Challenges and solutions: surveying researchers on what type of community engagement and involvement activities are feasible in low and middle income countries during the COVID-19 pandemic.

OBJECTIVES: Measures to limit the spread of infection during the COVID-19 global pandemic have made engaging and involving members of the community in global health research more challenging. This research aimed to explore how global health researchers adapted to the imposed pandemic measures in low and middle income countries (LMICs) and how they overcame challenges to effective community engagement and involvement (CEI). DESIGN: A qualitative two-stage mixed-methods study involving an online survey and a virtual round table. SETTING: The survey and round table were completed online. PARTICIPANTS: Of 53 participants, 43 were LMIC-based or UK-based global health researchers and/or CEI professionals, and 10 worked for the National Institute for Health Research or UK Government's Department of Health and Social Care. OUTCOME MEASURES: This study aimed to capture data on: the number of CEI activities halted and adapted because of the COVID-19 pandemic; where CEI is possible; how it has been adapted; what the challenges and successes were; and the potential impact of adapted or halted CEI on global health research. RESULTS: Pandemic control measures forced the majority of researchers to stop or amend their planned CEI activities. Most face-to-face CEI activities were replaced with remote methods, such as online communication. Virtual engagement enabled researchers to maintain already established relationships with community members, but was less effective when developing new relationships or addressing challenges around the inclusion of marginalised community groups. CONCLUSIONS: COVID-19 has highlighted the need for contingency planning and flexibility in CEI. The redesigning and adopting of remote methods has come with both advantages and disadvantages, and required new skills, access to technology, funding, reliable services and enthusiasm from stakeholders. The methods suggested have the potential to augment or substitute previously preferred CEI activities. The effectiveness and impact of these remote CEI activities need to be assessed.

Atopic dermatitis and the hygiene hypothesis: a case-control study.

BACKGROUND: The notion that lack of exposure to infection in early life leads to development of atopic disease has come to be known as the hygiene hypothesis. It has arisen from observations of the rapidly rising prevalence of atopic diseases in recent decades and the lower prevalence of atopy with rising birth order. Direct evidence for the hypothesis to date is inconsistent. METHODS: A case-control study set in Norfolk, UK of 602 children aged 1-5 years. Cases and controls were defined using the UK Diagnostic Criteria for atopic dermatitis (AD) and a range of direct and indirect methods were used to measure exposure to infection during infancy. Odds ratios (OR) for the effect of these measures were calculated using logistic regression with adjustment for possible biological and social confounding factors. RESULTS: Reduced odds of AD were associated with rising birth order (OR for one older sibling 0.59, 95% CI: 0.42, 0.84 and for >or=2 older siblings 0.49, 95% CI: 0.31, 0.77). None of the measures of infection reduced the odds of AD significantly, either in the unadjusted or adjusted analyses. None of the measures of infection explained the protective effect of older siblings. CONCLUSIONS: Increased exposure to infection does not explain the reduced risk of AD in second and subsequent siblings. More generally, these data cast doubt on the hygiene hypothesis as a causal explanation for AD in young children.

What criteria do patients use when judging the effectiveness of psoriasis management?

Judgements on the effectiveness of psoriasis management are based on clinical criteria employed by dermatologists, and how they take account of patients' experiences in the process of history taking. In this study the aim was to gain the in-depth patients' perspective and investigate the criteria that they employ when making judgements about the effectiveness of their therapy. These findings were then compared with the clinical and research literature on the clinical effectiveness of psoriasis treatments. The study design is exploratory-descriptive, using a qualitative ethnographic approach. In-depth interviews were undertaken in an outpatient department dermatology clinic. A purposive sample of 20 adult patients currently attending represented the following types of psoriasis: guttate, chronic plaque and scalp. A key comparable finding between the literature and the interview data is that dermatologists emphasize observable criteria of effectiveness, such as clearance of the lesion, whereas patients emphasis focuses on the subjective concerns, such as suppleness, softness and alleviation of itch. This discrepancy needs to be considered during history taking, in relation to its impact on therapy concordance and in the use and development of outcome measures used for clinical assessment and evaluations of psoriasis therapy.

