An exploration of the statutory Healthy Start vitamin supplementation scheme in North West England.

BACKGROUND: Government nutritional welfare support from the English 'Healthy Start' scheme is targeted at low-income pregnant women and preschool children, but take-up of its free food vouchers is much better than its free vitamin vouchers. While universal implementation probably requires a more extensive scheme to be cost-effective, the everyday experience of different ways of receiving or facilitating Healthy Start, especially via children's centres, also requires further evidence. This study therefore aimed to explore (in the context of low take-up levels) perceptions of mothers, health professionals, and commissioners about Healthy Start vitamin and food voucher take-up and compare experiences in a targeted and a universal implementation-area for those vitamins. METHODS: Informed by quantitative analysis of take-up data, qualitative analysis focused on 42 semi-structured interviews with potentially eligible mothers and healthcare staff (and commissioners), purposively sampled via children's centres in a similarly deprived universal and a targeted implementation-area of North West England. RESULTS: While good food voucher take-up appeared to relate to clear presentation, messaging, practicality, and monetary (albeit low) value, poor vitamin take-up appeared to relate to overcomplicated procedures and overreliance on underfunded centres, organizational goodwill, and families' resilience. CONCLUSION: Higher 'universal' vitamin take-up may well have reflected fewer barriers when it became everyone's business to be vitamin-aware. Substantive Healthy Start reform in England (not just cosmetic tinkering) is long overdue. Our study highlights that 'policy, politics, and problem' should be aligned to reach considerable unmet need.

Mediators of socioeconomic inequalities in preterm birth: a systematic review.

BACKGROUND: Rates of preterm birth are substantial with significant inequalities. Understanding the role of risk factors on the pathway from maternal socioeconomic status (SES) to preterm birth can help inform interventions and policy. This study therefore aimed to identify mediators of the relationship between maternal SES and preterm birth, assess the strength of evidence, and evaluate the quality of methods used to assess mediation. METHODS: Using Scopus, Medline OVID, "Medline In Process & Other Non-Indexed Citation", PsycINFO, and Social Science Citation Index (via Web of Science), search terms combined variations on mediation, socioeconomic status, and preterm birth. Citation and advanced Google searches supplemented this. Inclusion criteria guided screening and selection of observational studies Jan-2000 to July-2020. The metric extracted was the proportion of socioeconomic inequality in preterm birth explained by each mediator (e.g. 'proportion eliminated'). Included studies were narratively synthesised. RESULTS: Of 22 studies included, over one-half used cohort design. Most studies had potential measurement bias for mediators, and only two studies fully adjusted for key confounders. Eighteen studies found significant socioeconomic inequalities in preterm birth. Studies assessed six groups of potential mediators: maternal smoking; maternal mental health; maternal physical health (including body mass index (BMI)); maternal lifestyle (including alcohol consumption); healthcare; and working and environmental conditions. There was high confidence of smoking during pregnancy (most frequently examined mediator) and maternal physical health mediating inequalities in preterm birth. Significant residual inequalities frequently remained. Difference-of-coefficients between models was the most common mediation analysis approach, only six studies assessed exposure-mediator interaction, and only two considered causal assumptions. CONCLUSIONS: The substantial socioeconomic inequalities in preterm birth are only partly explained by six groups of mediators that have been studied, particularly maternal smoking in pregnancy. There is, however, a large residual direct effect of SES evident in most studies. Despite the mediation analysis approaches used limiting our ability to make causal inference, these findings highlight potential ways of intervening to reduce such inequalities. A focus on modifiable socioeconomic determinants, such as reducing poverty and educational inequality, is probably necessary to address inequalities in preterm birth, alongside action on mediating pathways.

A Best Evidence Medical Education (BEME) systematic review of: What works best for health professions students using mobile (hand-held) devices for educational support on clinical placements? BEME Guide No. 52.

