Core competencies in applied infectious disease epidemiology: a framework for countries in Europe.

In 2009, the European Centre for Disease Prevention and Control (ECDC) developed a competency framework to support European Union countries and the European Commission in ensuring a competent public health workforce for Europe. The coronavirus disease (COVID-19) pandemic emphasised the importance of harmonised public health strategies and competencies across international boundaries, specifically for infectious diseases. This perspective presents the process to update the competency framework for applied infectious disease epidemiology, highlighting ECDC's efforts to support countries with using the framework. ECDC commissioned the Association of Schools of Public Health in the European Region (ASPHER) to update the framework through publication and dissemination of a technical report and a self-assessment tool linked to training resources. A mixed methods approach to gather input from experts in relevant specialities included qualitative interviews with 42 experts, workshops with ECDC Technical Advisory Group and an online survey of 212 public health professionals across Europe and beyond. Modifications resulted in 157 core competencies in 23 domains, each mapping to one of six subject areas of importance in applied infectious disease epidemiology. The framework serves as a basis to update the curriculum of the ECDC Fellowship programme with two alternative paths: intervention epidemiology or public health microbiology.

Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework.

BACKGROUND: UK and global policies recommend whole-school approaches to improve childrens' inadequate physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure 'systems' change, a framework is required that identifies all components of a whole-school PA approach. The study's aim was to co-develop a whole-school PA framework using the double diamond design approach (DDDA). METHODOLOGY: Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same stakeholder (n = 9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers, active partner schools specialists, national organisations, Sport England local delivery pilot representatives and international researchers) and mixed (n = 6) stakeholder groupings. Six draft frameworks were created before stakeholders voted for one 'initial' framework. Next, stakeholders reviewed the 'initial' framework, proposing modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire. RESULTS: Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and practice drive school policy and vision, creating the physical and social environments in which five key stakeholder groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the model, initial and in-service teacher training foster teachers' capability, opportunity and motivation (COM-B) to deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder whole-school PA. To the authors' knowledge, this is the first time practitioners, policymakers and researchers have co-designed a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity required to create systems change. The framework can be used to shape future policy, research and practice to embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift, providing a map and method to guide future co-production by multiple experts of PA initiatives 'with' schools, while abandoning outdated traditional approaches of implementing interventions 'on' schools.

The applicability of the UK Public Health Skills and Knowledge Framework to the practitioner workforce: lessons for competency framework development.

BACKGROUND: Many countries have developed competency frameworks for public health practice. While the number of competencies vary, frameworks cover similar knowledge and skills although they are not explicitly based on competency theory. METHODS: A total of 15 qualitative group interviews (of up to six people), were conducted with 51 public health practitioners in 8 local authorities to assess the extent to which practitioners utilize competencies defined within the UK Public Health Skills and Knowledge Framework (PHSKF). Framework analysis was applied to the transcribed interviews. RESULTS: The overall framework was seen positively although no participants had previously read or utilized the PHSKF. Most could provide evidence, although some PHSKF competencies required creative thinking to fit expectations of practitioners and to reflect variation across the domains of practice which are impacted by job role and level of seniority. Evidence from previous NHS jobs or education may be needed as some competencies were not regularly utilized within their current local authority role. CONCLUSIONS: Further development of the PHSKF is required to provide guidance on how it should be used for practitioners and other members of the public health workforce. Empirical research can help benchmark knowledge/skills for workforce levels so improving the utility of competency frameworks.

The impact of care farms on quality of life, depression and anxiety among different population groups: A systematic review.

Care farming (also called social farming) is the therapeutic use of agricultural and farming practices. Service users and communities supported through care farming include people with learning disabilities, mental and physical health problems, substance misuse, adult offenders, disaffected youth, socially isolated older people and the long term unemployed. Care farming is growing in popularity, especially around Europe. This review aimed to understand the impact of care farming on quality of life, depression and anxiety, on a range of service user groups. It also aimed to explore and explain the way in which care farming might work for different groups. By reviewing interview studies we found that people valued, among other things, being in contact with each other, and feeling a sense of achievement, fulfilment and belonging. Some groups seemed to appreciate different things indicating that different groups may benefit in different ways but, it is unclear if this is due to a difference in the types of activities or the way in which people take different things from the same activity. We found no evidence that care farms improved people's quality of life and some evidence that they might improve depression and anxiety. Larger studies involving single service user groups and fully validated outcome measures are needed to prove more conclusive evidence about the benefits of care farming.

Monocular and binocular visual impairment in the UK Biobank study: prevalence, associations and diagnoses.

