Tackling cancers of unmet need: the pancreatic cancer pathway

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An exploration of lay epidemiology and cancer

Some estimates suggest that as much as 70% of cancer is preventable by disease modification alone (Peto 1991). Disease prevention via behavioural change is a challenging endeavour. There is widespread recognition that for behaviour to be better understood there is a need to understand the context in which it occurs, and the beliefs that underpin it. Lay epidemiology illustrates the sophistication of belief formation. The arrival at a coronary candidate provides according to Davison, Frankel and Davey Smith (1991), a cultural mechanism that aids the estimation of risk as observed from known cases in the family and wider society. Consequently, the estimate provides the potential motivation for behavioural choices. Other studies that followed the original model of lay epidemiology have similarly described the coronary candidate (Preston 1997; Emslie, Hunt & Watt 2001a; Frich, Malterud & Fugelli 2007; Weiner 2009) and suggest that the lay public have an understanding of the risk profile for Coronary Heart Disease. This study aimed to explore the utility of the elements held within lay epidemiology in cancer beliefs. Do the lay public recognise a ‘cancer candidate’? Method: A series of 31 in-depth semi-structured interviews were conducted between November 2007 and October 2008. Interviews took place in two communities in Glasgow, Scotland – one affluent, one deprived. The sample was drawn from a number of community organisations and leisure clubs in the communities to facilitate accessing an ‘ordinary’ view. Cancer sufferers were excluded from the study. A topic guide was used to ensure consistency throughout interviews and focused on participants’ experience of cancer. Although the study did not adhere to a strict grounded theory approach, the analytic method of constant comparative analysis was followed. Findings: The complexity of the scheme described by Davison, where a wide range of sources of knowledge to inform beliefs resonated. Sophisticated and complex explanatory models of cancer were described. Cancer inhabited an important cultural position and was most commonly associated with fear and dread. Possible aetiological explanations included behavioural, environmental, biological and psychological factors. Smoking was the most widely recognised risk factor. Knowledge of other risk factors for individual cancers was patchy. Candidacy therefore was not as unequivocal for cancer. Many ‘anomalous cases’ (those without obvious explanation) were proffered. Ultimately the randomness of cancer was emphasised. Conclusion: Cancer is a more complex disease than CHD, both culturally and biomedically and this is reflected in the beliefs voiced by participants in this study. This complexity is a barrier to the adoption of a cancer candidate

Interventions targeted at primary care practitioners to improve the identification and referral of patients with co-morbid obesity: a realist review protocol

<b>Background </b>Obesity is one of the most significant public health challenges in the developed world. Recent policy has suggested that more can be done in primary care to support adults with obesity. In particular, general practitioners (GPs) and practice nurses (PNs) could improve the identification and referral of adults with obesity to appropriate weight management services. Previous interventions targeted at primary care practitioners in this area have had mixed results, suggesting a more complex interplay between patients, practitioners, and systems. The objectives of this review are (i) to identify the underlying ‘programme theory’ of interventions targeted at primary care practitioners to improve the identification and referral of adults with obesity and (ii) to explore how and why GPs and PNs identify and refer individuals with obesity, particularly in the context of weight-related co-morbidity. This protocol will explain the rationale for using a realist review approach and outline the key steps in this process. <p></p> <b>Methods</b> Realist review is a theory-led approach to knowledge synthesis that provides an explanatory analysis aimed at discerning what works, for whom, in what circumstances, how, and why. In this review, scoping interviews with key stakeholders involved in the planning and delivery of adult weight management services in Scotland helped to inform the identification of formal theories - from psychology, sociology, and implementation science - that will be tested as the review progresses. A comprehensive search strategy is described, including scope for iterative searching. Data analysis is outlined in three stages (describing context-mechanism-outcome configurations, exploring patterns in these configurations, and developing and testing middle-range theories, informed by the formal theories previously identified), culminating in the production of explanatory programme theory that considers individual, interpersonal, and institutional/systems-level components. <p></p> <b>Discussion </b>This is the first realist review that we are aware of looking at interventions targeted at primary care practitioners to improve the weight management of adults with obesity. Engagement with stakeholders at an early stage is a unique feature of realist review. This shapes the scope of the review, identification of candidate theories and dissemination strategies. The findings of this review will inform policy and future interventions. Systematic review registration PROSPERO CRD4201400939

Scalable distributed event detection for Twitter

Social media streams, such as Twitter, have shown themselves to be useful sources of real-time information about what is happening in the world. Automatic detection and tracking of events identified in these streams have a variety of real-world applications, e.g. identifying and automatically reporting road accidents for emergency services. However, to be useful, events need to be identified within the stream with a very low latency. This is challenging due to the high volume of posts within these social streams. In this paper, we propose a novel event detection approach that can both effectively detect events within social streams like Twitter and can scale to thousands of posts every second. Through experimentation on a large Twitter dataset, we show that our approach can process the equivalent to the full Twitter Firehose stream, while maintaining event detection accuracy and outperforming an alternative distributed event detection system

