Category: Health

Sepsis: getting the balance right

An editorial published in the BMJ by Paul  Morgan and me discusses the importance of getting the balance right in the diagnosis and treatment of sepsis. Public and professional understanding of sepsis has increased greatly in recent years. This has led to campaigns to diagnose sepsis early in the clinical course of the illness and to start treatment with antibiotics and fluid replacement promptly. Examples include the Survive Sepsis campaign, which led to the creation of the UK Sepsis Trust, and the establishment of the Global Sepsis Alliance and World Sepsis Day. But could this pressure to improve sepsis management be counterproductive and lead to overdiagnosis of sepsis?


Digital health: A greater focus on human factors is needed

There is growing appreciation that the success of digital health – whether digital tools, digital interventions or technology-based change strategies – is linked to the extent to which human factors are considered throughout the design, development and implementation. A shift in focus to individuals as users and consumers of digital health highlights the capacity of the field to respond to recent developments, such as the adoption of person-centred care and consumer health technologies.

In an article published in the journal BMC Medicine, we argue that this project is not only incomplete, but is fundamentally ‘uncompletable’ in the face of a highly dynamic landscape of both technological and human challenges. These challenges include the effects of consumerist, technology-supported care on care delivery, the rapid growth of digital users in low-income and middle-income countries and the impacts of machine learning.

Digital health research will create most value by retaining a clear focus on the role of human factors in maximising health benefit, by helping health systems to anticipate and understand the person-centred effects of technology changes and by advocating strongly for the autonomy, rights and safety of consumers.

Digital Education in Health Professions: The Need for Overarching Evidence Synthesis

Synthesizing evidence from randomized controlled trials of digital health education is challenging. Problems include a lack of clear categorization of digital health education in the literature; constantly evolving concepts, pedagogies, or theories; and a multitude of methods, features, technologies, or delivery settings.

The Digital Health Education Collaboration was established to evaluate the evidence on digital education in health professions; inform policymakers, educators, and students; and change the way in which these professionals learn and are taught. In a paper published in the Journal of Medical Internet Research, we presented the overarching methods we use to synthesize evidence across our digital health education reviews and to discuss challenges related to the process.

For our research, we followed Cochrane recommendations for the conduct of systematic reviews; all reviews are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. This included assembling experts in various digital health education fields; identifying gaps in the evidence base; formulating focused research questions, aims, and outcome measures; choosing appropriate search terms and databases; defining inclusion and exclusion criteria; running the searches jointly with librarians and information specialists; managing abstracts; retrieving full-text versions of papers; extracting and storing large datasets, critically appraising the quality of studies; analyzing data; discussing findings; drawing meaningful conclusions; and drafting research papers.

The approach used for synthesizing evidence from digital health education trials is the most rigorous benchmark for conducting systematic reviews. Although we acknowledge the presence of certain biases ingrained in the process, we have clearly highlighted and minimized those biases by strictly adhering to scientific rigor, methodological integrity, and standard operating procedures. our paper will be a valuable asset for researchers and methodologists undertaking systematic reviews in digital health education.

Is it getting easier to obtain antibiotics in the UK?

In the UK, antibiotics are, with very few exceptions, only prescribable by doctors or other health professionals with prescribing qualifications. This has meant that, until recently, access to antibiotics has been possible only through face-to-face medical assessment in primary or secondary care, providing a significant disincentive to seeking antibiotics unnecessarily.

Inappropriate prescribing of antibiotics in UK primary care remains of concern, but antimicrobial stewardship initiatives are having a measurable effect, with prescribing rates falling in response to interventions. However, novel routes to obtaining antibiotics, associated with either a lower threshold for prescribing or issuing of antibiotics without medical assessment, undermine these strategies and are likely to increase inappropriate use.

These issues are discussed further in an article published in the British Journal of General Practice.

Type 2 Diabetes in Children and Young Adults

Newly published statistics show that nearly 7,000 children and adults aged under 25 in the UK have been diagnosed with type 2 diabetes. The onset of Type 2 Diabetes is strongly associated with lifestyle factors such as obesity, lack of exercise and high calorie (high sugar) diets. In recent decades, countries such as USA and UK have seen large increases in the number of people with type 2 diabetes. Most of these cases have been among older people but we are now also seeing an increasing number of cases of Type 2 Diabetes among younger people.