The introduction of integrated out-of-hours arrangements in England: a discrete choice experiment of public preferences for alternative models of care.

OBJECTIVE: To establish which generic attributes of general practice out-of-hours health services are important to the public. METHODS: A discrete choice experiment postal survey conducted in three English general practitioner (GP) co-operatives. A total of 871 individuals aged 20-70 years registered with a GP. Outcomes were preferences for, and trade-offs between: time to making initial contact, time waiting for advice/treatment, informed of expected waiting time, type of contact, professional providing advice, chance contact relieves anxiety, and utility estimates for valuing current models of care. RESULTS: Response rate was 37%. Respondents valued out-of-hours contact for services for reducing anxiety but this was not the only attribute of importance. They had preferences for the way in which services were organized and valued information about expected waiting time, supporting findings from elsewhere. Participants were most willing to make trade-offs between waiting time and professional person. Of the predicted utility for three models of care utility was higher for fully integrated call management. CONCLUSIONS: Greater utility might be achieved if existing services are re-configured more in line with the government's fully integrated call management model. Because the attributes were described in generic terms, the findings can be applied more generally to the plethora of models that exist (and many that might exist in the future). The approach used is important for achieving greater public involvement in how health services develop. Few experiments have elicited public preferences for health services in the UK to date. This study showed valid preferences were expressed but there were problems obtaining representative views from the public.

Effect of introduction of integrated out of hours care in England: observational study.

OBJECTIVES: To quantify service integration achieved in the national exemplar programme for single call access to out of hours care through NHS Direct, and its effect on the wider health system. DESIGN: Observational before and after study of demand, activity, and trends in the use of other health services. PARTICIPANTS: 34 general practice cooperatives with NHS Direct partners (exemplars): four were case exemplars; 10 control cooperatives. SETTING: England. MAIN OUTCOME MEASURES: Extent of integration; changes in demand, activity, and trends in emergency ambulance transports; attendances at emergency departments, minor injuries units, and NHS walk-in centres; and emergency admissions to hospital in the first year. RESULTS: Of 31 distinct exemplars, 21 (68%) integrated all out of hours call management. Nine (29%) achieved single call access for all patients. In the only case exemplar where direct comparison was possible, a higher proportion of telephone calls were handled by cooperative nurses before integration than by NHS Direct afterwards (2622/6687 (39%) v 2092/7086 (30%): P < 0.0001). Other case exemplars did not achieve 30%. A small but significant downturn in overall demand for care seen in two case exemplars was also seen in the control cooperatives. The number of emergency ambulance transports increased in three of the four case exemplars after integration, reaching statistical significance in two (5%, -0.02% to 10%, P = 0.06; 6%, 1% to 12%, P = 0.02; 7%, 3% to 12%, P = 0.001). This was always accompanied by a significant reduction in the number of calls to the integrated service. CONCLUSION: Most exemplars achieved integration of call management but not single call access for patients. Most patients made at least two telephone calls to contact NHS Direct, and then waited for a nurse to call back. Evidence for transfer of demand from case exemplars to 999 ambulance services may be amenable to change, but NHS Direct may not have sufficient capacity to support national implementation of the programme.

Infant immunization and family size.

BACKGROUND: To investigate whether a delay in infant immunization is associated with the number of older siblings. METHODS: A cohort analysis of cumulative immunization uptake in 616 children aged 1-4 years recruited for a case-control study of atopic dermatitis in Norwich, UK was performed. The main outcome measures were the age of third pertussis and MMR immunizations. Delayed immunization was defined as a pertussis immunization age 6 months or greater, and MMR immunization aged 16 months or greater. RESULTS: Having a larger number of older siblings was associated with a delay in pertussis immunization (6.2 per cent for children with no older siblings versus 23.3 per cent for children with two or more older siblings), but not in MMR immunization. CONCLUSION: Infants with older siblings are at greater risk of pertussis infection from intrafamilial contagion yet are less likely to be immunized on time.