BACKGROUND: Ingrained assumptions about clinical placements (clerkships) for health professions students pursuing primary basic qualifications might undermine best educational use of mobile devices. QUESTION: What works best for health professions students using mobile (hand-held) devices for educational support on clinical placements? METHODS: A Best Evidence Medical Education (BEME) effectiveness-review of "justification" complemented by "clarification" and "description" research searched: MEDLINE, Educational Resource Information Center, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Cochrane Central, Scopus (1988-2016). Reviewer-pairs screened titles/abstracts. One pair coded, extracted, and synthesized evidence, working within the pragmatism paradigm. SUMMARY OF RESULTS: From screening 2279 abstracts, 49 articles met inclusion-criteria, counting four systematic reviews for context. The 45 articles of at least Kirkpatrick K2 primary research mostly contributed K3 (39/45, 86.7%), mixed methods (21/45, 46.7%), and S3-strength (just over one-half) evidence. Mobile devices particularly supported student: assessment; communication; clinical decision-making; logbook/notetaking; and accessing information (in about two-thirds). Informal and hidden curricula included: concerns about: disapproval; confidentiality and privacy; security;-distraction by social connectivity and busy clinical settings; and mixed messages about policy. DISCUSSION AND CONCLUSION: This idiosyncratic evidence-base of modest robustness suggested that mobile devices provide potentially powerful educational support on clinical placement, particularly with student transitions, metalearning, and care contribution. Explicit policy must tackle informal and hidden curricula though, addressing concerns about transgressions.

The impacts of profound gender discrimination on the survival of girls and women in son-preference countries - A systematic review.

Amartya Sen first used the phrase 'missing women' to describe a survival disadvantage for women exposed to extreme gender discrimination in son-preference countries. In 1989 he estimated that, despite a biological survival advantage for females, there were 100 million fewer women in Asia and north Africa than expected. He blamed corrosive gender discrimination restricting the resources needed for survival. This systematic review examined demographic evidence on the impacts of profound gender discrimination on the survival of girls and women in son-preference countries. Thirty-four included studies provided consistent evidence of lower-than-expected female survival in 15 societies. Male-to-female sex ratios rose particularly in China and India between the 1980s and 2010s, despite general improvements in female mortality. High sex ratios in South Korea, however, returned to biologically normal levels. The number of 'missing women' rose steadily from 61 million in 1970 to 126 million in 2010 and was predicted to continue to rise until 2035. The number of 'missing women' in the world increased in relative and absolute terms between 1980 and 2020. Profound discrimination reduces female survival at every stage of life. Future research is needed to understand the complete pathways and mechanisms leading to poorer survival and the major policy drivers of these trends to devise the best possible ways of preventing the tragedy of 'missing women'.

Mixing it but not mixed-up: mixed methods research in medical education (a critical narrative review).

BACKGROUND: Some important research questions in medical education and health services research need 'mixed methods research' (particularly synthesizing quantitative and qualitative findings). The approach is not new, but should be more explicitly reported. AIM: The broad search question here, of a disjointed literature, was thus: What is mixed methods research - how should it relate to medical education research?, focused on explicit acknowledgement of 'mixing'. METHODS: Literature searching focused on Web of Knowledge supplemented by other databases across disciplines. FINDINGS: Five main messages emerged: - Thinking quantitative and qualitative, not quantitative versus qualitative - Appreciating that mixed methods research blends different knowledge claims, enquiry strategies, and methods - Using a 'horses for courses' [whatever works] approach to the question, and clarifying the mix - Appreciating how medical education research competes with the 'evidence-based' movement, health services research, and the 'RCT' - Being more explicit about the role of mixed methods in medical education research, and the required expertise CONCLUSION: Mixed methods research is valuable, yet the literature relevant to medical education is fragmented and poorly indexed. The required time, effort, expertise, and techniques deserve better recognition. More write-ups should explicitly discuss the 'mixing' (particularly of findings), rather than report separate components.

Age-Adjusted Associations Between Comorbidity and Outcomes of COVID-19: A Review of the Evidence From the Early Stages of the Pandemic.

Objectives: Early in the COVID-19 pandemic, people with underlying comorbidities were overrepresented in hospitalised cases of COVID-19, but the relationship between comorbidity and COVID-19 outcomes was complicated by potential confounding by age. This review therefore sought to characterise the international evidence base available in the early stages of the pandemic on the association between comorbidities and progression to severe disease, critical care, or death, after accounting for age, among hospitalised patients with COVID-19. Methods: We conducted a rapid, comprehensive review of the literature (to 14 May 2020), to assess the international evidence on the age-adjusted association between comorbidities and severe COVID-19 progression or death, among hospitalised COVID-19 patients - the only population for whom studies were available at that time. Results: After screening 1,100 studies, we identified 14 eligible for inclusion. Overall, evidence for obesity and cancer increasing risk of severe disease or death was most consistent. Most studies found that having at least one of obesity, diabetes mellitus, hypertension, heart disease, cancer, or chronic lung disease was significantly associated with worse outcomes following hospitalisation. Associations were more consistent for mortality than other outcomes. Increasing numbers of comorbidities and obesity both showed a dose-response relationship. Quality and reporting were suboptimal in these rapidly conducted studies, and there was a clear need for additional studies using population-based samples. Conclusions: This review summarises the most robust evidence on this topic that was available in the first few months of the pandemic. It was clear at this early stage that COVID-19 would go on to exacerbate existing health inequalities unless actions were taken to reduce pre-existing vulnerabilities and target control measures to protect groups with chronic health conditions.

