Delivery of supported self-management in asthma reviews: a mixed methods observational study nested in the IMP²ART programme of work

BACKGROUND: Supported self-management (SSM) reduces the risk of asthma attacks, improves asthma control and quality of life. During routine primary care asthma consultations, healthcare professional (HCP) communication and behaviour can influence a person's skills, knowledge and confidence to manage their own condition. Therefore understanding how supported self-management is delivered in UK primary care can help towards improved HCP delivery of care. This PhD project has been nested within the IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) programme, which is a UK-Wide trial, developing and evaluating a strategy delivering patient, professional, and organisational resources to improve self-management. AIMS AND OBJECTIVES: The aim of this PhD project was to assess HCP delivery of supported self-management, including patient-centred care and behaviour change strategies to promote asthma self-management during routine primary care reviews. Additional objectives included to explore the influence of the IMP2ART programme on the delivery of supported self-management, and investigate differences (if any) in remote and face-to-face delivery of asthma care. METHODOLOGY: The PhD programme of work consisted of three phases: 1. Understanding the Evidence Base: Firstly, following systematic realist review methodology, I systematically reviewed the existing evidence investigating the delivery of supported self-management during routine remote asthma consultations. The realist review aimed to; 1) identify and synthesise studies that explored remote asthma consultations and the delivery of supported self-management, 2) explore the context and mechanisms that have contributed to clinically effective, safe and acceptable delivery of supported self-management during remote asthma consultations, and 3) produce recommendations and guidelines for best practice in the delivery of supported self-management during remote consultations for people with asthma. 2. Understanding current clinical practice: I conducted an observational study using video-recordings of routine face-to-face and telephone asthma reviews in a sub-sample of practices participating in the IMP2ART UK-wide cluster-randomised controlled trial (implementation n~4; control n~6). Analytical methods included: ALFA Toolkit Multi-Channel Video Observation, to code and quantify types of speech, Patient-Centred Observation Form and The Behaviour Change Counselling Index, to assess patient-centeredness and behaviour change counselling used by HCPs. 3. Understanding the clinician’s perspective: In the qualitative phase of the PhD, I conducted semi-structured interviews with seven HCPs to explore clinician’s perceptions, opinions and experiences of delivering supported self-management during routine asthma reviews. Interviews were audio recorded, transcribed and findings were explored using thematic analysis. Results of the three phases were initially analysed separately using the outlined approaches. A ‘Triangulation Protocol’ process was then conducted to compare, contrast and amalgamate the findings of the mixed methods approaches. RESULTS: 1. Results of the systematic rapid realist review identified six themes using data from 18 articles to describe how supported self-management is delivered during remote asthma consultations. The findings identified positive benefits associated with remote asthma care including; increased convenience, improved access and attendance at reviews, ability to conduct the core content of an asthma review remotely, completion of asthma action plans, and continuity of care. Typically, these overrode any challenges associated with technological difficulties imposed by remote consultations. The data suggest that overall remote consultations were as, or more highly, accepted than in person consultations for the studies I included, and were as effective and safe as face-to-face reviews. 2. Findings of the observational recordings revealed that HCPs spent the most time during a routine review discussing; an individual’s asthma condition and it’s management, collaboratively reviewing and completing personalised asthma action plan and, training for practical self-management activities (e.g., inhaler technique). Areas of patient-centred care delivery which HCPs discussed using a biopsychosocial focus were; creating and maintaining relationships with patients, as well as discussing asthma action plans and medication reconciliation. HCPs delivered empathetic behavioural discussions, however, did not collaboratively discuss individualised approaches for ways in which a patient could proactively change their behaviour. There was a statistically significant difference for the delivery of supported self-management between IMP2ART implementation and control group healthcare professionals. Healthcare professionals from the IMP2ART implementation group spent a higher percentage of time during routine reviews incorporating and discussing SSM strategies (ALFA) (t (62), =2.122, p =0.038). Professionals of implementation group practices also delivered a more person-centred review (PCOF) (t (60), = 2.06, p = 0.044), and used more behaviour change communication strategies (BECCI) (U= 336.5, p = 0.03) than professionals of the IMP2ART control group. I concluded that, on average, professionals in IMP2ART implementation group practices delivered more effective SSM strategies during routine asthma reviews. Findings from the between group analysis of the face-to-face and remote consultation groups found that on average, both groups spent similar percentages of time on SSM tasks during routine asthma reviews (ALFA). Similarly, both groups had similar scores the delivery of patient-centred care (PCOF) and behaviour change discussions (BECCI), showing no significant differences in healthcare professional delivery of SSM between face-to-face and remote consultations. 3. The findings from the qualitative, semi-structured interviews with healthcare professionals identified five themes. The main findings from the themes included; healthcare professionals shared understanding of supported self-management, barriers and facilitators of supported self-management delivery (including healthcare professional motivations, confidence and time barriers), important strategies for supported self-management delivery (including patient education, asthma action plans and inhaler technique), and that there is a place in primary care for remote asthma care. Five key findings emerged from completing the Triangulation Protocol process, which amalgamated the findings of the three phases of the PhD study; 1. HCP confidence and motivations, and general practice culture are facilitators of effective HCP delivery of supported self-management. 2. Lack of time and large, challenging workloads are perceived as barriers to HCP delivery of supported self-management. 3. HCP and patient asthma education is an effective supported self-management strategy. 4. IMP2ART implementation strategies are associated with increased HCP delivery of asthma supported self-management. 5. Remote consultations devote similar proportion of time to face-to-face reviews for delivery of asthma supported self-management. CONCLUSIONS: HCP communication and behaviour can positively or negatively impact a patient’s ability to self-manage their condition. The insights from this mixed methods PhD programme of work, including the observation of routine asthma reviews, has provided evidence that training programmes directed at providing healthcare professionals with the skills they need to implement a motivating and patient-centred asthma review, in which behaviour change and collaborative supported self-management strategies, can be effective, and should be prioritised during the delivery of routine primary care asthma management. Routine remote reviews are also an acceptable alternative to delivery of supported self-management for asthma care for specific patient groups