Performance of Cognitive Radio Networks with Unknown Dynamic Primary User Signals

The current static assignment of RF spectrum in the United States and other parts of the world has led to a large portion of the RF spectrum to be geographically and temporally underutilized. While the amount of RF spectrum is finite, the demand for spectrum continues to increase making it necessary to increase utilization of many bands. Several innovative methods for allowing licensed primary users (PUs) to share spectrum with unlicensed secondary users (SUs) have being proposed. Of these methods Cognitive Radio (CR) has emerged as a promising technology that enables SUs to dynamically access spectrum after first sensing the spectrum to ensure the PU is not active. Sensing performance is critical to a successful CR implementation, and within the last decade there has been significant CR research examining various sensing challenges and methods to improve sensing performance. The majority of this research has focused on PUs that utilize spectrum with relatively long idle and transmission periods which in turn allows for SU sensing periods with an extended duration. The work presented in this dissertation focuses on CR systems where the PU is highly dynamic and addresses several issues that arise when attempting to access this spectrum. In the case of a highly dynamic PU, it is not possible for the SU to increase the sensing period to improve performance, resulting in suboptimal sensing performance. A proposed hybrid framework is described which allows for suboptimal sensing performance by limiting the SU transmission power dependent on the sensing capabilities. In order to quantify sensing capabilities, a mathematical model for describing the PU activity with respect to the SU sensing period is derived using the mean active and idle durations of the PU. Using this PU activity model, closed form mathematical expressions for sensing performance are provided for two different hypothesis tests. Finally, the PU activity model and corresponding expressions for sensing performance depend on knowing the mean PU active and idle durations; because the SU may not know these PU parameters, a modified expectation maximization algorithm is proposed to estimate these parameters and corresponding sensor performance

The role of primary care in adult weight management: qualitative interviews with key stakeholders in weight management services

Background: Primary care has a key role to play in the prevention and management of obesity, but there remain barriers to engagement in weight management by primary care practitioners. The aim of this study was to explore the views of key stakeholders in adult weight management services on the role of primary care in adult weight management. Methods: Qualitative study involving semi-structured interviews with nine senior dietitians involved in NHS weight management from seven Scottish health boards. Transcripts were analysed using an inductive thematic approach. Results: A range of tensions were apparent within three key themes: weight management service issues, the role of primary care, and communication with primary care. For weight management services, these tensions were around funding, the management model of obesity, and how to configure access to services. For primary care, they were around what primary care should be doing, who should be doing it, and where this activity should fit within wider weight management policy. With regard to communication between weight management services and primary care, there were tensions related to the approach taken (locally adapted versus centralised), the message being communicated (weight loss versus wellbeing), and the response from practitioners (engagement versus resistance). Conclusions: Primary care can do more to support adult weight management, but this requires better engagement and communication with weight management services, to overcome the tensions highlighted in this study. This, in turn, requires more secure, sustained funding. The example of smoking cessation in the UK, where there is a network of well-resourced NHS Stop Smoking Services, accessible via different means, could be a model to follow

Long-term condition management in adults with intellectual disability in primary care: a systematic review

Background: Adults with intellectual disabilities have higher morbidity and earlier mortality than the general population. Access to primary health care is lower, despite a higher prevalence of many long-term conditions. Aim: To synthesise the evidence for the management of long-term conditions in adults with intellectual disabilities and identify barriers and facilitators to management in primary care. Design & setting: Mixed-methods systematic review. Method: Seven electronic databases were searched to identify both quantitative and qualitative studies concerning identification and management of long-term conditions in adults with intellectual disability in primary care. Both the screening of titles, abstracts, and full texts, and the quality assessment were carried out in duplicate. Findings were combined in a narrative synthesis. Results: Fifty-two studies were identified. Adults with intellectual disabilities are less likely than the general population to receive screening and health promotion interventions. Annual health checks may improve screening, identification of health needs, and management of long-term conditions. Health checks have been implemented in various primary care contexts, but the long-term impact on outcomes has not been investigated. Qualitative findings highlighted barriers and facilitators to primary care access, communication, and disease management. Accounts of experiences of adults with intellectual disabilities reveal a dilemma between promoting self-care and ensuring access to services, while avoiding paternalistic care. Conclusion: Adults with intellectual disabilities face numerous barriers to managing long-term conditions. Reasonable adjustments, based on the experience of adults with intellectual disability, in addition to intervention such as health checks, may improve access and management, but longer-term evaluation of their effectiveness is required

