Tiered restrictions for COVID-19 in England: knowledge, motivation and self-reported behaviour.

OBJECTIVES: To test whether public knowledge and confidence in one's understanding of the local restrictions, motivation to adhere to local restrictions, and self-reported behaviour (going out for exercise, to work, socially) differed according to tier level. STUDY DESIGN: Cross-sectional, nationally representative, online survey of 1728 participants living in England (data collection: 26 to 28 October 2020). METHODS: We conducted logistic regression analyses to investigate whether knowledge of restrictions, confidence in knowledge of restrictions, motivation to adhere to restrictions, and self-reported behaviour were associated with personal characteristics and tier. RESULTS: Between 81% (tier 2) and 89% (tier 3) of participants correctly identified which tier they lived in. Knowledge of specific restrictions was variable. 73% were confident that they understood which tier was in place in their local area, whereas 71% were confident they understood the guidance in their local area. Confidence was associated with being older and living in a less deprived area. 73% were motivated to adhere to restrictions in their local area. Motivation was associated with being female and older. People living in tiers with greater restrictions were less likely to report going out to meet people from another household socially; reported rates of going out for exercise and for work did not differ. CONCLUSIONS: Although recognition of local tier level was high, knowledge of specific guidance for tiers was variable. There was some indication that nuanced guidance (e.g. behaviour allowed in some settings but not others) was more poorly understood than guidance which was absolute (i.e. behaviour is either allowed or not allowed).

Factors associated with non-essential workplace attendance during the COVID-19 pandemic in the UK in early 2021: evidence from cross-sectional surveys.

OBJECTIVES: Working from home where possible is important in reducing the spread of COVID-19. In early 2021, a quarter of people in England who believed they could work entirely from home reported attending their workplace. To inform interventions to reduce this, this study examined associated factors. STUDY DESIGN: Data from the ongoing COVID-19 Rapid Survey of Adherence to Interventions and Responses survey series of nationally representative samples of people in the UK aged 16+ years in January-February 2021 were used. METHODS: The study sample was 1422 respondents who reported that they could work completely from home. The outcome measure was self-reported workplace attendance at least once during the preceding week. Factors of interest were analysed in three blocks: 1) sociodemographic variables, 2) variables relating to respondents' circumstances and 3) psychological variables. RESULTS: 26.8% (95% confidence interval [CI] = 24.5%-29.1%) of respondents reported having attended their workplace at least once in the preceding week. Sociodemographic variables and living circumstances significantly independently predicted non-essential workplace attendance: male gender (odds ratio [OR] = 1.85, 95% CI = 1.33-2.58); dependent children in the household (OR = 1.65, 95% CI = 1.17-2.32); financial hardship (OR = 1.14, 95% CI = 1.08-1.21); lower socio-economic grade (C2DE; OR = 1.65, 95% CI = 1.19-2.53); working in sectors such as health or social care (OR = 4.18, 95% CI = 2.56-6.81), education and childcare (OR = 2.45, 95% CI = 1.45-4.14) and key public service (OR = 3.78, 95% CI = 1.83-7.81) and having been vaccinated (OR = 2.08, 95% CI = 1.33-3.24). CONCLUSIONS: Non-essential workplace attendance in the UK in early 2021 during the COVID-19 pandemic was significantly independently associated with a range of sociodemographic variables and personal circumstances. Having been vaccinated, financial hardship, socio-economic grade C2DE, having a dependent child at home and working in certain key sectors were associated with higher likelihood of workplace attendance.

Do members of the public think they should use lateral flow tests (LFT) or polymerase chain reaction (PCR) tests when they have COVID-19-like symptoms? The COVID-19 Rapid Survey of Adherence to Interventions and Responses study.

