Timely digital patient-clinician communication in specialist clinical services for young people : a mixed-methods study (the LYNC study)

BACKGROUND: Young people (aged 16-24 years) with long-term health conditions can disengage from health services, resulting in poor health outcomes, but clinicians in the UK National Health Service (NHS) are using digital communication to try to improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, and ethical and safety issues. OBJECTIVE: Our objective was to understand how the use of digital communication between young people with long-term conditions and their NHS specialist clinicians changes engagement of the young people with their health care; and to identify costs and necessary safeguards. METHODS: We conducted mixed-methods case studies of 20 NHS specialist clinical teams from across England and Wales and their practice providing care for 13 different long-term physical or mental health conditions. We observed 79 clinical team members and interviewed 165 young people aged 16-24 years with a long-term health condition recruited via case study clinical teams, 173 clinical team members, and 16 information governance specialists from study NHS Trusts. We conducted a thematic analysis of how digital communication works, and analyzed ethics, safety and governance, and annual direct costs. RESULTS: Young people and their clinical teams variously used mobile phone calls, text messages, email, and voice over Internet protocol. Length of clinician use of digital communication varied from 1 to 13 years in 17 case studies, and was being considered in 3. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged, particularly at times of change for young people. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver, but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information, and communication failures, which are mostly mitigated by young people and clinicians using common-sense approaches. CONCLUSIONS: As NHS policy prompts more widespread use of digital communication to improve the health care experience, our findings suggest that benefit is most likely, and harms are mitigated, when digital communication is used with patients who already have a relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments, or lived context. Clinical teams need a proactive approach to ethics, governance, and patient safety

To add or not to add a new treatment arm to a multiarm study: A decision-theoretic framework.

Multiarm clinical trials, which compare several experimental treatments against control, are frequently recommended due to their efficiency gain. In practise, all potential treatments may not be ready to be tested in a phase II/III trial at the same time. It has become appealing to allow new treatment arms to be added into on-going clinical trials using a "platform" trial approach. To the best of our knowledge, many aspects of when to add arms to an existing trial have not been explored in the literature. Most works on adding arm(s) assume that a new arm is opened whenever a new treatment becomes available. This strategy may prolong the overall duration of a study or cause reduction in marginal power for each hypothesis if the adaptation is not well accommodated. Within a two-stage trial setting, we propose a decision-theoretic framework to investigate when to add or not to add a new treatment arm based on the observed stage one treatment responses. To account for different prospect of multiarm studies, we define utility in two different ways; one for a trial that aims to maximise the number of rejected hypotheses; the other for a trial that would declare a success when at least one hypothesis is rejected from the study. Our framework shows that it is not always optimal to add a new treatment arm to an existing trial. We illustrate a case study by considering a completed trial on knee osteoarthritis

Malaria vector control practices in an irrigated rice agro-ecosystem in central Kenya and implications for malaria control

<p>Abstract</p> <p>Background</p> <p>Malaria transmission in most agricultural ecosystems is complex and hence the need for developing a holistic malaria control strategy with adequate consideration of socio-economic factors driving transmission at community level. A cross-sectional household survey was conducted in an irrigated ecosystem with the aim of investigating vector control practices applied and factors affecting their application both at household and community level.</p> <p>Methods</p> <p>Four villages representing the socio-economic, demographic and geographical diversity within the study area were purposefully selected. A total of 400 households were randomly sampled from the four study villages. Both semi-structured questionnaires and focus group discussions were used to gather both qualitative and quantitative data.</p> <p>Results</p> <p>The results showed that malaria was perceived to be a major public health problem in the area and the role of the vector <it>Anopheles </it>mosquitoes in malaria transmission was generally recognized. More than 80% of respondents were aware of the major breeding sites of the vector. Reported personal protection methods applied to prevent mosquito bites included; use of treated bed nets (57%), untreated bed nets (35%), insecticide coils (21%), traditional methods such as burning of cow dung (8%), insecticide sprays (6%), and use of skin repellents (2%). However, 39% of respondents could not apply some of the known vector control methods due to unaffordability (50.5%), side effects (19.9%), perceived lack of effectiveness (16%), and lack of time to apply (2.6%). Lack of time was the main reason (56.3%) reported for non-application of environmental management practices, such as draining of stagnant water (77%) and clearing of vegetations along water canals (67%).</p> <p>Conclusion</p> <p>The study provides relevant information necessary for the management, prevention and control of malaria in irrigated agro-ecosystems, where vectors of malaria are abundant and disease transmission is stable.</p

