Tonsillectomy or adenotonsillectomy reduces the number of sore throats in children; however, insufficient information is available on the effectiveness in adults

Commentary on: Burton MJ, Glasziou PP, Chong LY, et al. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev 2014;11:CD001802. Context Sore throats cost the National Health Service (NHS) over £120 million per annum with approximately £60 million for general practitioner consultations and medical therapy. From 2011 to 2012, in England alone,1 secondary care costs included £10 million for bed usage by over 37 000 emergency hospital admissions and over £20 million in elective adult tonsillectomy. Upper respiratory tract infections are the most common cause of consultation in the USA.2 The place of tonsillectomy in the management of sore throat remains uncertain. Absolute numbers of tonsillectomy in the UK have fallen

Standardized packaging and illicit tobacco use: A systematic review

Introduction To systematically review the evidence regarding the effect of standardized packaging on illicit tobacco use. Material and Methods Data sources were EMBASE, Web of Knowledge, Scopus, PsycInfo, Medline, and the British Library catalogue, from 01/01/1987 to 28/11/2016. Reference lists of included studies were hand searched for additional papers. Search strategies were based on the terms ‘tobacco’, ‘packaging’ and ‘illicit’. The search was restricted to English language references. Two reviewers screened titles and abstracts for empirical studies that addressed the topic of standardized packaging and illicit tobacco use. This resulted in 153 full text papers retrieved for screening. Following exclusions, ten papers were included in the review. Two reviewers’ extracted data using piloted standardized data extraction forms. Studies were assessed for quality and relevance using CASP. Results There was little homogeneity between included studies, so a narrative synthesis was employed. Of the relevant studies five reported smokers did not intend to or actually purchase further illicit tobacco following standardized packaging, although one suggested a small number of responders to online news felt smokers would be more inclined to purchase illicit tobacco, following standardized packaging. Two studies reported retailers did not intend to or actually increase sales of illicit tobacco following standardized packaging. Finally, two studies reported industry data on illicit tobacco were of poor quality and not supported by independent data. Conclusions There were few studies examining tobacco standardized packaging and illicit trade, however those available showed no evidence that standardized packaging could lead to increases in illicit trade

Staff perspectives on the impact of COVID 19 on the delivery of specialist domestic abuse services in the UK: A qualitative study

Domestic abuse is a significant public health issue effecting 2.4 million adults in England and Wales each year. In March 2020 the World Health Organisation declared a global pandemic following the outbreak of COVID-19. As a result, the UK moved to a period of lockdown. There is growing evidence that highlights the unintended negative consequences of lockdown, particularly in households where abuse is present. The aim of this study was to explore the experiences of frontline specialist domestic abuse staff who continued to support victims during the period of lockdown to understand the impact of COVID-19 on service delivery. Ten, one to one, semi structured qualitative interviews were carried out with staff from a specialist domestic abuse service that operates in regions across the north-east of England. All participants had been involved in service delivery for a minimum of 12 months prior to March 2020 and had continued to deliver services throughout the UK initial lockdown period between March and July 2020. Each interview was transcribed verbatim, anonymised, then subjected to thematic analysis. Six themes were developed from the data covering: emergency support for victims; wider service efficiencies; victim safety; group work versus one-to-one support; criminal and family courts; and workforce development. While lockdown resulted in increased levels and severity of referrals, the switch to remote working brought a range of service efficiencies including time and money saved by negating the need to travel. Remote working also enhanced support offered to male victims and those with mental health issues but not those in rural locations with poor connectivity and those effected by the digital divide. Services should not underestimate the long-term benefits of peer support both to clients and staffs

Impact of financial incentives on alcohol intervention delivery in primary care: a mixed-methods study

Background Local and national financial incentives were introduced in England between 2008 and 2015 to encourage screening and brief alcohol intervention delivery in primary care. We used routine Read Code data and interviews with General Practitioners (GPs) to assess their impact. Methods A sequential explanatory mixed-methods study was conducted in 16 general practices representing 106,700 patients and 99 GPs across two areas in Northern England. Data were extracted on screening and brief alcohol intervention delivery for 2010-11 and rates were calculated by practice incentive status. Semi-structured interviews with 14 GPs explored which factors influence intervention delivery and recording in routine consultations. Results Screening and brief alcohol intervention rates were higher in financially incentivised compared to non-incentivised practices. However absolute rates were low across all practices. Rates of short screening test administration ranged from 0.05% (95% CI: 0.03-0.08) in non-incentivised practices to 3.92% (95% CI: 3.70-4.14) in nationally incentivised practices. For the full AUDIT, rates were also highest in nationally incentivised practices (3.68%, 95% CI: 3.47-3.90) and lowest in non-incentivised practices (0.17%, 95% CI: 0.13-0.22). Delivery of alcohol interventions was highest in practices signed up to the national incentive scheme (9.23%, 95% CI: 8.91-9.57) and lowest in non-incentivised practices (4.73%, 95% CI: 4.50-4.96). GP Interviews highlighted a range of influences on alcohol intervention delivery and subsequent recording including: the hierarchy of different financial incentive schemes; mixed belief in the efficacy of alcohol interventions; the difficulty of codifying complex conditions; and GPs’ beliefs about patient-centred practice. Conclusions Financial incentives have had some success in encouraging screening and brief alcohol interventions in England, but levels of recorded activity remain low. To improve performance, future policies must prioritise alcohol prevention work within the quality and outcomes framework, and address the values, attitudes and beliefs that shape how GPs’ provide care