Delivery of supported self-management in remote asthma reviews:a systematic rapid realist review

Abstract Background The COVID‐19 pandemic forced health care systems globally to adapt quickly to remote modes of health care delivery, including for routine asthma reviews. A core component of asthma care is supporting self‐management, a guideline‐recommended intervention that reduces the risk of acute attacks, and improves asthma control and quality of life. Objective We aimed to explore context and mechanisms for the outcomes of clinical effectiveness, acceptability and safety of supported self‐management delivery within remote asthma consultations. Design The review followed standard methodology for rapid realist reviews. An External Reference Group (ERG) provided expert advice and guidance throughout the study. We systematically searched four electronic databases and, with ERG advice, selected 18 papers that explored self‐management delivery during routine asthma reviews. Setting, Participants and Intervention Health care professional delivery of supported self‐management for asthma patients during remote (specifically including telephone and video) consultations. Main Outcome Measures Data were extracted using Context‐Mechanism‐Outcome (C‐M‐O) configurations and synthesised into overarching themes using the PRISMS taxonomy of supported self‐management as a framework to structure the findings. Results The review findings identified how support for self‐management delivered remotely was acceptable (often more acceptable than in‐person consultations), and was a safe and effective alternative to face‐to‐face reviews. In addition, remote delivery of supported self‐management was associated with; increased patient convenience, improved access to and attendance at remote reviews, and offered continuity of care. Discussion Remote delivery of supported self‐management for asthma was generally found to be clinically effective, acceptable, and safe with the added advantage of increasing accessibility. Remote reviews could provide the core content of an asthma review, including remote completion of asthma action plans. Conclusion Our findings support the option of remote delivery of routine asthma care for those who have this preference, and offer healthcare professionals guidance on embedding supported self‐management into remote asthma reviews. Patient and Public Contribution Patient and public contribution was provided by a representative of the Asthma UK Centre for Applied Research (AUKCAR) patient and public involvement (PPI) group. The PPI representative reviewed the findings, and feedback and comments were considered. This lead to further interpretations of the data which were included in the final manuscript

Patient and public involvement in research:the need for budgeting PPI staff costs in funding applications

BACKGROUND: Patient and Public Involvement (PPI) groups are becoming more established as collaborators with academic researchers and institutions to ensure that research is important and relevant to end users, and to identify areas that might have ethical considerations, as well as to advise on solutions. The National Institute for Health and Care Research UK Standards for Public Involvement in Research embody best practice for PPI, including support and learning opportunities that build confidence and skills for members of the public to play an invaluable and mutually productive role in research. However, the pivotal role of research and professional services (management and administrative) staff within academic institutions for sustaining and making this involvement successful is often overlooked. MAIN BODY: It takes significant effort to develop and sustain effective PPI in research. The six UK Standards for Public Involvement highlight the need for consistent, inclusive, well-governed and mutually respectful working relationships to sustain effective PPI contributions in health research. Productivity across a team of lay and academic members requires organisation and experience of implementing these standards by a dedicated PPI team, yet advice on PPI finances is usually focused on costs for patient panel members, and budgets in funding applications rarely consider the wider PPI team behind this involvement. As an exemplar, we reflect on how the Asthma UK Centre for Applied Research (AUKCAR) has developed a dedicated PPI Platform, with guidance for how PPI should be embedded throughout the research lifecycle, and detailed information to support the costing of PPI in funding applications. AUKCAR's work with established researchers, as well as Early Career Researchers and PhD students, is at the heart of a campaign to raise awareness of the importance of PPI in effective research planning. CONCLUSION: Focusing attention on the staff behind best practice involvement in health research may stimulate a much-needed discussion to ensure flourishing PPI capacity, with significant patient and public benefit. With adaptation, the PPI expertise within AUKCAR can be translated more widely

