An investigation into the social integration of Young Adult Carers who are undergraduate students into Higher Education Institutions in England

This thesis investigates the social integration of young adult carers (YACs) who are undergraduates in a higher education institution (HEI) in England. This study recognises the increasingly neoliberal nature of higher education (HE) and that it was carried out during a pandemic. YACs are defined as ‘young people aged 16–25 who care, unpaid, for a family member or friend with an illness or disability, mental health condition or an addiction’ (Carers Trust, 2022). It has been estimated that there are 376,000 YACs in the UK (Carers Trust, 2022), but there are no definitive figures for how many of these young people are studying at university. It is widely acknowledged that YACs are an under-researched student group, and it is the intention of this thesis to contribute to the growing body of knowledge about them. Following an initial review of documentary evidence from 50 HEIs on the levels of support for YACs from an institutional perspective, this study takes an interpretive approach employing narrative inquiry as the research methodology. Participants (n=5) were recruited from HEIs across England and interviewed at three points across the academic year. They were also invited to keep a reflective journal of their experiences. Findings and discussion chapters were presented as a combined narrative, in order to represent the student life cycle in terms of transition into, through and potentially out of university. Findings indicated that YACs felt there were a limited number of named contacts, no personalised support plans, varying financial support, and an absence of acknowledgement of the challenges this group of young people encountered on a daily basis. The study also found that family and friends were, and are the most important groups of people in a YAC’s social network. It also found that academics could be more supportive in terms of understanding YACs and their different situations and how these impact their educational journey. It concluded that both HEIs and students’ unions could do more to recognise YACs, and therefore ensure they feel more socially integrated into their respective universities

Recognition of physical and psychological symptoms: no influence of GP demographic factors

AIM: To describe the relationship between general practitioner demographic factors and the recognition of psychological and physical symptoms in consultation. METHODS: A survey of a random sample of 70 GPs and their patients (n=3414) from the lower North Island of New Zealand. RESULTS: No relationship was found between GP personal and practice demographic characteristics and GP identification of psychological and physical symptoms. Patients were more likely not to present psychological symptoms (62%) than not present physical symptoms (5%) in consultation. Thirteen percent of GPs wanted more formal psychiatric training, 45% wanted more contact time in consultation, and 72% thought that cost was a barrier to patients attending. No significant relationship was found between these factors and GP detection of significant psychological symptoms in consultation. DISCUSSION: Personal and practice demographics of GPs may not predict their ability to detect physical and psychological symptoms. More research is needed to explore these findings which contradict previous work

Identifying key health system components associated with improved outcomes to inform the reconfiguration of services for adults with rare autoimmune rheumatic diseases : a mixed methods study.

Open Access via the Elsevier agreementPeer reviewe

Identifying key health system components associated with improved outcomes to inform the reconfiguration of services for adults with rare autoimmune rheumatic diseases: a mixed methods study

Background Adults with rare autoimmune rheumatic diseases face unique challenges and struggles to navigate health-care systems designed to manage common conditions. Evidence to inform an optimal service framework for their care is scarce. Using systemic vasculitis as an exemplar, we aimed to identify and explain the key service components underpinning effective care for rare diseases. Methods In this mixed-methods study, data were collected as part of a survey of vasculitis service providers across the UK and Ireland, interviews with patients, and from organisational case studies to identify key service components that enable good care. The association between these components and patient outcomes (eg, serious infections, mortality) and provider outcomes (eg, emergency hospital admissions) were examined in a population-based data linkage study using routine health-care data obtained from patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis from national health datasets in Scotland. We did univariable and multivariable analyses using Bayesian poisson and negative binomial regression to estimate incident rate ratios (IRRs), and Cox proportional hazards models to estimate hazard ratios (HRs). People with lived experiences were involved in the research and writing process. Findings Good care was characterised by service components that supported timely access to services, integrated care, and expertise. In 1420 patients with ANCA-associated vasculitis identified from national health datasets, service-reported average waiting times for new patients of less than 1 week were associated with fewer serious infections (IRR 0·70 [95% credibility interval 0·55–0·88]) and fewer emergency hospital admissions (0·78 [0·68–0·92]). Nurse-led advice lines were associated with fewer serious infections (0·76 [0·58–0·93]) and fewer emergency hospital admissions (0·85 [0·74–0·96]). Average waiting times for new patients of less than 1 week were also associated with reduced mortality (HR 0·59 [95% credibility interval 0·37–0·93]). Cohorted clinics, nurse-led clinics, and specialist vasculitis multi-disciplinary team meetings were associated with fewer serious infections (IRR 0·75 [0·59–0·96] for cohorted clinics; 0·65 [0·39–0·84] for nurse-led clinics; 0·72 [0·57–0·90] for specialist vasculitis multi-disciplinary team meetings) and emergency hospital admissions (0·81 [0·71–0·91]; 0·75 [0·65–0·94]; 0·86 [0·75–0·96]). Key components were characterised by their ability to overcome professional tensions between specialties. Interpretation Key service components associated with important health outcomes and underpinning factors were identified to inform initiatives to improve the design, delivery, and effectiveness of health-care models for rare autoimmune rheumatic diseases

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

New Zealand men's health care: are we meeting the needs of men in general practice?

Aim: To describe and compare how men and health professionals perceive men's health and health care. Method: A qualitative study with an inductive thematic analysis of transcripts from three sequential sets of focus groups. The first set included groups totalling 21 general practitioners and 10 practice nurses; the second set with a group of 12 men under 25 years and a group of 10 older men over 35 years; and the third set with the original groups of health professionals. Datasets were analysed individually, sequentially and comparatively for men's and health professionals' beliefs about health and health care. Results: In the initial focus groups, health professionals reported system, structural, and attitudinal barriers inhibiting men attending general practice. Men reported broad-based health beliefs and, despite reluctance to seek formal health care, men value general practice care and want recognition of their preferred consulting styles. In the final focus groups, researchers fed-back analysis of the health professionals' and men's focus group data with the aim of encouraging further focussed men's health initiatives. However, there was a general lack of enthusiasm from health professionals to do more than what was being done already. Conclusions: Despite men and health professionals recognising the importance of men's health, there is general unwillingness on the part of both men and health professionals, for different reasons, to engage with men's health care in general practice. Understanding how men view health and health care delivery has the potential to inform alternative approaches in general practice care

Genital examination training: assessing the effectiveness of an integrated female and male teaching programme

Abstract Background Learning to undertake intimate female and male examinations is an important part of medical student training but opportunities to participate in practical, supervised learning in a safe environment can be limited. A collaborative, integrated training programme to provide such learning was developed by two university teaching departments and a specialist sexual health service, utilising teaching associates trained for intimate examinations in a simulated clinical educational setting. The objective of this research was to determine changes in senior medical students’ self- reported experience and confidence in performing male and female genital examinations, before and after participating in a new clinical teaching programme. Methods A quasi-experimental mixed methods design, using pre and post programme questionnaires and focus groups, was used to assess the effectiveness of the programme. Results The students reported greatly improved skill, confidence and comfort levels for both male and female genital examination following the teaching programme. Skill, confidence and comfort regarding male examinations were rated particularly low on the pre-teaching programme self- assessment, but post-programme was rated at similar levels to the female examination. Conclusions This integrated female–male teaching programme (utilising trained teaching associates as simulated patients in a supervised clinical teaching environment) was successful in increasing senior medical students’ skills and levels of confidence in performing genital examinations. There were differences between female and male medical students in their learning. Suggestions for improvement included providing more detailed instruction to some clinical supervisors about their facilitation role in the session

GPs’ views and experiences of prescribing non-steroidal anti-inflammatory drugs: a qualitative study

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in primary care despite being a high-risk drug group causing significant adverse events, yet little is known about GPs’ perceptions of NSAID risks and benefits. Aim: To explore GPs’ experiences with NSAID prescribing and views about the risks and benefits of this group of medicines. Design & setting: A qualitative, inductive study in general practice. Method: Individual interviews with 15 GPs using a semi-structured interview guide. Interviews were audiorecorded and transcribed. An inductive, thematic approach was used for analysis. Sampling continued until data saturation was achieved. Results: Three main themes illustrate GPs’ key concerns with managing NSAID risks. The first theme was perceptions of risks and benefits of NSAIDs: GPs expressed differing attitudes towards prescribing medication generally. GPs were aware of the general risks of NSAIDs but weighed these up against specific risk factors and potential benefits for particular patients. They were most concerned about long-term use, risks for children, older people, and patients with comorbidities. The second theme was assessing and mitigating risks when prescribing NSAIDs: GPs considered gastric, cardiac, and renal risks of patients as well as drug interactions. Mitigation strategies included alternative treatment, choice and dose of NSAID, and use of gastroprotective agents. The final theme was other factors impacting on NSAID risks: particularly patient expectations and over-the-counter (OTC) availability. Conclusion: NSAID prescribing is a complex balance between pragmatism and potential adverse events. Given the costs of morbidity, hospitalisation, and patient demand there is an urgent need to secure a more detailed evidence base and develop practical pathways to support safer prescribing