OBJECTIVES: This study aimed to investigate public use of lateral flow tests (LFT) and polymerase chain reaction (PCR) tests when experiencing key COVID-19 symptoms. STUDY DESIGN: In this study, data from two waves of a cross-sectional nationally representative online survey (data collected 1 and 2 June, and 14 and 15 June 2021; n = 3665 adults aged ≥18 years living in England or Scotland) were used. METHODS: We report data investigating which type of test, if any, the public think Government guidance asks people to use if they have COVID-19 symptoms. In people with key COVID-19 symptoms (high temperature / fever; new, continuous cough; loss of sense of smell; loss of taste), we also describe the uptake of testing, if any. RESULTS: Ten percent of respondents thought Government guidance stated that they should take an LFT if symptomatic, whereas 18% of people thought that they should take a PCR test; 60% of people thought they should take both types of test (12% did not select either option). In people who were symptomatic, 32% reported taking a test to confirm whether they had COVID-19. Of these, 53% reported taking a PCR test and 44% reported taking an LFT. CONCLUSIONS: Despite Government guidance stating that anyone with key COVID-19 symptoms should complete a PCR test, a significant percentage of the population use LFT tests when symptomatic. Communications should emphasise the superiority of, and need for, PCR tests in people with symptoms.

Prevalence of GMC performance assessments in the United Kingdom: a retrospective cohort analysis by country of medical qualification.

BACKGROUND: The demographics of doctors working in the UK are changing. The United Kingdom (UK) has voted to leave the European Union (EU) and there is heightened political discourse around the world about the impact of migration on healthcare services. Previous work suggests that foreign trained doctors perform worse than UK graduates in postgraduate medical examinations. We analysed the prevalence by country of primary medical qualification of doctors who were required to take an assessment by the General Medical Council (GMC) because of performance concerns. METHODS: This was a retrospective cohort analysis of data routinely collected by the GMC. We compared doctors who had a GMC performance assessment between 1996 and 2013 with the medical register in the same period. The outcome measures were numbers experiencing performance assessments by country or region of medical qualification. RESULTS: The rate of performance assessment varied significantly by place of medical qualification and by year; χ 2(17) = 188, p < 0.0001, pseudo-R2 = 15%. Doctors who trained outside of the UK, including those trained in the European Economic Area (EEA), were more likely to have a performance assessment than UK trained doctors, with the exception of South African trained doctors. CONCLUSIONS: The rate of performance assessment varies significantly by place of medical qualification. This is the first study to explore the risk of performance assessment by individual places of medical qualification. While concern has largely focused on the competence of non-EEA, International Medical Graduates, we discuss implications for how to ensure European trained doctors are fit to practise before their medical licence in the UK is granted. Further research is needed to investigate whether these country effects hold true when controlling for factors like doctors' sex, age, length of time working in the UK, and English language skills. This will allow evidence-based decisions to be made around the regulatory environment the UK should adopt once it leaves the EU. Patients should be reassured that the vast majority of all doctors working in the UK are competent.

Who is sceptical about emerging public health threats? Results from 39 national surveys in the United Kingdom.

OBJECTIVES: Members of the public are often sceptical about warnings of an impending public health crisis. Breaking through this scepticism is important if we are to convince people to take urgent protective action. In this paper we explored correlates of perceiving that 'too much fuss' was being made about the 2009/10 influenza A H1N1v ('swine flu') pandemic. STUDY DESIGN: A secondary analysis of data from 39 nationally representative telephone surveys conducted in the UK during the pandemic. METHODS: Each cross-sectional survey (combined n = 42,420) collected data over a three day period and asked participants to state whether they agreed or disagreed that 'too much fuss is being made about the risk of swine flu.' RESULTS: Overall, 55.1% of people agreed or strongly agreed with this sentiment. Perceiving that too much fuss was being made was associated with: being male, being white, being generally healthy, trusting most in a primary care physician to provide advice, not knowing someone who had contracted the illness, believing you know a lot about the outbreak, not wishing to receive additional information about the outbreak and possessing worse factual knowledge about the outbreak than other people. CONCLUSIONS: In future disease outbreaks merely providing factual information is unlikely to engage people who are sceptical about the need to take action. Instead, messages which challenge their perceived knowledge and which present case studies of people who have been affected may prove more effective, especially when delivered through trusted channels.

An app with brief behavioural support to promote physical activity after a cancer diagnosis (APPROACH): study protocol for a pilot randomised controlled trial.

