Effectiveness and implementation of lower-intensity weight management interventions delivered by the non-specialist workforce in postnatal women: a mixed-methods systematic review.

Lower-intensity interventions delivered in primary and community care contacts could provide more equitable and scalable weight management support for postnatal women. This mixed-methods systematic review aimed to explore the effectiveness, implementation, and experiences of lower-intensity weight management support delivered by the non-specialist workforce. We included quantitative and qualitative studies of any design that evaluated a lower-intensity weight management intervention delivered by non-specialist workforce in women up to 5 years post-natal, and where intervention effectiveness (weight-related and/or behavioural outcomes), implementation and/or acceptability were reported. PRISMA guidelines were followed, and the review was prospectively registered on PROSPERO (CRD42022371828). Nine electronic databases were searched to identify literature published between database inception to January 2023. This was supplemented with grey literature searches and citation chaining for all included studies and related reviews (completed June 2023). Screening, data extraction and risk of bias assessments were performed in duplicate. Risk of bias was assessed using the Joanna Briggs Institute appraisal tools. Narrative methods were used to synthesise outcomes. Seven unique studies described in 11 reports were included from the Netherlands (n = 2), and the United Kingdom, Germany, Taiwan, Finland, and the United States (n = 1 each). All studies reported weight-related outcomes; four reported diet; four reported physical activity; four reported intervention implementation and process outcomes; and two reported intervention acceptability and experiences. The longest follow-up was 13-months postnatal. Interventions had mixed effects on weight-related outcomes: three studies reported greater weight reduction and/or lower postnatal weight retention in the intervention group, whereas four found no difference or mixed effects. Most studies reporting physical activity or diet outcomes showed no intervention effect, or mixed effects. Interventions were generally perceived as acceptable by women and care providers, although providers had concerns about translation into routine practice. The main limitations of the review were the limited volume of evidence available, and significant heterogeneity in interventions and outcome reporting which limited meaningful comparisons across studies. There is a need for more intervention studies, including process evaluations, with longer follow-up in the postnatal period to understand the role of primary and community care in supporting women's weight management. Public Health Wales was the primary funder of this review.

A comparison of social prescribing approaches across twelve high-income countries.

BACKGROUND: Social prescribing connects patients with community resources to improve their health and well-being. It is gaining momentum globally due to its potential for addressing non-medical causes of illness while building on existing resources and enhancing overall health at a relatively low cost. The COVID-19 pandemic further underscored the need for policy interventions to address health-related social issues such as loneliness and isolation. AIM: This paper presents evidence of the conceptualisation and implementation of social prescribing schemes in twelve countries: Australia, Austria, Canada, England, Finland, Germany, Portugal, the Slovak Republic, Slovenia, the Netherlands, the United States and Wales. METHODS: Twelve countries were identified through the Health Systems and Policy Monitor (HSPM) network and the EuroHealthNet Partnership. Information was collected through a twelve open-ended question survey based on a conceptual model inspired by the WHO's Health System Framework. RESULTS: We found that social prescribing can take different forms, and the scale of implementation also varies significantly. Robust evidence on impact is scarce and highly context-specific, with some indications of cost-effectiveness and positive impact on well-being. CONCLUSIONS: This paper provides insights into social prescribing in various contexts and may guide countries interested in holistically tackling health-related social factors and strengthening community-based care. Policies can support a more seamless integration of social prescribing into existing care, improve collaboration among sectors and training programs for health and social care professionals.

Assessing the relationship between adverse pregnancy outcomes and area-level deprivation in Wales 2014-2019: a national population-based cross-sectional study.