How is high quality research evidence used in everyday decisions about induction of labour between pregnant women and maternity care professionals? An exploratory study

Objective : To explore the use of high quality research evidence in women's and maternity care professionals’ decisions about induction of labour (IOL). Methods : a qualitative study underpinned by a social constructionist framework, using semi-structured interviews and generative thematic analysis. Setting : a large tertiary referral maternity unit in northern England in 2013/14. Participants : 22 randomly selected health care professionals involved in maternity care (midwives, obstetricians, maternity service managers), and 16 postnatal women, 3-8 weeks post-delivery, who were offered IOL in their most recent pregnancy. Findings : Three themes were identified in the data; (1) the value of different forms of knowledge, (2) accessing and sharing knowledge, and (3) constrained pathways and default choices. Findings echo other evidence in suggesting that women do not feel informed about IOL or that they have choices about the procedure. This study illuminates potential explanatory factors by considering the complex context within which IOL is discussed and offered (e.g. presentation of IOL as routine rather than a choice, care pathways that make declining IOL appear undesirable, blanket use of clinical guidelines without consideration of individual circumstances and preferences). Key conclusions : This study suggests that organisational, social, and professional factors conspire towards a culture where (a) IOL has become understood as a routine part of maternity care rather than an intervention to make an informed choice about, (b) several factors contribute to demotivate women and health care practitioners from seeking to understand the evidence base regarding induction, and (c) health care professionals can find themselves ill-equipped to discuss the relative risks and benefits of IOL and its alternatives. Implications for practice : It is important that IOL is recognised as an optional intervention and is not presented to women as a routine part of maternity care. When IOL is offered it should be accompanied by an evidence informed discussion about the options available to support informed decision making. Health care professionals should be supported to understand the evidence base and our findings suggest that any attempt to facilitate this needs to acknowledge and tackle complex organisational, social and professional influences that contribute to current care practices

Promoting physical activity with a school-based dance mat exergaming intervention: qualitative findings from a natural experiment

Background: Physical activity is critical to improving health and well-being in children. Quantitative studies have found a decline in activity in the transition from primary to secondary education. Exergames (active video games) might increase physical activity in adolescents. In January 2011 exergame dance mat systems were introduced in to all secondary schools across two local authority districts in the UK. We performed a quasi-experimental evaluation of a natural experiment using a mixed methods design. The quantitative findings from this work have been previously published. The aim of this linked qualitative study was to explore the implementation of the dance mat scheme and offer insights into its uptake as a physical activity intervention. Methods: Embedded qualitative interviews at baseline and 12 month follow-up with purposively selected physical education teachers (n=20) and 25 focus groups with a convenience sample of pupils (n=120) from five intervention schools were conducted. Analysis was informed by sociology of translation approach. Results: At baseline, participants (both teachers and pupils) reported different expectations about the dance mats and how they could be employed. Variation in use was seen at follow-up. In some settings they were frequently used to engage hard to reach groups of pupils. Overall, the dance mats were not used routinely to increase physical activity. However there were other unanticipated benefits to pupils such as improved reaction time, co-ordination and mathematic skills. The use of dance mats was limited in routine physical education classes because of contextual issues (school/government policy) technological failures (batteries/updates) and because of expectations about how and where they could be used. Conclusions: Our linked quantitative study (previously published) suggested that the dance mats were not particularly effective in increasing physical activity, but the qualitative results (reported here) show that the dance mats were not used routinely enough to show a significant effect on physical activity of the intervention. This research demonstrates the benefit of using mixed methods to evaluate complex physical activity interventions. Those planning any intervention for promoting physical activity in schools need to understand the distinction between physical activity and physical education

The NAtional randomised controlled Trial of Tonsillectomy IN Adults (NATTINA): a clinical and cost-effectiveness study: study protocol for a randomised control trial