Public health education for medical students: rising to the professional challenge.

Public health competencies, especially as they relate to the management of chronic disease, will be of increasing importance to the global health-care workforce. The General Medical Council's recommendations on basic medical education have helped to entrench the position of public health and related disciplines. Tomorrow's Doctors has recently been updated. This article describes the indicative goals that should underpin the development of undergraduate medical education in public health, presented in a national statement. The statement was originally produced on behalf of academic departments of public health and related disciplines in UK medical schools. The dearth of evidence in this field leaves many questions for future educational research.

Medical students' and prospective medical students' uncertainties about career intentions: cross-sectional and longitudinal studies.

BACKGROUND: Policy prompts medical students' earlier career awareness. AIM: To explore changes and uncertainty in medical (and prospective medical) students' career intentions in a 5-year problem-based curriculum. METHODS: Six postal questionnaire surveys of medical students and one survey of prospective medical students sought career intentions from three entry-cohorts (one also seeking why they chose medicine, and one, the reason for the career intention). RESULTS: From the 973 (91.4%) 2001/02 admission interviewees responding, 74/189 (39.2%) of those admitted and remaining 'in-year' re-reported career intentions 5 years later (2006/07). Of the 1999 entrants (start-Year 1; end-Year 1; and mid-Year 3) and 2001 entrants (start-Year 1 and end-Year 1), 61.2-77.9% responded. Up to mid-programme, only 9.5-18.8% reported general practice, significantly more of whom described altruistic reasons for choosing medicine (2001 entrants). Tracked longitudinally, career intentions stayed relatively stable, but a small significant retreat from general practice over Year 1 predated clinical placements. From pre-admission to mid-Year 5, uncertainty decreased significantly, but 14.9% replied 'do not know' both times. Significantly more prospective students from the least affluent English or Welsh postcodes specified a career intention. CONCLUSION: Many students might delay considering career intentions, particularly general practice. Socioeconomic determinants of early medical career decision making merit further study.

Analysing synthesis of evidence in a systematic review in health professions education: observations on struggling beyond Kirkpatrick.

Background: Systematic reviews in health professions education may well under-report struggles to synthesize disparate evidence that defies standard quantitative approaches. This paper reports further process analysis in a previously reported systematic review about mobile devices on clinical placements.Objective: For a troublesome systematic review: (1) Analyse further the distribution and reliability of classifying the evidence to Maxwell quality dimensions (beyond 'Does it work?') and their overlap with Kirkpatrick K-levels. (2) Analyse how the abstracts represented those dimensions of the evidence-base. (3) Reflect on difficulties in synthesis and merits of Maxwell dimensions.Design: Following integrative synthesis of 45 K2-K4 primary studies (by combined content-thematic analysis in the pragmatism paradigm): (1) Hierarchical cluster analysis explored overlap between Maxwell dimensions and K-levels. Independent and consensus-coding to Maxwell dimensions compared (using: percentages; kappa; McNemar hypothesis-testing) pre- vs post-discussion and (2) article abstract vs main body. (3) Narrative summary captured process difficulties and merits.Results: (1) The largest cluster (five-cluster dendrogram) was acceptability-accessibility-K1-appropriateness-K3, with K1 and K4 widely separated. For article main bodies, independent coding agreed most for appropriateness (good; adjusted kappa = 0.78). Evidence increased significantly pre-post-discussion about acceptability (p = 0.008; 31/45→39/45), accessibility, and equity-ethics-professionalism. (2) Abstracts suggested efficiency significantly less than main bodies evidenced: 31.1% vs 44.4%, p = 0.031. 3) Challenges and merits emerged for before, during, and after the review.Conclusions: There should be more systematic reporting of process analysis about difficulties synthesizing suboptimal evidence-bases. In this example, Maxwell dimensions were a useful framework beyond K-levels for classifying and synthesizing the evidence-base.

Problem-based learning at the receiving end: a 'mixed methods' study of junior medical students' perspectives.