OBJECTIVES: The aim of this study was to assess the relationship between deciles of area-level deprivation and seven adverse pregnancy outcomes in Wales. DESIGN: Cross-sectional analysis. SETTING: 64 699 live births in Wales from 31 March 2014 to 16 September 2019. PRIMARY OUTCOME VARIABLE: We examined each of the following seven adverse pregnancy outcomes: (1) small for gestational age (SGA); (2) large for gestational age; (3) preterm birth; (4) third-degree or fourth-degree perineal tear; (5) major postpartum haemorrhage (MPPH); (6) a lower Apgar score at 5 min and (7) emergency caesarean section. RESULTS: There was no significant association between increasing aggregate measures of area-level deprivation and the adverse pregnancy outcomes we studied. Women living in an area with greater access to services are more likely to have a baby that is SGA (1.27, 95% CI 1.11 to 1.49), have a greater likelihood of a perineal tear (1.74, 95% CI 1.15 to 2.61), are significantly less likely to have MPPH (0.79, 95% CI 0.64 to 0.96), have a baby with an Apgar score of 0.26 higher (95% CI 0.22 to 0.29) and are significantly less likely to have an emergency caesarean section (0.81, 95% CI 0.73 to 0.88). Women living in areas with higher employment (0.26, 95% CI 0.19 to 0.36) and better health (0.26, 95% CI 0.19 to 0.35) were less likely to experience perineal tear. CONCLUSIONS: There was no clear social-spatial gradient in area-level deprivation and adverse pregnancy outcomes. We found a stronger association for individual-level behavioural risk factors than area-level factors. These findings support the benefits that accessible and holistic person-centred care may bring through addressing individual behavioural risk factors. There is a need for improved data completeness and further individual-level data on risk factors such as employment and income to better understand the role which may be played by population-level policies and their pathways to affecting outcomes.

Socioeconomic inequalities and adverse pregnancy outcomes in the UK and Republic of Ireland: a systematic review and meta-analysis.

OBJECTIVE: There has been an unprecedented rise in infant mortality associated with deprivation in recent years in the United Kingdom (UK) and Republic of Ireland. A healthy pregnancy can have significant impacts on the life chances of children. The objective of this review was to understand the association between individual-level and household-level measures of socioeconomic status and adverse pregnancy outcomes. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Nine databases were searched (Medline, Embase, Scopus, ASSIA, CINAHL, PsycINFO, BNI, MIDRIS and Google Scholar) for articles published between 1999 and August 2019. Grey literature searches were also assessed. STUDY SELECTION CRITERIA: Studies reporting associations between individual-level or household socioeconomic factors on pregnancy outcomes in the UK or Ireland. RESULTS: Among the 82 353 search results, 53 821 titles were identified and 35 unique studies met the eligibility criteria. Outcomes reported were neonatal, perinatal and maternal mortality, preterm birth, birth weight and mode of delivery. Pooled effect sizes were calculated using random-effects meta-analysis. There were significantly increased odds of women from lower levels of occupation/social classes compared with the highest level having stillbirth (OR 1.40, 95% CI 1.23 to 1.59, I298.62%), neonatal mortality (OR 1.39, 95% CI 1.22 to 1.57, I297.09%), perinatal mortality (OR 1.39, 95% CI 1.23 to 1.57, I298.69%), preterm birth (OR 1.41, 95% CI 1.33 to 1.50, I270.97%) and low birth weight (OR 1.40, 95% CI 1.19 to 1.61, I299.85%). Limitations relate to available data, unmeasured confounders and the small number of studies for some outcomes. CONCLUSIONS: This review identified consistent evidence that lower occupational status, especially manual occupations and unemployment, were significantly associated with increased risk of multiple adverse pregnancy outcomes. Strategies to improve pregnancy outcomes should incorporate approaches that address wider determinants of health to provide women and families with the best chances of having a healthy pregnancy and baby and to decrease pregnancy-related health inequalities in the general population. PROSPERO REGISTRATION NUMBER: PROSPERO CRD42019140893.

COVID-19 contact tracing: The Welsh experience.