Patient and practice characteristics predicting attendance and completion at a specialist weight management service in the UK: a cross-sectional study

Objective: To determine the association between patient and referring practice characteristics and attendance and completion at a specialist health service weight management service (WMS). Design: Cross-sectional study. Setting: Regional specialist WMS located in the West of Scotland. Participants: 9677 adults with obesity referred between 2012 and 2014; 3250 attending service and 2252 completing. Primary and secondary outcome measures: Primary outcome measure was attendance at the WMS; secondary outcome was completion, defined as attending four or more sessions. Analysis: Multilevel binary logistic regression models constructed to determine the association between patient and practice characteristics and attendance and completion. Results: Approximately one-third of the 9677 obese adults referred attended at least one session (n=3250, 33.6%); only 2252 (23%) completed by attending four or more sessions. Practice referrals ranged from 1 to 257. Patient-level characteristics were strongest predictors of attendance; odds of attendance increased with age (OR 4.14, 95% CI 3.27 to 5.26 for adults aged 65+ compared with those aged 18–24), body mass index (BMI) category (OR 1.83, 95% CI 1.56 to 2.15 for BMI 45+ compared with BMI 30–35) and increasing affluence (OR 1.96, 95% CI 1.17 to 3.28). Practice-level characteristics most strongly associated with attendance were being a non-training practice, having a larger list size and not being located in the most deprived areas. Conclusions: There was wide variation in referral rates across general practice, suggesting that there is still much to do to improve engagement with weight management by primary care practitioners. The high attrition rate from referral to attendance and from attendance to completion suggests ongoing barriers for patients, particularly those from the most socioeconomically deprived areas. Patient and practice-level characteristics can help us understand the observed variation in attendance at specialist WMS following general practitioner (GP) referral and the underlying explanations for these differences merit further investigation

Illness identity as an important component of candidacy: Contrasting experiences of help-seeking and access to care in cancer and heart disease

How and when we use health services or healthcare provision has dominated exploration of and debates around healthcare access. Levels of utilisation are assumed as a proxy for access. Yet, focusing on utilisation conceals an important aspect of the access conundrum: the relationships that patients and potential patients have with the healthcare system and the professionals within those systems. Candidacy has been proposed as an antidote to traditional utilisation models. The Candidacy construct offers the ability to include patient-professional aspects alongside utilisation and thus promotes a deeper understanding of access. Originally applied to healthcare access for vulnerable populations, additional socio-demographic factors, including age and ethnicity, have also been shown to influence the Candidacy process. Here we propose a further extension of the Candidacy construct and illustrate the importance of illness identities when accessing healthcare. Drawing on a secondary data analysis of three data sets of qualitative interviews from colorectal cancer and heart failure patients we found that though similar access issues are apparent pre-diagnosis, diagnosis marks a critical juncture in the experience of access. Cancer patients describe a person-centred responsive healthcare system where their patienthood requires only modest assertion. Cancer speaks for itself. In marked contrast heart failure patients, describe struggling within a seemingly impermeable system to understand their illness, its implications and their own legitimacy as patients. Our work highlights the pressing need for healthcare professionals, systems and policies to promote a person centred approach, which is responsive and timely, regardless of illness category. To achieve this, attitudes regarding the importance or priority afforded to different categories of illness need to be tackled as they directly influence ideas of Candidacy and consequently access and experiences of care

GP speciality training in areas of deprivation: factors influencing engagement. A qualitative study

Background: GP training practices are less likely to be situated in areas of deprivation; little is known about GP views of postgraduate training in such areas. Aim: To explore the views of GPs working in deprived areas about GP speciality training (GPST). Design & setting: Qualitative in-depth interviews with GPs working in practices in deprived areas in Scotland. Method: Ten in-depth interviews were conducted with GPs in training and non-training practices, to explore views on training. Interviews were audiotaped and transcribed verbatim, and inductive thematic analysis was undertaken. Results: The importance of producing ‘well-rounded’ GPs who are able to work in a variety of environments was highlighted. Trainees need exposure to the specific challenges of deprived contexts (such as early multimorbidity, child protection, and addiction) and the benefit of this for trainees was thought to be invaluable. GPs identified many perceived barriers and benefits to training, some generic but some — such as inspiring the next generation (benefit) or overwhelming workload (barrier) — may be more relevant in areas of high deprivation. Overwhelming workload was the main reason for not becoming a training practice, though some would consider it if supported to develop a training culture. All the GPs, including non-trainers, were involved in optional activities which were felt to be important for resilience. Conclusion: GPs in areas of deprivation highlighted specific skills that could be gained by undertaking at least a part placement in deprived areas, with different skills likely to be gained from affluent areas. National education bodies should consider GP training rotations ensure a variety of training environments