Reversing the increase in Type 2 Diabetes is not easy. It requires action by individuals, and also by governments and societies. For individuals, it is important that people eat a healthy, balanced diet that is not too high in calories, and not high in refined carbohydrates and sugars. Dietary changes need to be combined with regular exercise to keep weight down to healthy levels, thereby reducing the risk of developing type 2 diabetes.

A number of people with established type 2 diabetes have reversed their condition through measures such as dieting and exercise. This shows even if an individual has Type 2 Diabetes, they can resolve this through appropriate lifestyle measures.

Measures taken by individuals need to be backed by measures targeting the entire population. This can include for example, ‘sugar taxes’ on high-calorie drinks to encourage individuals to consume them less and to encourage manufacturers to produce lower calorie version of these drinks. Calorie labelling of food can also help people make suitable choices about their diets. We also need measures to encourage physical activity, for example, making it easier and safer for people to cycle and walk rather than using cars.

It’s important that regular exercise and healthy diets are introduced at a young age. Hence, nurseries, schools, colleges and universities also have an important role to play in addressing the causes of Type 2 Diabetes.

Improving patient safety in developing countries

In an article published in the journal JRSM Open, we discuss patient safety in developing countries. Through a review of the literature, lessons and interventions from developed countries have been taken into consideration to identify the themes needed for patient safety improvement. We provide an integrated approach based on best practice which can be used to guide the development of a national strategy for improving patient safety. Policy makers need to focus on developing a holistic and comprehensive approach to patient safety improvement that takes into account the themes discussed in this article.


The costs to the NHS of prescribing for diabetes

Drugs used to treat diabetes are now responsible for 11.4% of total primary care prescribing costs in England, £1,012 million annually. The very high costs to the NHS of treating diabetes are an inevitable consequence of the increase in the prevalence of type 2 diabetes in recent decades. This increase in the prevalence of type 2 diabetes is in turn a consequence of lifestyle factors such as high-calorie diets (particularly diets high in sugars and refined carbohydrates), physical inactivity and obesity. We need effective strategies at both population and individual level, and changes in the obesogenic environment we live in, to reverse these adverse lifestyle- associated factors and bring down the prevalence of type 2 diabetes.

Source: NHS Digital

Integrating a nationally scaled workforce of community health workers in primary care

Increasing workload, a reduced percentage of the budget and workforce retention and recruitment problems challenge the capacity of available general practitioners in the UK NHS. Consequently, patients’ ability to obtain general practitioner appointments has declined. Political pressure to improve access has been accompanied by promises of increased general practitioner numbers, but with a reported fall in 2016–2017,5 it remains unclear how this will be achieved. Meanwhile, financial constraints have also led to the loss of some community-based health services, such as district nursing and fragmentation of others.

In a study published in the Journal of the Royal Society of Medicine, we examined whether the systematic deployment of community health workers in the NHS could help address current problems of fragmentation and inefficiency, while improving clinical outcomes through improved uptake of appropriate services.

Conservative modelling suggested that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workers could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease.

We concluded that the integration of community health workers at scale in NHS primary care could represent a timely and relatively rapidly implemented approach to the workload crisis. Chronic disease management, cancer screening and MMR immunisation uptake provide examples of potential benefits; there is a need for formal piloting to establish the impact of community health workers in NHS primary care.


Presentation of the 2017-2018 MPH Student Research Projects

On Thursday 20 September 2018, our MPH students will be presenting their research projects. This will be the last assessment for the 2017-18 course. We have a wide-range of presentations on very topical issues in global health and health policy. The topic of the projects may help prospective students as they can see the kind of dissertations that our students complete.