Background The role of tonsillectomy in the management of adult tonsillitis remains uncertain and UK regional variation in tonsillectomy rates persists. Patients, doctors and health policy makers wish to know the costs and benefits of tonsillectomy against conservative management and whether therapy can be better targeted to maximise benefits and minimise risks of surgery, hence maximising cost-effective use of resources. NATTINA incorporates the first attempt to map current NHS referral criteria against other metrics of tonsil disease severity. Methods/design A UK multi-centre, randomised, controlled trial for adults with recurrent tonsillitis to compare the clinical and cost-effectiveness of tonsillectomy versus conservative management. An initial feasibility study comprises qualitative interviews to investigate the practicality of the protocol, including willingness to randomise and be randomised. Approximately 20 otolaryngology staff, 10 GPs and 15 ENT patients will be recruited over 5 months in all 9 proposed main trial participating sites. A 6-month internal pilot will then recruit 72 patients across 6 of the 9 sites. Participants will be adults with recurrent acute tonsillitis referred by a GP to secondary care. Randomisation between tonsillectomy and conservative management will be according to a blocked allocation method in a 1:1 ratio stratified by centre and baseline disease severity. If the pilot is successful, the main trial will recruit a further 528 patients over 18 months in all 9 participating sites. All participants will be followed up for a total of 24 months, throughout which both primary and secondary outcome data will be collected. The primary outcome is the number of sore throat days experienced over the 24-month follow-up. The pilot and main trials include an embedded qualitative process evaluation. Discussion NATTINA is designed to evaluate the relative effectiveness and efficiency of tonsillectomy versus conservative management in patients with recurrent sore throat who are eligible for surgery. Most adult tonsil disease and surgery has an impact on economically active age groups, with individual and societal costs through loss of earnings and productivity. Avoidance of unnecessary operations and prioritisation of those individuals likely to gain most from tonsillectomy would reduce costs to the NHS and society

Combining Realist approaches and Normalization Process Theory to understand implementation: a systematic review

Background: Realist approaches and Normalization Process Theory (NPT) have both gained significant traction in implementation research over the past 10 years. The aim of this study was therefore to explore how the approaches are combined to understand problems of implementation, to determine the degree of complementarity of the two approaches and to provide practical approaches for using them together. Methods: Systematic review of research studies combining Realist and NPT approaches. Realist methodology is concerned with understanding and explaining causation, that is, how and why policies, programmes and interventions achieve their effects. NPT is a theory of implementation that explains how practices become normalised. Databases searched (January 2020) were ASSIA, CINAHL, Health Research Premium Collection via Proquest (Family Health Database, Health & Medical Collection, Health Management Database, MEDLINE, Nursing & Allied Health Database, Psychology Database, Public Health Database) and PsycARTICLES. Studies were included if the author(s) stated they used both approaches: a scientific Realist perspective applying the principles of Pawson and Tilley’s Realist Evaluation or Pawson’s Realist Synthesis and Normalization Process Theory either solely or in addition to other theories. Two authors screened records; discrepancies were reviewed by a third screener. Data was extracted by three members of the team and a narrative synthesis was undertaken. Results: Of 245 total records identified, 223 unique records were screened and 39 full-text papers were reviewed, identifying twelve papers for inclusion in the review. These papers represented eight different studies. Extent and methods of integration of the approaches varied. In most studies (6/8), Realist approaches were the main driver. NPT was mostly used to enhance the explanatory power of Realist analyses, informing development of elements of Contexts, Mechanisms and Outcomes (a common heuristic in realist work). Authors’ reflections on the integration of NPT and Realist approaches were limited. Conclusions: Using Realist and NPT approaches in combination can add explanatory power for understanding the implementation of interventions and programmes. Attention to detailed reporting on methods and analytical process when combining approaches, and appraisal of theoretical and practical utility is advised for advancing knowledge of applying these approaches in research

The effect of COVID rehabilitation for ongoing symptoms Post HOSPitalisation with COVID-19 (PHOSP-R):protocol for a randomised parallel group controlled trial on behalf of the PHOSP consortium

Introduction Many adults hospitalised with COVID-19 have persistent symptoms such as fatigue, breathlessness and brain fog that limit day-to-day activities. These symptoms can last over 2 years. Whilst there is limited controlled studies on interventions that can support those with ongoing symptoms, there has been some promise in rehabilitation interventions in improving function and symptoms either using face-to-face or digital methods, but evidence remains limited and these studies often lack a control group. Methods and analysis This is a nested single-blind, parallel group, randomised control trial with embedded qualitative evaluation comparing rehabilitation (face-to-face or digital) to usual care and conducted within the PHOSP-COVID study. The aim of this study is to determine the effectiveness of rehabilitation interventions on exercise capacity, quality of life and symptoms such as breathlessness and fatigue. The primary outcome is the Incremental Shuttle Walking Test following the eight week intervention phase. Secondary outcomes include measures of function, strength and subjective assessment of symptoms. Blood inflammatory markers and muscle biopsies are an exploratory outcome. The interventions last eight weeks and combine symptom-titrated exercise therapy, symptom management and education delivered either in a face-to-face setting or through a digital platform (www.yourcovidrecovery.nhs.uk). The proposed sample size is 159 participants, and data will be intention-to-treat analyses comparing rehabilitation (face-to-face or digital) to usual care. Ethics and dissemination Ethical approval was gained as part of the PHOSP-COVID study by Yorkshire and the Humber Leeds West Research NHS Ethics Committee, and the study was prospectively registered on the ISRCTN trial registry (ISRCTN13293865). Results will be disseminated to stakeholders, including patients and members of the public, and published in appropriate journals. Article summary Strengths and limitations of this study • This protocol utilises two interventions to support those with ongoing symptoms of COVID-19 • This is a two-centre parallel-group randomised controlled trial • The protocol has been supported by patient and public involvement groups who identified treatments of symptoms and activity limitation as a top priorit