BACKGROUND: There are multiple health benefits from participating in physical activity after a cancer diagnosis, but many people living with and beyond cancer (LWBC) are not meeting physical activity guidelines. App-based interventions offer a promising platform for intervention delivery. This trial aims to pilot a theory-driven, app-based intervention that promotes brisk walking among people living with and beyond cancer. The primary aim is to investigate the feasibility and acceptability of study procedures before conducting a larger randomised controlled trial (RCT). METHODS: This is an individually randomised, two-armed pilot RCT. Patients with localised or metastatic breast, prostate, or colorectal cancer, who are aged 16 years or over, will be recruited from a single hospital site in South Yorkshire in the UK. The intervention includes an app designed to encourage brisk walking (Active 10) supplemented with habit-based behavioural support in the form of two brief telephone/video calls, an information leaflet, and walking planners. The primary outcomes will be feasibility and acceptability of the study procedures. Demographic and medical characteristics will be collected at baseline, through self-report and hospital records. Secondary outcomes for the pilot (assessed at 0 and 3 months) will be accelerometer measured and self-reported physical activity, body mass index (BMI) and waist circumference, and patient-reported outcomes of quality of life, fatigue, sleep, anxiety, depression, self-efficacy, and habit strength for walking. Qualitative interviews will explore experiences of participating or reasons for declining to participate. Parameters for the intended primary outcome measure (accelerometer measured average daily minutes of brisk walking (≥ 100 steps/min)) will inform a sample size calculation for the future RCT and a preliminary economic evaluation will be conducted. DISCUSSION: This pilot study will inform the design of a larger RCT to investigate the efficacy and cost-effectiveness of this intervention in people LWBC. TRIAL REGISTRATION: ISRCTN registry, ISRCTN18063498 . Registered 16 April 2021.

Does the method of detection of breast cancer affect subsequent psychiatric morbidity?

The aim of this prospective study was to compare the prevalence of psychiatric morbidity following diagnosis of breast cancer between a group of women presenting with screen-detected cancer and a group presenting with symptomatic disease. Psychiatric symptoms were elicited using the Structured Clinical Interview (SCID) and classified according to DSM-III criteria. 61 (46%) of 132 women interviewed experienced an episode of psychiatric disorder between 1 month before diagnosis and 12 months post-diagnosis. There was no association between detection by screening of breast cancer and psychiatric disorder (Odds Ratio (OR) 0.8, 95% Confidence Interval (CI) 0.4-1.8 P=0.7). The occurrence of an episode of psychiatric disorder was associated with a previous history of treatment for psychological problems (OR 2.4, 95% CI 1.1-5.5, P=0.02). The results suggest there is no increased risk of developing psychiatric morbidity associated with the detection of cancer through the National Breast Screening Programme.

An evaluation of the impact of computer-based prompts on screen readers' interpretation of mammograms.

The NHS Breast Screening Programme is changing working practices in response to increased workload and manpower shortages. Radiographers are being trained as film readers. Computer aids are being considered. We have evaluated the impact of prompts placed by the R2 ImageChecker 1000 on the sensitivity and specificity of film readers, including non-radiologist film readers. 30 radiologists, 5 breast clinicians and 15 radiographers each read 180 films, including 60 cancers (20 false negative interval cases and 40 screen detected cancers). Each reader read each case twice, once with and once without computer prompts. The order in which the reading sessions were carried out was randomized separately for each reader. 36 out of 40 screen-detected cases were prompted by the ImageChecker, a sensitivity of 90%. Eight out of 20 interval cases were prompted, a sensitivity of 40%. No significant difference was found for readers' sensitivity or specificity between the prompted and unprompted conditions. No significant difference was found between the sensitivity and specificity of the different groups of film reader. No difference in impact of prompts was found for well or poorly performing film readers. The result suggests that this version of the ImageChecker would not have a significant impact on the UK screening programme.

The impact of communications about swine flu (influenza A H1N1v) on public responses to the outbreak: results from 36 national telephone surveys in the UK.

