Creating expert patients: outcomes from a national digital therapeutic approach for people with asthma in Wales

National applications (apps) for adults with asthma were implemented as part of a respiratory toolkit across Wales from 2020. Data were collected on patient recorded asthma control including the Royal College of Physicians three questions. All general practices in Wales had patients registered on the asthma app and by September 2024, 12,567 (57.8%) of patients who downloaded the app went on to register. Analysis comparing baseline with four or more months of app use demonstrated improvements in the percent of those having a Royal College of Physicians asthma score of 0 (26.5% vs 40.7%, p = 0.0011), together with improvements in those not using a reliever inhaler at all (29.1% vs 39.2%, p = 0.0001). Where we had paired data one year apart, the improvements in asthma control were greater in those from most deprived areas. For those who used the app there were improvements across important metrics of asthma control consistent with better patient self-management

Association between income, employment status, and asthma outcomes: a systematic review and meta-analysis

Background: Health inequalities are deeply entrenched in society, and finding ways to reduce these, therefore, represents a major health policy challenge. Focusing on the two highest weighted Index of Multiple Deprivation domains, namely income and employment, we sought to synthesise the evidence on the association between these major determinants of socioeconomic status and asthma outcomes. Methods: In this systematic review and meta-analysis, we searched key concepts related to employment, income, and asthma outcomes using Medline and Embase for studies published between January 1, 2010 and April 3, 2025. Studies were eligible for inclusion if they were in English and described an association between income and/or employment and asthma outcomes, including exacerbations, hospital admissions and mortality, in people with asthma. Risk Of Bias In Non-randomized Studies–of Exposures (ROBINS-E), Risk of Bias (RoB) and adapted RoB tools were used to assess the risk of bias in the included studies. Using the restricted maximum likelihood method, we meta-analysed the rate of exacerbations and explored heterogeneity between age-related population groups: children (under 18 years) and adults (18 years and older). This study was registered with PROSPERO, CRD42024527300. Findings: We identified 4153 potentially eligible studies, of which 3141 were screened. 30 studies met the inclusion criteria, with most having a low risk of bias. 19 studies reported income as the exposure and exacerbation as the outcome, of which ten were included in the meta-analysis. People in the lowest income group were more likely to experience an asthma exacerbation than those in the highest income group: OR 1.25; 95% CI 1.13–1.37 overall and when stratified by age: children (1.36 [1.23–1.50]) and adults (1.19 [1.05–1.33]). Only three studies investigated the role of unemployment and were narratively synthesised. While unemployment was associated with increased emergency care visits, its role in predicting exacerbations was less clear. Interpretation: There is a need for upstream interventions aiming to reduce income inequalities and to investigate their impact on reducing asthma inequalities. Funding: Health Data Research UK, Inflammation and Immunity Driver Programme

Objective measurement of posture allocation and sedentary behaviours in the pre-school child: a validation study

Sedentary behaviours contribute to energy imbalance in young children. Time spent sitting may be an important component of sedentary behaviour but validated measures of posture and posture transitions in the pre-school child are lacking. Accelerometer based posture detection systems validated in the adult literature have often shown excellent agreement with the gold standard of direct observation in controlled environments, but their potential use for the young child is likely to be limited by weight and the need to use multiple sensor sites. Single unit sensors are a potentially more practical alternative that may be suitable for use in research involving young children. This thesis describes the validation of two single unit accelerometer based monitors for their ability to each measure posture and postural transition objectively: the activPAL (PAL Technologies, UK) and the DynaPort MicroMod MoveMonitor 1.2 (McRoberts, NL). It also compares sedentary behaviours as detected by the activPAL and DynaPort monitors with conventional accelerometry using the ActiGraph. The activPAL and DynaPort MoveMonitor algorithms for posture and activity identification in comparison to the gold standard of direct observation have been validated in adults. Neither has previously been validated in young children. A validation study of the activPAL and DynaPort MicroMod MoveMonitor involving 30 pre-school children is described. The study took place in each child’s usual nursery environment. Children were videoed for one hour undertaking usual activities in nursery while wearing an activPAL and DynaPort MicroMod. In addition, children also wore an ActiGraph accelerometer. The ActiGraph does not measure posture but is well established in physical activity research in childhood. It provided objective information about activity intensity (in particular sedentary behaviour) for each child during the observation period. Video (gold standard) was analyzed on a second-by-second basis and compared with monitor output. From direct video observation, the proportion of time spent during the one hour of video recording was sit/lie 46%; stand 35%; and walk 16%. The remaining 3% of time was spent in non-sit/lie/upright postures (e.g. crawl, crouch, kneel up) although transitions involving these contributed disproportionately to total posture transitions. The number of sit-stand posture transitions on direct observation was not associated with time spent sedentary. The overall proportion of time detected as ‘sit/lie’ was 42% and 32% as detected by activPAL and DynaPort respectively. Similarly, for activPAL and DynaPort detected ‘walk’, this was 16% and 15% respectively. Overall sensitivity for time detected as activPAL ‘sit/lie’ was 87%, specificity 97% and positive predictive value 96%. DynaPort MicroMod sensitivity for ‘sit’ was lower but specificity remained high (91%). There was poor correlation between activPAL ‘sit/lie’ and ActiGraph-defined sedentary behaviour (<1100 counts per minute), r = 0.16. However, there was good correlation (r=0.87) between activPAL [‘sit/lie’ + ‘stand’] and ActiGraph defined sedentary behaviour. The validation results for the activPAL were similar to those described in the adult literature and although those for the DynaPort monitor were less good, both show promise as measurement tools in this age group. Single unit accelerometers capable of detecting posture may have a role in the evaluation of sedentary behaviour in young children, beyond the capabilities of currently used objective monitors such as the ActiGraph. However the role of (and importance of objectively capturing) posture transitions, including non-sit/lie/upright postures requires further investigation. Ultimately, knowledge of posture and postural transitions may provide a better understanding of movement and activity in young children. This potential to help evaluate sedentary behaviours is of interest for childhood obesity research