OBJECTIVE: To determine the prevalence of, associations with and diagnoses leading to mild visual impairment or worse (logMAR >0.3) in middle-aged adults in the UK Biobank study. METHODS AND ANALYSIS: Prevalence estimates for monocular and binocular visual impairment were determined for the UK Biobank participants with fundus photographs and spectral domain optical coherence tomography images. Associations with socioeconomic, biometric, lifestyle and medical variables were investigated for cases with visual impairment and matched controls, using multinomial logistic regression models. Self-reported eye history and image grading results were used to identify the primary diagnoses leading to visual impairment for a sample of 25% of cases. RESULTS: For the 65 033 UK Biobank participants, aged 40-69 years and with fundus images, 6682 (10.3%) and 1677 (2.6%) had mild visual impairment or worse in one or both eyes, respectively. Increasing deprivation, age and ethnicity were independently associated with both monocular and binocular visual impairment. No primary diagnosis for the recorded level of visual impairment could be identified for 49.8% of eyes. The most common identifiable diagnoses leading to visual impairment were cataract, amblyopia, uncorrected refractive error and vitreoretinal interface abnormalities. CONCLUSIONS: The prevalence of visual impairment in the UK Biobank study cohort is lower than for population-based studies from other industrialised countries. Monocular and binocular visual impairment are associated with increasing deprivation, age and ethnicity. The UK Biobank dataset does not allow confident identification of the causes of visual impairment, and the results may not be applicable to the wider UK population.

Assessing the impact of care farms on quality of life and offending: a pilot study among probation service users in England.

OBJECTIVES: To assess the feasibility of conducting a cost-effectiveness study of using care farms (CFs) to improve quality of life and reduce reoffending among offenders undertaking community orders (COs). To pilot questionnaires to assess quality of life, connection to nature, lifestyle behaviours, health and social-care use. To assess recruitment and retention at 6 months and feasibility of data linkage to Police National Computer (PNC) reconvictions data and data held by probation services. DESIGN: Pilot study using questionnaires to assess quality of life, individually linked to police and probation data. SETTING: The pilot study was conducted in three probation service regions in England. Each site included a CF and at least one comparator CO project. CFs are working farms used with a range of clients, including offenders, for therapeutic purposes. The three CFs included one aquaponics and horticulture social enterprise, a religious charity focusing on horticulture and a family-run cattle farm. Comparator projects included sorting secondhand clothes and activities to address alcohol misuse and anger management. PARTICIPANTS: We recruited 134 adults (over 18) serving COs in England, 29% female. RESULTS: 52% of participants completed follow-up questionnaires. Privatisation of UK probation trusts in 2014 negatively impacted on recruitment and retention. Linkage to PNC data was a more successful means of follow-up, with 90% consenting to access their probation and PNC data. Collection of health and social-care costs and quality-adjusted life year derivation were feasible. Propensity score adjustment provided a viable comparison method despite differences between comparators. We found worse health and higher reoffending risk among CF participants due to allocation of challenging offenders to CFs, making risk of reoffending a confounder. CONCLUSIONS: Recruitment would be feasible in a more stable probation environment. Follow-up was challenging; however, assessing reconvictions from PNC data is feasible and a potential primary outcome for future studies.

The economic impact of sight loss and blindness in the UK adult population.

BACKGROUND: To quantify the economic impact of sight loss and blindness in the United Kingdom (UK) population, including direct and indirect costs, and its burden on health. METHODS: Prevalence data on sight loss and blindness by condition, Census demographic data, data on indirect costs, and healthcare cost databases were used. Blindness was defined as best corrected visual acuity (BCVA) of < 6/60, and sight loss as BCVA < 6/12 to 6/60, in the better-seeing eye. RESULTS: Sight loss and blindness from age-related macular degeneration (AMD), cataract, diabetic retinopathy, glaucoma and under-corrected refractive error are estimated to affect 1.93 (1.58 to 2.31) million people in the UK. Direct health care system costs were £3.0 billion, with inpatient and day care costs comprising £735 million (24.6%) and outpatient costs comprising £771 million (25.8%). Indirect costs amounted to £5.65 (5.12 to 6.22) billion. The value of the loss of healthy life associated with sight loss and blindness was estimated to be £19.5 (15.9 to 23.3) billion or £7.2 (5.9 to 8.6) billion, depending on the set of disability weights used. For comparison with other published results using 2004 disability weights and the 2008 estimates, the total economic cost of sight loss and blindness was estimated to be £28.1 (24.0 to 32.5) billion in 2013. Using 2010 disability weights, the estimated economic cost of sight loss and blindness was estimated to be £15.8 (13.5 to 18.3) billion in 2013. CONCLUSIONS: The large prevalence of sight loss and blindness in the UK population imposes significant costs on public funds, private expenditure, and health. Prevalence estimates relied on dated epidemiological studies and may not capture recent advances in treatment, highlighting the need for population-based studies that track the prevalence of sight-impairing eye conditions and treatment effects over time.