Assessing the risk of self-diagnosed malaria in urban informal settlements of Nairobi using self-reported morbidity survey

<p>Abstract</p> <p>Background</p> <p>Because of the belief that Nairobi is a low risk zone for malaria, little empirical data exists on malaria risk in the area. The aim of this study was to explore the risk of perceived malaria and some associated factors in Nairobi informal settlements using self-reported morbidity survey.</p> <p>Methods</p> <p>The survey was conducted from May to August 2004 on 7,288 individuals in two informal settlements of Nairobi. Participants were asked to report illnesses they experienced in the past 14 days. Logistic regression was used to estimate the odds of perceived-malaria. The model included variables such as site of residence, age, ethnicity and number of reported symptoms.</p> <p>Results</p> <p>Participants reported 165 illnesses among which malaria was the leading cause (28.1%). The risk of perceived-malaria was significantly higher in Viwandani compared to Korogocho (OR 1.61, 95%CI: 1.10–2.26). Participants in age group 25–39 years had significantly higher odds of perceived-malaria compared to those under-five years (OR 2.07, 95%CI: 1.43–2.98). The Kikuyu had reduced odds of perceived-malaria compared to other ethnic groups. Individuals with five and more symptoms had higher odds compared to those with no symptoms (OR 23.69, 95%CI: 12.98–43.23).</p> <p>Conclusion</p> <p>Malaria was the leading cause of illness as perceived by the residents in the two informal settlements. This was rational as the number of reported symptoms was highly associated with the risk of reporting the illness. These results highlight the need for a more comprehensive assessment of malaria epidemiology in Nairobi to be able to offer evidence-based guidance to policy on malaria in Kenya and particularly in Nairobi.</p

Target product profile choices for intra-domiciliary malaria vector control pesticide products: repel or kill?

BACKGROUND\ud \ud The most common pesticide products for controlling malaria-transmitting mosquitoes combine two distinct modes of action: 1) conventional insecticidal activity which kills mosquitoes exposed to the pesticide and 2) deterrence of mosquitoes away from protected humans. While deterrence enhances personal or household protection of long-lasting insecticidal nets and indoor residual sprays, it may also attenuate or even reverse communal protection if it diverts mosquitoes to non-users rather than killing them outright.\ud \ud METHODS\ud \ud A process-explicit model of malaria transmission is described which captures the sequential interaction between deterrent and toxic actions of vector control pesticides and accounts for the distinctive impacts of toxic activities which kill mosquitoes before or after they have fed upon the occupant of a covered house or sleeping space.\ud \ud RESULTS\ud \ud Increasing deterrency increases personal protection but consistently reduces communal protection because deterrent sub-lethal exposure inevitably reduces the proportion subsequently exposed to higher lethal doses. If the high coverage targets of the World Health Organization are achieved, purely toxic products with no deterrence are predicted to generally provide superior protection to non-users and even users, especially where vectors feed exclusively on humans and a substantial amount of transmission occurs outdoors. Remarkably, this is even the case if that product confers no personal protection and only kills mosquitoes after they have fed.\ud \ud CONCLUSIONS\ud \ud Products with purely mosquito-toxic profiles may, therefore, be preferable for programmes with universal coverage targets, rather than those with equivalent toxicity but which also have higher deterrence. However, if purely mosquito-toxic products confer little personal protection because they do not deter mosquitoes and only kill them after they have fed, then they will require aggressive "catch up" campaigns, with behaviour change communication strategies that emphasize the communal nature of protection, to achieve high coverage rapidly

Factors influencing the use of topical repellents: implications for the effectiveness of malaria elimination strategies