Patient and public involvement workshop to shape artificial intelligence-supported connected asthma self-management research

Digital interventions with artificial intelligence (AI) can potentially support people with asthma to reduce the risk of exacerbation. Engaging patients throughout the development process is essential to ensure usability of the intervention for the end-users. Using our Connected for Asthma (C4A) intervention as an exemplar, we explore how patient involvement can shape a digital intervention. Seven Patient and Public Involvement (PPI) colleagues from the Asthma UK Centre for Applied Research participated in four advisory workshops to discuss how they would prefer to use/interact with AI to support living with their asthma, the benefit and caveats to use the AI that incorporated asthma monitoring and indoor/outdoor environmental data. Discussion focussed on the three most wanted use cases identified in our previous studies. PPI colleagues wanted AI to support data collection, remind them about self-management tasks, teach them about asthma environmental triggers, identify risk, and empower them to confidently look after their asthma whilst emphasising that AI does not replace clinicians. The discussion informed the key components in the next C4A interventions, including the approach to interacting with AI, the technology features and the research topics. Attendees highlighted the importance of considering health inequities, the presentation of data, and concerns about data accuracy, data privacy, security and ownership. We have demonstrated how patient roles can shift from that of ‘user’ (the traditional ‘tester’ of a digital intervention), to a co-design partner who shapes the next iteration of the intervention. Technology innovators should seek practical and feasible strategies to involve PPI colleagues throughout the development cycle of a digital intervention; supporting researchers to explore the barriers, concerns, enablers and advantages of implementing digital healthcare.<br/

Ultralight vector dark matter search using data from the KAGRA O3GK run

Among the various candidates for dark matter (DM), ultralight vector DM can be probed by laser interferometric gravitational wave detectors through the measurement of oscillating length changes in the arm cavities. In this context, KAGRA has a unique feature due to differing compositions of its mirrors, enhancing the signal of vector DM in the length change in the auxiliary channels. Here we present the result of a search for U(1)B−L gauge boson DM using the KAGRA data from auxiliary length channels during the first joint observation run together with GEO600. By applying our search pipeline, which takes into account the stochastic nature of ultralight DM, upper bounds on the coupling strength between the U(1)B−L gauge boson and ordinary matter are obtained for a range of DM masses. While our constraints are less stringent than those derived from previous experiments, this study demonstrates the applicability of our method to the lower-mass vector DM search, which is made difficult in this measurement by the short observation time compared to the auto-correlation time scale of DM

Understanding interventions delivered in the emergency department targeting improved asthma outcomes beyond the emergency department: an integrative review

Objectives The emergency department (ED) represents a place and moment of opportunity to provide interventions to improve long-term asthma outcomes, but feasibility, effectiveness and mechanisms of impact are poorly understood. We aimed to review the existing literature on interventions that are delivered in the ED for adults and adolescents, targeting asthma outcomes beyond the ED, and to code the interventions according to theory used, and to understand the barriers and facilitators to their implementation.Methods We systematically searched seven electronic databases and research registers, and manually searched reference lists of included studies and relevant reviews. Both quantitative and qualitative studies that reported on interventions delivered in the ED which aimed to improve asthma outcomes beyond management of the acute exacerbation, for adolescents or adults were included. Methodological quality was assessed using the Mixed Methods Appraisal Tool and informed study interpretation. Theory was coded using the Theoretical Domains Framework. Findings were summarised by narrative synthesis.Results 12 articles were included, representing 10 unique interventions, including educational and medication-based changes (6 randomised controlled trials and 4 non-randomised studies). Six trials reported statistically significant improvements in one or more outcome measures relating to long-term asthma control, including unscheduled healthcare, asthma control, asthma knowledge or quality of life. We identified limited use of theory in the intervention designs with only one intervention explicitly underpinned by theory. There was little reporting on facilitators or barriers, although brief interventions appeared more feasible.Conclusion The results of this review suggest that ED-based asthma interventions may be capable of improving long-term outcomes. However, there was significant variation in the range of interventions, reported outcomes and duration of follow-up. Future interventions would benefit from using behaviour change theory, such as constructs from the Theoretical Domains Framework.PROSPERO registration number CRD 42020223058

Health Security State of the Region 2019 in the Indo-Pacific

Health security is here defined as the avoidance and containment of infectious disease threats with the potential to cause social and economic harms on a national, regional or global scale (1). It is a regional and global public good that provides benefit to all members of society and is central to the achievement of many of the Sustainable Development Goals (SDGs). Health security goes beyond the domain of human public health: animal health is integral to health security, given that the majority of emerging diseases in humans are of animal origin (i.e. zoonoses), and transboundary animal diseases pose a threat to food security.This report was commisioned by Australian Governmen