  1. Systematic review on the association between Chronic Hepatitis B infection and Malaria; and report on Hepatitis B control strategy in The Gambia
  2. Perceptions of need among parents of children with a developmental delay from black, Asian and minority ethnic (BAME) backgrounds and their experiences of accessing support services
  3. A systematic review of risk factors of knife carrying, usage, and stabbing among young people in United Kingdom.
  4. Perceived context and its role in quality improvement initiatives
  5. The Quality of Diabetes and Hypertension Care among Palestine Refugees in the Middle East: A Cross-sectional Analysis
  6. Associations between air pollution and birthweight in the Avon Longitudinal Study of Parents and Children (ALSPAC) study
  7. A systematic review of community- based interventions for improving health and wellbeing in refugee children and adolescents after resettlement in high income
  8. What is the evidence for the effectiveness of lung cancer awareness schemes in the UK?
  9. Alcohol intake and risk of coronary artery disease: a Mendelian randomisation study
  10. An investigation into experience-based food insecurity indicators: how consistently it captures food hardships and its correlation with objective food insecurity measures across four low- and middle- income countries
  11. Identifying barriers to accessing healthcare in Manicaland, Zimbabwe
  12. Patient data sharing for immigration enforcement purposes: perceptions among Healthcare Providers (HCPs) of a Memorandum of Understanding (MoU) between NHS Digital and the Home Office
  13. Exploring the familial, peer, media and environmental influences that affect adolescents’ health behaviours in the United Kingdom: A qualitative evidence synthesis
  14. Household food insecurity and adolescent non-communicable disease risk behaviours: new evidence from low- and middle-income countries
  15. Blood pressure, hypertension and the risk of sudden cardiac death: A systematic review and meta-analysis of cohort studies
  16. “What matters to me?” An evaluation of a quality improvement intervention in paediatric services at Imperial Healthcare NHS Trust
  17. Trends in antimalarial drug resistance mutations in Africa
  18. Parental employment and child health outcomes
  19. Suicide Watch 2.0: A systematic review of machine learning algorithms to detect suicide risk on social media
  20. Rollout and organisational readiness: The spread of a heart failure care bundle across Northwest London
  21. A Case Study of Caregiver-friendly Workplace Policy (CFWP) in Hong Kong
  22. Determinants of Cognitive Decline and Markers of Aging in Working-Aged Adults: Results from the UK AIRWAVE Cohort
  23. Blood Pressure or Hypertension and The Incidence of Aortic Dissection: Systematic Review and Meta-analysis of Cohort Study
  24. Investigating changes in malaria parasite species composition as a country approaches elimination: A retrospective study of the Global Malaria Eradication Programme
  25. Affordability of Tobacco Products in 79 Countries in 2016
  26. The role of geographic bias in knowledge diffusion
  27. Patient feedback for quality improvement: an evaluation of the use of Friends and Family data at a large NHS Trust in London
  28. A longitudinal analysis of tobacco industry pricing strategies in 23 European Union countries from 2006 to 2017
  29. Have inequalities in cardiovascular outcomes changed with the reductions in public sector spending: an interrupted time series analysis
  30. Children as Frequent Attenders in Primary Care: A Systematic Review
  31. Pilot Study- Patterns of Population Movement in Onchocerciasis foci in Ghana: Parameterising Meta-Population Models for Disease Elimination
  32. Male involvement in Reproductive, Maternal, New-born and Child Health: Evaluating gaps between policy and practice in Uganda
  33. Prevalence of and factors associated with repeat adolescent childbearing in Ethiopia: A secondary data analysis of the 2016 Ethiopian Demographic and Health Survey
  34. Characterising prescribing trends of dependence forming medicines in the management of chronic pain and anxiety; a secondary analysis of national primary care prescribing patterns
  35. How cost-effective is dolutegravir? A systematic review of price, clinical and economic evidence in HIV-1 infected treatment-naïve, treatment-experienced and switch patients
  36. Effects of exposure to both tobacco and e-cigarette advertisements on perceptions and use of tobacco products and e-cigarettes: an analysis of the 2015 National Youth Tobacco Survey
  37. Risk factors associated with antibiotic resistance in inpatients with Escherichia coli infections.
  38. A meta-analysis of how exposure to land uses affects risk of infectious disease in a sample of Sub-Saharan African countries
  39. Predictors of non-adherence to long-term antiretroviral therapy in people living with HIV in Brazil
  40. Trends in Experimentation of Tobacco Products among Adolescents in USA
  41. Integration of sexual and reproductive health services in primary care. A systematic review on the uptake of chlamydia screening in the WHO European region
  42. A systematic review of the safety and otoprotective efficacy of sodium thiosulphate on aminoglycoside-/cisplatin-induced ototoxicity
  43. Exploring the needs for support among parents of children with special educational needs and/or disabilities through the peri-diagnostic period
  44. Pharmaceutical innovation and global health: measuring inequality in pharmaceutical innovation for infectious diseases and assessing the impact of World Bank income classification on market launch and inequality in market launch
  45. Blood pressure, hypertension and the risk of abdominal aortic aneurysms – a systematic review and meta-analysis of cohort studies
  46. From policy to monitoring: evaluating the tool for monitoring impact, performance, and capacity of primary health care in high-performing countries in the WHO European Region
  47. Vaccine-preventable diseases among migrant populations in Europe: a systematic analysis
  48. HIV Prevalence and ART Uptake in Children in East Zimbabwe
  49. Costs and cost-effectiveness of multiple HIV counselling and testing modalities: Evidence from a prospective cohort study in Southern Mozambique
  50. Predictors of Skilled Birth Attendants in Ethiopia
  51. A systematic review and meta-analysis on the prevalence and impact of occult hepatitis B infection (OBI) on advanced liver disease
  52. Prevalence and determinants of cigarette smoking relapse among US adult smokers – a longitudinal study.
  53. Exploring the use and application of sustainability methods in healthcare practice: a systematic scoping review
  54. Factors associated with use of short-acting and long-acting reversible contraceptives in Ethiopia
  55. Evaluation of Country Cooperation Strategies in three countries of WHO regions for Health System Strengthening
  56. Characteristics of patients initiating second medical opinions, and impact on management and satisfaction: a systematic review
  57. Anthropogenic land use and infectious disease risks in South America: a systematic review and meta-analysis of the evidence
  58. The Impact of Grenfell on Health Service Provision and Community Health; a Literature Review and Data Analysis
  59. The effective use of the Country Cooperation Strategy as a tool to assess health improvements in Uruguay, Argentina and Honduras
  60. Time series analysis of WHO/UNICEF Estimates of National Immunization Coverage (WUENIC) data of Pakistan, India, Nigeria, Ethiopia and Democratic Republic of the Congo
  61. The Acute Effects of Polyphenols on Cognitive Function: A Systematic Review and Meta-Analysis
  62. Understanding the Drivers of Paternal Involvement: Interviews with Ugandan Fathers Positively Involved in Maternal and New-born Health
  63. Comparison of safety of TDF and TAF based drugs in two HIV study cohorts of patients with HIV-1 infection
  64. Biological, behavioural and socio-demographic correlates with heterosexual anal intercourse in Manicaland, Zimbabwe
  65. Engagement and acceptability of educational telehealth interventions among family caregivers with a child with Autism spectrum disorder: a systematic review
  66. The role of family in determining dietary and physical activity habits and motivating/discouraging change in children
  67. An evidence synthesis into the epidemiological transmission modelling of Bovine tuberculosis

Health outcomes in the UK: how do we compare with Europe?

In an article published in the British Medical Journal, I discuss the health outcomes achieved by the NHS in the UK and how these compare with other European countries. Health outcomes in the UK have improved substantially since the NHS was established in 1948. The NHS also performs well in many international comparisons on measures such as efficiency, equity, and access.

Despite these achievements, however, problems with health outcomes remain. Moreover, other European countries have also improved their health outcomes in recent decades, often at a faster rate than the UK. Consequently, the UK now lags behind many other European countries in key health outcomes in areas such as child health and cancer survival.

I conclude that new health policies in the UK should help the NHS to focus on improving health outcomes and that politically expedient schemes that are not evidence-based – such as extended opening hours in primary care – should be abandoned. Continued progress is also needed on wider determinants of health such as poverty, housing, education, employment, and the environment.