In Cambodia, despite an impressive decline in prevalence over the last 10 years, malaria is still apublic health problem in some parts of the country. This is partly due to vectors that bite earlyand outdoors reducing the effectiveness of measures such as Long-Lasting Insecticidal Nets.Repellents have been suggested as an additional control measure in such settings. As part of acluster-randomized trial on the effectiveness of topical repellents in controlling malaria infections atcommunity level, a mixed-methods study assessed user rates and determinants of use. Repellentswere made widely available and Picaridin repellent reduced 97% of mosquito bites. However,despite high acceptability, daily use was observed to be low (8%) and did not correspond to thereported use in surveys (around 70%). The levels of use aimed for by the trial were never reachedas the population used it variably across place (forest, farms and villages) and time (seasons), or inalternative applications (spraying on insects, on bed nets, etc.). These findings show the key role ofhuman behavior in the effectiveness of malaria preventive measures, questioning whether malaria inlow endemic settings can be reduced substantially by introducing measures without researching andoptimizing community involvement strategies

“Keep our markets open”: Remaking Urban Marketplaces and Everyday Financial Practices in Nairobi in the Time of COVID-19

This research engages with geographical scholarship to better understand the role of crisis and its narratives in shaping socioeconomic and financial development. Previous research on crisis narratives has focused on the power dynamics and policies that underpin crisis formation, and the influence of these narratives on global governance strategies. Critical literature has drawn attention to the ways in which political actors utilise crisis and its narratives to advance global policy agendas that fail to consider local contexts, calling attention to the need for more empirical studies of crisis that are grounded in local policy needs. In response, this research is driven by three questions: how did state policies enacted in the name of the COVID-19 pandemic (re)shape social mobilities and financial practices? How were these policies experienced by market vendors and traders in Nairobi? And to what extent did they remake urban markets as social, economic and technological spaces? The thesis is based upon 14 months of fieldwork in Nairobi between February 2020 and August 2021. Using a mixed methods approach, qualitative interviews were conducted with urban traders and vendors in the Gikomba and Kamukunji markets and key institutional and private sector actors. Further evidence was drawn from an extensive analysis of policy documents, media reportage, and archival research. This thesis demonstrates that the Kenyan government's COVID-19 pandemic governance strategies allowed for the suspension of democratic control rules, exposing the systemic inequalities and exclusionary tendencies of crisis policies and financial inclusion infrastructures that have endured since the colonial era. With the unequal breakdown of economic and financial practices, urban market traders relied on digital and mobile financial products, trapping them in a cycle of debt, extracting future revenue over current livelihood needs. With limited social mobility, urban market traders adapted and modified their economic practices by engaging their social networks to shift their selling practices to social media platforms. On these social media platforms such as; WhatsApp, Telegram and Facebook, urban traders combined the physical marketplace with digital platforms integrating them into the everyday practice of the market trading business. In summary, this thesis contributes a theoretical and empirical understanding of crisis narratives and their role in re making economic financial practices and social mobilities in popular marketplaces

Timely Digital Patient-Clinician Communication in Specialist Clinical Services for Young People:A Mixed-Methods Study (The LYNC Study)

Background Young people (age 16-24 years) with long-term health conditions can disengage from health services resulting in poor health outcomes, but clinicians in the UK NHS are using digital communication to try and improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, ethical and safety issues. Objectives To understand how the use of digital communication between young people with long-term conditions and their UK NHS specialist clinicians changes engagement of the young people with their health care; to identify costs and necessary safeguards. Methods Mixed method case studies of 20 NHS specialist clinical teams from across England and Wales and their current practice providing care for 13 different long-term physical or mental health conditions. Observation of 79 clinical team members; interviews with 165 young people aged 16-24 years living with a long-term health condition recruited via case study clinical teams, 173 clinical team members, 16 Information Governance Specialists from study NHS Trusts. Analysis: thematic analysis of how digital communication works; ethics, safety and governance; annual direct costs. Results Young people and their clinical teams variously used: mobile phone calls, text messages, email, Voice over Internet Protocol. Length of clinician use of digital communication varied from one to 13 years in 17 case studies, and was being considered in three. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, which are mostly mitigated by young people and clinicians using common sense approaches. Conclusions Timely digital access to clinical teams is providing a flexible, personalised service for young people with long-term conditions. It engages young people with their health care including those who are otherwise hard to reach. As NHS policy prompts more widespread use of digital communication to improve health care experience, our findings suggest benefit is most likely, and harms mitigated, when used with patients where there is already an existing relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments or lived context. Clinical teams need a proactive approach to ethics, governance and patient safety