analyses estimated impacts of CAD and double reading on odds ratios for cancer detection and recall rates. Sub-group analyses considered double reading with arbitration., Results: Ten studies compared single reading with CAD to single reading. Seventeen compared double to single reading. Double reading increases cancer detection and recall rates. Double reading with arbitration increases detection rate (confidence interval (CI): 1.02, 1.15) and decreases recall rate (CI: 0.92, 0.96). CAD does not have a significant effect on cancer detection rate (CI: 0.96, 1.13) and increases recall rate (95% CI: 1.09, 1.12). However, there is considerable heterogeneity in the impact on recall rate in both sets of studies., Conclusion: The evidence that double reading with arbitration enhances screening is stronger than that for single reading with CAD.

A number of studies have identified problems with undergraduate oncology teaching. We have investigated how well prepared newly qualified doctors (first foundation year, or FY1 doctors) are for treating patients with cancer. Twenty-five FY1 doctors and 15 senior doctors participated in interviews. We turned the emergent themes into a questionnaire for all 5143 UK FY1 doctors in 2005. The response rate was 43% (2062 responses). Sixty-one percent of FY1 doctors had received oncology teaching at medical school, but 31% recalled seeing fewer than 10 patients with cancer. Forty percent of FY1 doctors felt prepared for looking after patients with cancer. Sixty-five percent felt prepared for diagnosing cancer, 15% felt they knew enough about chemotherapy and radiotherapy, and 11% felt prepared for dealing with oncological emergencies. Respondents believed medical students should learn about symptom control (71%) and communication skills (41%). Respondents who had received oncology teaching were more likely to feel prepared for looking after patients with cancer (OR 1.52; 95% CI 1.14-2.04). Preparedness also correlated with exposure to patients with cancer (OR 1.48; 95% CI 1.22-1.79). We have found worryingly low levels of exposure of medical students to patients with cancer. First foundation year doctors lack knowledge about cancer care and symptom control. Oncologists should maintain involvement in undergraduate teaching, and encourage greater involvement of patients in this teaching.

The aim of this study was to compare reported behavior in the sun in melanoma families with that of geographical healthy controls and to determine the predictors of that behavior to inform the process of counseling melanoma families. One hundred and seventy individuals with a family history of melanoma and 140 controls completed a postal questionnaire. Thirty-one percent of relatives reported sunburn in the previous summer, compared with 41% of controls. Fifty-five percent of relatives had acquired a suntan so that adherence to health education advice was disappointing. Male relatives were particularly likely to report sunburn. Higher knowledge scores correlated well with greater belief in ability to prevent melanoma, less desire for a tan, and more protective behaviors in relatives only (not in controls). We have shown that some psychological characteristics, sex, and age have an effect on behavior, so that the educational approaches needed will vary. "Better" behaviors were reported by melanoma cases than other relatives and by members of families with larger numbers of cases, which suggests that a belief that an individual is at particular risk of melanoma is important for compliance with preventive behaviors.

Women who delay their presentation with breast cancer for three months or longer are more likely to be diagnosed with later stage disease and have poorer survival. Older women, who are at greater risk of developing breast cancer, are also more likely to delay their presentation. Factors associated with delayed presentation were assessed in 69 women (>65 years) with breast cancer. Previous factors identified for women of all ages were confirmed (having a non-lump symptom p=0.003) or strengthened (non-disclosure of symptom discovery to a relative or close friend p=0.001). Additional factors for delay in this older group included reservations about seeing their GP (p=0.02) and fear of the consequences of cancer (p=0.04). These factors should inform the design of interventions to reduce delays.