OBJECTIVES: To assess the association between levels of worry about the possibility of catching swine flu and the volume of media reporting about it; the role of psychological factors in predicting likely uptake of the swine flu vaccine; and the role of media coverage and advertising in predicting other swine flu-related behaviours. DESIGN: Data from a series of random-digit-dial telephone surveys were analysed. A time series analysis tested the association between levels of worry and the volume of media reporting on the start day of each survey. Cross-sectional regression analyses assessed the relationships between likely vaccine uptake or behaviour and predictor variables. SETTING: Thirty-six surveys were run at, on average, weekly intervals across the UK between 1 May 2009 and 10 January 2010. Five surveys (run between 14 August and 13 September) were used to assess likely vaccine uptake. Five surveys (1-17 May) provided data relating to other behaviours. PARTICIPANTS: Between 1047 and 1173 people aged 16 years or over took part in each survey: 5175 participants provided data about their likely uptake of the swine flu vaccine; 5419 participants provided data relating to other behaviours. MAIN OUTCOME MEASURES: All participants were asked to state how worried they were about the possibility of personally catching swine flu. Subsets were asked how likely they were to take up a swine flu vaccination if offered it and whether they had recently carried tissues with them, bought sanitising hand gel, avoided using public transport or had been to see a general practitioner, visited a hospital or called NHS Direct for a flu-related reason. RESULTS: The percentage of 'very' or 'fairly' worried participants fluctuated between 9.6% and 32.9%. This figure was associated with the volume of media reporting, even after adjusting for the changing severity of the outbreak [chi2(1) = 6.6, p = 0.010, coefficient for log-transformed data = 2.6]. However, this effect only occurred during the UK's first summer wave of swine flu. In total, 56.1% of respondents were very or fairly likely to accept the swine flu vaccine. The strongest predictors were being very worried about the possibility of oneself [adjusted odds ratio (aOR) 4.7, 95% confidence interval (CI) 3.2 to 7.0] or one's child (aOR 8.0, 95% CI 4.6 to 13.9) catching swine flu. Overall, 33.1% of participants reporting carrying tissues with them, 9.5% had bought sanitising gel, 2.0% had avoided public transport and 1.6% had sought medical advice. Exposure to media coverage or advertising about swine flu increased tissue carrying or buying of sanitising hand gel, and reduced avoidance of public transport or consultation with health services during early May 2009. Path analyses showed that media coverage and advertising had these differential effects because they raised the perceived efficacy of hygiene behaviours but decreased the perceived efficacy of avoidance behaviours. CONCLUSIONS: During the swine flu outbreak, uptake rates for protective behaviours and likely acceptance rates for vaccination were low. One reason for this may in part be explained by was the low level of public worry about the possibility of catching swine flu. When levels of worry are generally low, acting to increase the volume of mass media and advertising coverage is likely to increase the perceived efficacy of recommended behaviours, which, in turn, is likely to increase their uptake.

Medical student teaching in the UK: how well are newly qualified doctors prepared for their role caring for patients with cancer in hospital?

A number of studies have identified problems with undergraduate oncology teaching. We have investigated how well prepared newly qualified doctors (first foundation year, or FY1 doctors) are for treating patients with cancer. Twenty-five FY1 doctors and 15 senior doctors participated in interviews. We turned the emergent themes into a questionnaire for all 5143 UK FY1 doctors in 2005. The response rate was 43% (2062 responses). Sixty-one percent of FY1 doctors had received oncology teaching at medical school, but 31% recalled seeing fewer than 10 patients with cancer. Forty percent of FY1 doctors felt prepared for looking after patients with cancer. Sixty-five percent felt prepared for diagnosing cancer, 15% felt they knew enough about chemotherapy and radiotherapy, and 11% felt prepared for dealing with oncological emergencies. Respondents believed medical students should learn about symptom control (71%) and communication skills (41%). Respondents who had received oncology teaching were more likely to feel prepared for looking after patients with cancer (OR 1.52; 95% CI 1.14-2.04). Preparedness also correlated with exposure to patients with cancer (OR 1.48; 95% CI 1.22-1.79). We have found worryingly low levels of exposure of medical students to patients with cancer. First foundation year doctors lack knowledge about cancer care and symptom control. Oncologists should maintain involvement in undergraduate teaching, and encourage greater involvement of patients in this teaching.

Why do older women delay presentation with breast cancer symptoms?

Women who delay their presentation with breast cancer for three months or longer are more likely to be diagnosed with later stage disease and have poorer survival. Older women, who are at greater risk of developing breast cancer, are also more likely to delay their presentation. Factors associated with delayed presentation were assessed in 69 women (>65 years) with breast cancer. Previous factors identified for women of all ages were confirmed (having a non-lump symptom p=0.003) or strengthened (non-disclosure of symptom discovery to a relative or close friend p=0.001). Additional factors for delay in this older group included reservations about seeing their GP (p=0.02) and fear of the consequences of cancer (p=0.04). These factors should inform the design of interventions to reduce delays.

Assessing the impact of CAD on the sensitivity and specificity of film readers.

AIM: To assess the impact of computer-aided detection (CAD) prompts on film readers' sensitivity and specificity. MATERIAL AND METHODS: Thirty-five readers read 120 films, including 44 cancers, 40 of which were prompted. All readers looked at all cases with and without prompts. The sensitivity and specificity were calculated for each reader under each condition. RESULTS: The sensitivity improved when CAD prompts were used (0.80 from 0.77). The difference was slightly below the threshold for statistical significance (95% CI for the difference is -0.0027-0.064). The specificity also improved (0.86 from 0.85), but not significantly. There was a significant improvement in sensitivity when readers' judgements were combined to simulate double reading, from 0.77 to 0.81. (95% CI for the difference is 0.014-0.077). CONCLUSIONS: Analysis of prompted cancers that readers did and did not recall, found that cases were more likely to be correctly recalled if there were emphasized prompts, more prompts or if the case was harder. There was no statistically significant effect for type of abnormality or tumour size or for the performance, attitude or experience of the reader.

Reproducibility of prompts in computer-aided detection (CAD) of breast cancer.

AIM: We evaluated the reproducibility of prompts using the R2 ImageChecker M2000 computer-aided detection (CAD) system. MATERIALS AND METHODS: Forty selected two-view mammograms of women with breast cancer were digitized and analysed using the ImageChecker on 10 separate occasions. The mammograms were chosen to provide both straightforward and subtle signs of malignancy. Data analysed included mammographic abnormality, pathology, and whether the cancer was prompted or given an emphasized prompt. RESULTS: Correct prompts were generated in 86 out of 100 occasions for screen-detected cancers. Reproducibility was less in the other categories of more subtle cancers: 21% for cancers previously missed by CAD, a group that contained more grade 1 and small (<10 mm) tumours. Prompts for calcifications were more reproducible than those for masses (76% versus 53%) and these cancers were more likely to have an emphasized prompt. CONCLUSIONS: Probably the most important cause of variability of prompts is shifts in film position between sequential digitizations. Consequently subtle lesions that are only just above the threshold for display may not be prompted on repeat scanning. However, users of CAD should be aware that even emphasized prompts are not consistently reproducible.

The prognostic influence of bcl-2 in malignant glioma.

The bcl-2 gene is one of a complex group of genes which control programmed cell death. Bcl-2 acts to extend cell survival by blocking apoptosis, and thereby may influence tumour prognosis. This study of 187 high grade gliomas reviews clinicopathological prognostic features and the relationship to bcl-2 expression. Bcl-2 immunostaining was assessed in 159 specimens from these patients, by scoring systems of 0 to 3 for intensity of scoring and proportion of cells staining. Age, histology, pre- and post-operative performance status were found to be strongly predictive of survival (log rank test P<0.0001). The type of surgery performed did not influence survival in this group of patients. The expression of bcl-2 had a significant relationship with survival (univariate Cox model P=0.0302, hazard ratio 0.8, 95% confidence interval 0.65-0.98), with increased staining associated with improved survival. Multivariate analysis showed performance status, histology and proportion of cells staining for bcl-2 to be independently predictive of survival. Bcl-2 staining was not related to histological grade of tumours.