Master or apprentice: rethinking entry points and training in Public Health.

Background: The Public Health workforce needs to adapt to a policy environment in which the need to improve public health is not only a key challenge but also has to be delivered within financial constraints. Methods: A total of 14 qualitative individual interviews or focus groups (of up to 10 people), were conducted with senior Public Health staff in 12 local authorities and in Public Health England in the Yorkshire and the Humber region of England. Thematic analysis was applied to the transcribed interviews. Results: Despite cuts in training budgets, junior staff were increasingly expected to deliver Public Health functions. There is also an absence of a career ladder for this core Public Health workforce. There were concerns that financial constraints would lead to reductions in Public Health skills with fewer staff to provide critical analysis. Formal qualifications were increasingly less valued. Instead staff were expected to have a broader skill set with an emphasis on experience. Entry points into Public Health careers need rethinking. There was an expectation that Public Health departments would 'grow their own'. Conclusions: Apprenticeship schemes could help maintain or enhance the professional status of Public Health and provide a training route for Public Health practitioners.

Geographical inequalities in uptake of NHS funded eye examinations: Poisson modelling of small-area data for Essex, UK.

Background: Small-area analysis of National Health Service (NHS)-funded sight test uptake in Leeds showed significant inequalities in access among people aged <16 or ≥60. Methods: Data were extracted from 604 126 valid General Ophthalmic Services (GOS)1 claim forms for eye examinations for Essex residents between October 2013 and July 2015. Expected GOS1 uptake for each lower super output area was based on England annual uptake. Poisson regression modelling explored associations in GOS1 uptake ratio with deprivation. Results: People aged ≥60 or <16 living in the least deprived quintile were 15% and 26%, respectively, more likely to have an NHS funded eye examination than the most deprived quintile, although all are equally entitled. GOS1 uptake is higher in the more deprived quintiles among 16-59-year old, as means tested social benefits are the main eligibility criteria in this age-group. Inequalities were also observed at local authority level. Conclusions: Inequalities in access among people ≥60 years were not as large as those reported in Leeds, although inequalities in <16-year old were similar. However, demonstrable inequalities in this data set over a longer time period and a larger and more diverse area than Leeds, reinforce the argument that interventions are needed to address eye examination uptake inequalities.

A proposed minimum data set for international primary care optometry: a modified Delphi study.

PURPOSE: To identify a minimum list of metrics of international relevance to public health, research and service development which can be extracted from practice management systems and electronic patient records in primary optometric practice. METHODS: A two stage modified Delphi technique was used. Stage 1 categorised metrics that may be recorded as being part of a primary eye examination by their importance to research using the results from a previous survey of 40 vision science and public health academics. Delphi stage 2 then gauged the opinion of a panel of seven vision science academics and achieved consensus on contentious metrics and methods of grading/classification. RESULTS: A consensus regarding inclusion and response categories was achieved for nearly all metrics. A recommendation was made of 53 metrics which would be appropriate in a minimum data set. CONCLUSIONS: This minimum data set should be easily integrated into clinical practice yet allow vital data to be collected internationally from primary care optometry. It should not be mistaken for a clinical guideline and should not add workload to the optometrist. A pilot study incorporating an additional Delphi stage prior to implementation is advisable to refine some response categories.

Vitreoretinal interface abnormalities in middle-aged adults with visual impairment in the UK Biobank study: prevalence, impact on visual acuity and associations.

OBJECTIVE: The aim of this study was to determine the prevalence of vitreoretinal interface abnormalities (VRIA), the degree of visual impairment and associations with VRIA among adults, aged 40-69 years, in the UK Biobank study. METHODS AND ANALYSIS: Colour fundus photographs and spectral domain optical coherence tomography images were graded for 25% of the 8359 UK Biobank participants with mild visual impairment or worse (LogMAR >0.3 or Snellen <6/12) in at least one eye. The prevalence and contribution of VRIA to visual impairment was determined and multinomial logistic regression models were used to investigate association with known risk factors and other predetermined socioeconomic, biometric, lifestyle and medical variables for cases and matched controls. RESULTS: The minimum prevalence of any VRIA was 17.6% and 8.1% in the eyes with and without visual impairment, respectively. VRIA were identified as the primary cause of visual impairment in 3.6% of eyes. Although epiretinal membrane and vitreomacular traction were the most common VRIA, the degree of visual impairment was typically milder with these than with other VRIA. Visual impairment with a VRIA was positively associated with increasing age (relative risk ratio (RRR) 1.22 (95% CI 1.07 to 1.40)), female gender (RRR 1.28; 1.08 to 1.52) and Asian or Asian British ethnicity (RRR 1.60; 1.10 to 2.32). CONCLUSIONS: VRIA are common in middle-aged adults in the UK Biobank study, especially in eyes with visual impairment. VRIA were considered to be the primary cause of visual impairment in 3.6% of all eyes with visual impairment, although there was variation in the degree of visual impairment for each type of VRIA.