The medical culture of the Ovambo of Southern Angola and Northern Namibia

This thesis focusses on the medical culture of the Ovambo peoples of southern Angola and northern Namibia, a group who have been little-researched anthropologically. Because health and affliction are such poignant human concerns, the study of a society's medical culture can tell us much about their social and cultural organisation in general. It is for this reason that Ovambo medical culture has been examined in relation to the wider socio-cultural background, rather than in isolation; especially since Ovambo evidence has shown that concern about health and affliction is not confined to the physical and spiritual wellbeing of individuals, but extends to include harmonious social relations, environmental and economic prosperity, and politicaly stability. A holistic analytical approach has been adopted, whereby all aspects of the medical culture are considered (insofar as the data allow), as opposed to only certain aspects. Ovambo beliefs and practises relating to healt hand health maintenance are therefore discussed, as well as external (i.e. European) medical influences. Particular attention has been paid to Ovambo use of plants as medicines, as well as to their prophylactic and propitiatory measures, since these are areas of athnomedical research that are identified as being under-researched. Focussing upon these areas has also highlighted the significance of material culture in the Ovambo medical domain, and the value of museum collections of ethnography in this regard

Inclusive or random? A study of verbal interaction between practitioners and children at pre-school settings.

This small scale study examined the function and frequency of verbal interaction between adults and children within pre-school settings. A range of data collection methods were utilised to ascertain whether practitioners listened to children’s views and encouraged dialogue and discourse inclusively. A mixed methodology design was chosen to enable effective data collection and analysis. Data collection methods were piloted before the main study to test for suitability and effectiveness. Provision in three sample settings was examined. Research literature relating to verbal interaction was reviewed. The study concluded that practitioners were well-qualified and versed in the philosophy of child-directed play, but were preoccupied with product-based activities to the detriment of effective verbal interactions with children. The study recommended methods for raising awareness among practitioners in order to improve the quality of interaction and dialogue within pre-school settings. These methods included a programme of self- and peer-evaluation, further training and visits to other early years settings

Emulated trial investigating effects of multiple treatments: estimating combined effects of mucoactive nebulisers in cystic fibrosis using registry data

Introduction: People with cystic fibrosis (CF) are often on multiple long-term treatments, including mucoactive nebulisers. In the UK, the most common mucoactive nebuliser is dornase alfa (DNase). A common therapeutic approach for people already on DNase is to add hypertonic saline (HS). The effects of DNase and HS used alone have been studied in randomised trials, but their effects in combination have not. This study investigates whether, for people already prescribed DNase, adding HS has additional benefit for lung function or use of intravenous antibiotics.// Methods: Using UK CF Registry data from 2007 to 2018, we emulated a target trial. We included people aged 6 years and over who were prescribed DNase without HS for 2 years. We investigated the effects of combinations of DNase and HS over 5 years of follow-up. Inverse-probability-of-treatment weighting was used to control confounding. The period predated triple combination CF transmembrane conductance regulator modulators in routine care.// Results: 4498 individuals were included. At baseline, average age and forced expiratory volume in 1 s (FEV1%) predicted were 21.1 years and 69.7 respectively. During first year of follow-up, 3799 individuals were prescribed DNase alone; 426 added HS; 57 switched to HS alone and 216 were prescribed neither. We found no evidence that adding HS improved FEV1% at 1–5 years, or use of intravenous antibiotics at 1–4 years, compared with DNase alone.// Conclusion: For individuals with CF prescribed DNase, we found no evidence that adding HS had an effect on FEV1% or prescription of intravenous antibiotics. Our study illustrates the emulated target trial approach using CF Registry data

Investigating the causal effects of multiple treatments using longitudinal data: a simulation study

Many clinical questions involve estimating the effects of multiple treatments using observational data. When using longitudinal data, the interest is often in the effect of treatment strategies that involve sustaining treatment over time. This requires causal inference methods appropriate for handling multiple treatments and time-dependent confounding. Robins Generalised methods (g-methods) are a family of methods which can deal with time-dependent confounding and some of these have been extended to situations with multiple treatments, although there are currently no studies comparing different methods in this setting. We show how five g-methods (inverse-probability-of-treatment weighted estimation of marginal structural models, g-formula, g-estimation, censoring and weighting, and a sequential trials approach) can be extended to situations with multiple treatments, compare their performances in a simulation study, and demonstrate their application with an example using data from the UK CF Registry