OBJECTIVE: Contact tracing is one of the key public health response actions to control the outbreak of a novel virus. This paper describes the preparation process, activation and operational experience for contact tracing of individuals in response to confirmed COVID-19 cases in Wales. STUDY DESIGN: A descriptive approach has been adopted and lessons learned from our initial public health response to COVID-19 will be used to develop a new operational model for contact tracing in Wales. METHODS: As part of preparations for the response in Wales, Public Health Wales formed a Contact Tracing Cell (CTC) ready to be mobilised in the event of a confirmed case. RESULTS: Trial activation of the CTC during the preparation period helped to resolve some issues before 'real' activation. A highly flexible approach was needed due to the constant changes to the guidance that required rapid understanding, updates to pathways and clear communication to contact tracers. CONCLUSIONS: Our experience and recommendations may benefit future efforts to control the spread of the virus in Wales and elsewhere, particularly in supporting COVID-19 outbreaks in enclosed settings such as care homes or in geographically localised areas. Learning from the initial public health response to COVID-19 will guide the delivery and implementation of a new contact tracing model as we move to a later stage of the pandemic when containment measures become feasible in localised outbreaks. This may include scaling-up the CTC to mobilise contact tracers to local teams and the potential use of digital technologies to support the next operational model of the CTC in Wales.

Determinants of uptake of hepatitis B testing and healthcare access by migrant Chinese in the England: a qualitative study.

BACKGROUND: Global migration from hepatitis B endemic countries poses a significant public health challenge in receiving low-prevalence countries. In the UK, Chinese migrants are a high risk group for hepatitis B. However, they are an underserved population that infrequently accesses healthcare. This study sought to increase understanding of the determinants of hepatitis B testing and healthcare access among migrants of Chinese ethnicity living in England. METHODS: We sought to obtain and integrate insights from different key stakeholders in the system. We conducted six focus group discussions and 20 in-depth interviews with community members and patients identifying themselves as 'Chinese', and interviewed 21 clinicians and nine health service commissioners. Data were thematically analysed and findings were corroborated through two validation workshops. RESULTS: Three thematic categories emerged: knowledge and awareness, visibility of the disease, and health service issues. Low disease knowledge and awareness levels among community members contributed to erroneous personal risk perception and suboptimal engagement with services. Limited clinician knowledge led to missed opportunities to test and inaccurate assessments of infection risks in Chinese patients. There was little social discourse and considerable stigma linked to the disease among some sub-sections of the Chinese population. A lack of visibility of the issue and the population within the health system meant that these health needs were not prioritised by clinicians or commissioners. Service accessibility was also affected by the lack of language support. Greater use of community outreach, consultation aids, 'cultural competency' training, and locally adapted testing protocols may help. CONCLUSIONS: Hepatitis B among migrants of Chinese ethnicity in England can be characterised as an invisible disease in an invisible population. Multi-modal solutions are needed to tackle barriers within this population and the health system.

What factors facilitate the engagement with flipped classrooms used in the preparation for postgraduate medical membership examinations?

BACKGROUND: The "flipped classroom," a pedagogical model where typical lecture and homework elements are reversed, is being advocated in medical education to support the teaching of a large curriculum. However, research into the use of this model in postgraduate medical education, which requires the application of acquired knowledge, is limited. The aim of this study was to explore the barriers and facilitators to engagement with the flipped classroom model in preparation for the written element of postgraduate membership examinations. METHODS: Three focus groups (n=14) were held between February and June 2016. Participants were drawn from a membership examination preparation course, run by the University of Shef-field. Two of the groups (n=10) involved "students" (public health registrars) while the other focus group (n=4) was held with "tutors" (experienced registrars and consultants). The focus groups were audiorecorded and transcribed verbatim. Transcripts were thematically analyzed by using both predetermined and emergent themes. RESULTS: Key themes that emerged from the data included variation in learning and teaching styles of individuals as well as the feasibility and flexibility of the overall course design. However, management of students' expectations was found to be the fundamental factor, which underpinned the engagement. CONCLUSION: The complex interaction of factors affecting engagement in this study highlights the need to consider the appropriateness of the flipped classroom model. However, this must be balanced by the potential benefits of the approach for delivering a large curriculum. Recognizing the central importance of managing expectations at the outset would be useful when considering this model in postgraduate medical education.