Can data in optometric practice be used to provide an evidence base for ophthalmic public health?

PURPOSE: The purpose of this paper is to investigate the potential of using primary care optometry data to support ophthalmic public health, research and policy making. METHODS: Suppliers of optometric electronic patient record systems (EPRs) were interviewed to gather information about the data present in commercial software programmes and the feasibility of data extraction. Researchers were presented with a list of metrics that might be included in an optometric practice dataset via a survey circulated by email to 102 researchers known to have an interest in eye health. Respondents rated the importance of each metric for research. A further survey presented the list of metrics to 2000 randomly selected members of the College of Optometrists. The optometrists were asked to specify how likely they were to enter information about each metric in a routine sight test consultation. They were also asked if data were entered as free text, menus or a combination of these. RESULTS: Current EPRs allowed the input of data relating to the metrics of interest. Most data entry was free text. There was a good match between high priority metrics for research and those commonly recorded in optometric practice. CONCLUSIONS: Although there were plenty of electronic data in optometric practice, this was highly variable and often not in an easily analysed format. To facilitate analysis of the evidence for public health purposes a UK based minimum dataset containing standardised clinical information is recommended. Further research would be required to develop suitable coding for the individual metrics included. The dataset would need to capture information from all sectors of the population to ensure effective planning of any future interventions.

Influence of legal status on the uptake of cannabis in young people.

PURPOSE OF REVIEW: Policies that limit young people's access to cannabis may reduce early onset of use and minimize health-related harm. This review article provides an update of recent research examining the influence of the cannabis policy frameworks on the use of cannabis by young people. RECENT FINDINGS: There are significant concerns that ongoing policy changes in favour of legalization will increase the uptake of cannabis by young people. Evidence to support a causal effect of cannabis policy changes on increased uptake by young people is lacking; more time may be needed to assess the impact because the policies are still evolving. Policy changes in favour of legalization were associated with reduced risk perception although this may be a cause or consequence. The need to situate the impact of these policies in the context of specific policy features, social norms and perceptions about cannabis has been highlighted. SUMMARY: A more nuanced understanding of the impact of the legal status of cannabis on young people is needed to build evidence for future policy options. The impact of these policies may not be immediately apparent but limiting young people's access to cannabis must be prioritized during policy deliberations.

Addressing inequalities in eye health with subsidies and increased fees for General Ophthalmic Services in socio-economically deprived communities: a sensitivity analysis.

OBJECTIVES: Poor knowledge of eye health, concerns about the cost of spectacles, mistrust of optometrists and limited geographical access in socio-economically deprived areas are barriers to accessing regular eye examinations and result in low uptake and subsequent late presentation to ophthalmology clinics. Personal Medical Services (PMS) were introduced in the late 1990 s to provide locally negotiated solutions to problems associated with inequalities in access to primary care. An equivalent approach to delivery of optometric services could address inequalities in the uptake of eye examinations. STUDY DESIGN: One-way and multiway sensitivity analyses. METHODS: Variations in assumptions were included in the models for equipment and accommodation costs, uptake and length of appointments. The sensitivity analyses thresholds were cost-per-person tested below the GOS1 fee paid by the NHS and achieving break-even between income and expenditure, assuming no cross-subsidy from profits from sales of optical appliances. RESULTS: Cost per test ranged from £ 24.01 to £ 64.80 and subsidy required varied from £ 14,490 to £ 108,046. Unused capacity utilised for local enhanced service schemes such as glaucoma referral refinement reduced the subsidy needed. CONCLUSIONS: In order to support the financial viability of primary eye care in socio-economically deprived communities, income is required from additional subsidies or from sources other than eye examinations, such as ophthalmic or other optometric community services. This would require a significant shift of activity from secondary to primary care locations. The subsidy required could also be justified by the utility gain from earlier detection of preventable sight loss.

Training public health superheroes: five talents for public health leadership.

BACKGROUND: Public health leaders have been criticized for their policy stances, relationships with governments and failure to train the next generation. New approaches to the identification and training of public health leaders may be required. To inform these, lessons can be drawn from public health 'superheroes'; public health leaders perceived to be the most admired and effective by their peers. METHODS: Members and Fellows of the UK Faculty of Public Health were contacted via e-newsletter and magazine and asked to nominate their 'Public Health Superhero'. