The implementation of care pathways to improve children’s allergy services

National reviews demonstrate quality deficiencies in UK health services for allergic children. In response, the RCPCH developed care pathways to improve the organisation and delivery of allergy care. However, care pathway interventions have variable success. Consequently, a literature review and four ethnographic case studies were conducted to theorise care pathway implementation and inform practical recommendations for health service improvements. This process followed the four stages of MELD dialectic: First Moment (1M) of (non-)being, Second Edge (2E) of becoming, Third Level (3L) of integrated totality, and Fourth Dimension (4D) of agency. The 1M results define the mechanisms that cause allergy health service deficiencies and how to address them. Deficiencies were found to emerge from causal mechanisms interacting at physiological, inter-personal, and systemic levels. Care pathway interventions that address these mechanisms could improve the quality of children’s allergy services. However, healthcare improvements also depend on the implementation process and contextual influences. The 2E results describe the unfolding journeys of four teams improving their local health services for allergic children. The 3L results integrate the 1M theoretical understanding and 2E empirical experiences into an advanced understanding of allergy care pathway implementation. The improvement context totality captures contextual factors that manifest differently depending on geohistorical contingencies. This creates unique local challenges and opportunities. The child allergy intervention totality integrates care pathway interventions implemented across case studies. What intervention elements are implemented and to what degree is negotiated based on local challenges and opportunities. The improvement process totality captures the quality improvement methods used to develop interventions and overcome contextual challenges. Children’s allergy health service improvements emerge from the three totalities operating as a dynamic whole. The 4D results discuss the resolution of dialectical contradictions related to the improvement of children’s allergy services. They integrate contradictory theoretical insights identified across academic disciplines by grounding them in the 2L empirical case study experiences and relating them to the 3L structural understanding. These theoretical developments are subsequently translated into practical strategies to navigate and optimise local efforts to improve children’s allergy services. This study used MELD to make theoretical contributions in clinical allergy and improvement science with the aim to support the improvement of children’s allergy services in practice.Open Acces

Integrating Patients Into Programmes to Address the Allergy Knowledge Practice Gap

There is a wide gap between the first publication of new treatments with efficacy and their successful application in clinical practice. In many respects, the management of allergic diseases is a good exemplar of the knowledge/practice gap. It was assumed that systematic reviews and publication of guidelines would ensure timely delivery of effective care, but this has not proved to be the case. While there are many reasons to explain shortcomings in healthcare delivery, the lack of patient and carer involvement in the planning of research, evidence review, guideline development and guideline implementation is most compelling. To achieve adherence to evidence-based guidelines consistently across all levels of the health service requires the implementation of integrated care with clear pathways through which patients can navigate. Quality improvement methodology could be employed to plan and implement integrated care pathways (ICPs). There is evidence that ICPs achieve improved outcomes for acute hospital-based interventions, but less work has focussed on long-term conditions where more diverse agencies are involved. At all stages, stakeholder representation from the full range of healthcare professionals, patients, their families, social services, education, local government and employers must be involved. In this article we review the step-wise and iterative process by which knowledge is implemented into practice to improve patient experience and outcomes We argue how this process can benefit from the involvement of patients and their carers as equal partners, and we discuss how different initiatives have involved patients with allergic diseases. There currently is a gap in evidence that links patient involvement to improved outcomes. We recommend the use of the Core Outcome Sets (COS) and Patient Reported Experience Measures (PREMS) which have been developed for allergic diseases to monitor the effects of implementation research and the impact of patient and carer involvement on outcomes.</p

The recognition of acted interpersonal stance in police interrogations

This research aims at finding how suspects in police interrogations express their interpersonal stance -in terms of T.Leary’s interpersonal circumplex- through body postures and facial expressions and how this can be simulated by virtual humans. Therefore, four types of stances were acted by eight actors. To see if the resulted postures are valid, short recordings were shown online in a survey to subjects who were asked to describe them by a selection of a number of adjectives. Results of this annotation task show that some stance types are better recognized than others. Validity (recognizing the intended stance) and inter-rater agreement do not always go hand in hand. The body postures and facial expressions of the best recognized fragments are annotated so they can be implemented in the artificial agent. The results of this study are used in a serious game for police interrogation training where the role of the suspect is played by an artificial embodied conversational agent

The recognition of acted interpersonal stance in police interrogations and the influence of actor proficiency

This paper reports on judgement studies regarding the perception of interpersonal stances taken by humans playing the role of a suspect in a police interrogation setting. Our project aims at building believable embodied conversational characters to play the role of suspects in a serious game for learning interrogation strategies. The main question we ask is: do human judges agree on the way they perceive the various aspects of stance taking, such as friendliness and dominance? Four types of stances were acted by eight amateur actors. Short recordings were shown in an online survey to subjects who were asked to describe them using a selection of a number of adjectives. Results of this annotation task are reported in this paper. We explain how we computed the inter-rater agreement with Krippendorff’s alpha statistics using a set theoretical distance metric. Results show that for some of the stance types observers agreed more than for others. Some actors are better than others, but validity (recognizing the intended stance) and inter-rater agreement do not always go hand in hand. We further investigate the effect the expertise of actors has on the perception of the stance that is acted. We compare the fragments from amateur actors to fragments from professional actors taken from popular TV-shows

The reflexive imperative in the digital age:Using Archer’s ‘fractured reflexivity’ to theorise widening inequities in UK general practice

‘Reflexivity’, as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer’s theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from ‘Deep End’ practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients’ reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients’ fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care

The reflexive imperative in the digital age:Using Archer’s ‘fractured reflexivity’ to theorise widening inequities in UK general practice

‘Reflexivity’, as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer’s theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from ‘Deep End’ practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients’ reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients’ fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care

Virtual care pathways for people living with HIV:A mixed‐methods systematic review

Background: The COVID-19 pandemic prompted an unprecedented surge in virtual services, necessitating a rapid shift to digital healthcare approaches. This review focuses on evaluating the evidence of virtual care (VC) in delivering HIV care, considering the complex nature of HIV and the need for tailored-approaches, especially for marginalized populations.Methods: A mixed-methods systematic review was performed with searches on five databases, covering studies from January 1946 to May 2022. Inclusion criteria involved two-way virtual consultations between healthcare workers and people living with HIV (PLHIV), with detailed descriptions and outcomes. Qualitative and quantitative studies were included, and the risk of bias was assessed using the Newcastle–Ottawa score and Stenfors' framework.Results: Among 4143 identified records, 26 studies met the criteria, with various models of care described. The majority of studies were observational, and videoconferencing was the primary mode of virtual consultation employed. Quantitative analysis revealed PLHIV generally accept VC, with high attendance rates (87%). Mean acceptability and satisfaction rates were 80% and 85%, respectively, while 87% achieved HIV viral suppression. The setting and models of VC implementation varied, with some introduced in response to COVID-19 while others were as part of trials.Conclusions: VC for PLHIV is deemed an acceptable and effective approach and is associated with good virological outcomes. Data on other health outcomes is lacking. The review underscores the importance of diverse models of care, patient choice and comprehensive training initiatives for both staff and patients. Establishing a ‘gold standard’ for VC models is crucial for ensuring appropriate and effective reviews of PLHIV in virtual settings.</div