UNLABELLED: Qualitative insights about students' personal experience of inconsistencies in implementation of problem-based learning (PBL) might help refocus expert discourse about good practice. AIM: This study explored how junior medical students conceptualize: PBL; good tutoring; and less effective sessions. METHODS: Participants comprised junior medical students in Liverpool 5-year problem-based, community-orientated curriculum. Data collection and analysis were mostly cross-sectional, using inductive analysis of qualitative data from four brief questionnaires and a 'mixed' qualitative/quantitative approach to data handling. The 1999 cohort (end-Year 1) explored PBL, generated 'good tutor' themes, and identified PBL (dis)advantages (end-Year 1 then mid-Year 3). The 2001 cohort (start-Year 1) described critical incidents, and subsequently (end-Year 1) factors in less effective sessions. These factors were coded using coding-frames generated from the answers about critical incidents and 'good tutoring'. RESULTS: Overall, 61.2% (137), 77.9% (159), 71.0% (201), and 71.0% (198) responded to the four surveys, respectively. Responders perceived PBL as essentially process-orientated, focused on small-groupwork/dynamics and testing understanding through discussion. They described 'good tutors' as knowing when and how to intervene without dominating (51.1%). In longitudinal data (end-Year 1 to mid-Year 3), the main perceived disadvantage remained lack of 'syllabus' (and related uncertainty). For less effective sessions (end-Year 1), tutor transgressions reflected unfulfilled expectations of good tutors, mostly intervening poorly (42.6% of responders). Student transgressions reflected the critical incident themes, mostly students' own lack of work/preparation (54.8%) and other students participating poorly (33.7%) or dominating/being self-centred (31.6%). CONCLUSION: Compelling individual accounts of uncomfortable PBL experiences should inform improvements in implementation.

Making sense of trying not to teach: an interview study of tutors' ideas of problem-based learning.

PURPOSE: To explore how a cohort of first-ever "foundation" tutors in a new problem-based curriculum characterized and made sense of problem-based learning (PBL). METHOD: The sample consisted of all foundation tutors (n = 34) from The University of Liverpool's undergraduate medical curriculum, 1996-97, the first semester of the first year that PBL became a main vehicle for knowledge acquisition. The cross-sectional study design involved semistructured telephone interviews with the tutors about PBL and problem solving. The author taped and transcribed the interviews and conducted an inductive analysis of these qualitative data. RESULTS: All tutors responded, with interviews lasting about 20 minutes: 26/34 (76%) were men and 23 (68%) were medically qualified. Twenty-nine (85%) facilitated 19-21 of the 21 PBL sessions. Most tutors conceptualized PBL as being student-centered (68%), involving small-group work (53%), but ignored its reflective component. They conceptualized good PBL tutors diversely, but mostly as "knowing" when and how to intervene (41%) and empathizing with students (29%). Few tutors characterized PBL in terms of problem solving, yet over half agreed, cursorily, that they were intimately related. The tutors were generally unclear about this relationship. CONCLUSION: These tutors mostly characterized PBL positively as a philosophy, yet missed its reflective elements and were particularly challenged by their own fallibility in knowing when and how to intervene without teaching. Internal motivation and direct experience of PBL helped balance some of the tutors' confusion with the educational rationale, highlighting possibilities for future staff development.

Patients bringing information to primary care consultations: a cross-sectional (questionnaire) study of doctors' and nurses' views of its impact.

OBJECTIVES: To explore the perceived frequency and impact of patients bringing health information from the Internet to primary care consultations. METHOD: A questionnaire was sent to all general practitioners (GPs) and practice nurses (nurses) in a primary care trust in the North-west of England. RESULTS: The response was 52.3%, more nurses responding than GPs (61.2% vs 46.8%). A substantial majority (93.9% and 78.0%) had experienced patients bringing such information in the last 6 months, which often lengthened the consultations. Significantly more nurses than GPs felt that the information helped the consultation (87.1% vs 37.7%), but also reported that patients bringing such information was off-putting (21.9% vs 6.3%). CONCLUSIONS: Both GPs and nurses experienced patients bringing health information to consultations and significantly differed in their views about whether it helped or hindered. Primary care staff should anticipate patients' use of the Internet for health information and should actively manage patients introducing it into the consultation.

Time to think? Questionnaire survey of pre-registration house officers' experiences of critical appraisal in the Mersey Deanery.

CONTEXT: Workload pressures may lead pre-registration house officers (PRHOs) to undervalue critical appraisal and thinking skills. This study aimed to explore Mersey Deanery PRHOs' attitudes, experiences and perceived readiness for practising evidence-based medicine with critical appraisal skills. METHODS: A cross-sectional survey of 157 PRHOs from 5 postgraduate centres in the UK, using a semistructured questionnaire, at the beginning and end of the pre-registration year. Main outcome measures were level of agreement with closed statements exploring experiences and opinions about critical appraisal skills and evidence-based practice. Open questions explored personal experiences. RESULTS: Most PRHOs (69%) felt medical school prepared them to use critical appraisal skills and perceived such skills as relevant (63%). Fewer felt that their clinical work was based on best available evidence (57%). The busier the PRHOs, the less likely they were to agree that their practice followed best evidence. The PRHOs were more likely to feel supported and that their practice was evidence-based at the end of the year. Responders identified several reasons for their practice not being evidence-based, including workload, lack of skills, deferring to senior colleagues, and non-conducive hospital culture. CONCLUSIONS: The nature of PRHO work still mitigates against critical thinking and appraising evidence, with a lack of protected time and perceived inconsistent support from educational supervisors. Many PRHOs rely entirely on evidence-based summaries and guidelines from others. The PRHO year is a period of crucial transition, however, and critical appraisal skills and evidence-based approaches need developing post-qualification, with sufficient protected time for their integration into practice. Foundation year reforms reinforce such requirements.

Junior medical students' notions of a 'good doctor' and related expectations: a mixed methods study.

OBJECTIVE: To explore junior medical students' notions of a 'good doctor', given their ideas about: success in Year 1, house jobs, and their attraction to medicine. METHODS: Study participants were junior medical students (1999 and 2001 entry cohorts studied thrice and twice, respectively) and prospective students of the University of Liverpool's 5-year, problem-based, community-orientated curriculum. Data collection and analysis used a 'mixed methods' approach, cross-sectional design, and brief questionnaire surveys. In an index survey, open questions (analysed inductively) explored house jobs and Year 1 success. They also generated 'good doctor' themes, which a second survey confirmed and 3 surveys ranked. A sixth survey explored motivation for choosing medicine (open question). Good doctor rankings were analysed by postcode for prospective medical students classified as school-leaver residents of England and Wales. RESULTS: Response rates were: 91.4% (973) of the 2001-02 admission candidates, on interview days; 68.0% (155), 61.2% (137) and 77.9% (159) of the 1999 cohort (at entry, end-Year 1 and mid-Year 3, respectively), and 71.0% (201) and 71.0% (198) of the 2001 cohort (at entry and end-Year 1, respectively). From 9 themes generally compatible with self-reported motivations and expectations, junior and prospective medical students consistently valued a good doctor as a 'compassionate, patient-centred carer' and a 'listening, informative communicator' over an 'exemplary, responsible professional'. Prospective students from less affluent English and Welsh postcodes valued 'efficient, organised self-manager' very slightly more highly (r(s) = - 0.140, P = 0.003). CONCLUSIONS: This research provided empirical evidence to support ongoing commentary about patients mostly seeking qualities related to communication, caring, and competence in doctors. Weak evidence that socio-economic status might affect notions of a good doctor is worth pursuing.

The limits of tutors' comfort zones with four integrated knowledge themes in a problem-based undergraduate medical curriculum (Interview study).

PURPOSE: To explore how a cohort of problem-based learning (PBL) tutors (with diverse medical and other content expertise) conceptualised their students' integrated learning agenda, particularly for content less familiar to the vast majority, such as public health elements. SETTING: Problem-based undergraduate medical curriculum, The University of Liverpool, in its first-ever year. PARTICIPANTS: Foundation PBL tutors for Year 1 students, Semester 1. METHOD: A cross-sectional, semistructured telephone interview study was undertaken during spring 1997, with open-ended questions about Semester 1 experience of the four main themes. Qualitative data were analysed inductively and iteratively for emerging patterns and instances. RESULTS: All 34 tutors responded. Of these, 26/34 (76%) were male and 23 (68%) were medically qualified. Towards the end of each approximately (median) 20-minute interview, reflecting on the curriculum themes, tutors mostly identified with the basic/clinical science theme (Structure and Function). Almost half articulated a clear division (implicitly or explicitly 'fact' versus 'non-fact') between it and the 'other three' themes of behavioural science, population science, and ethicolegal aspects of professional practice, respectively. Only 14/34 (41%) of tutors (including both public health doctors) outlined the public health-based theme adequately without disclosing confusion, antagonism/indifference or difficulties/uncertainty. CONCLUSION: This study provides baseline qualitative insights about new PBL tutors' insecurities when facilitating student discussion across integrated content. Given the difficulties of recruiting suitable educators into this role and potential resource limitations, staff retention and development strategies still must confront the reality of PBL tutors' bemusement when they are placed outwith their usual comfort zones.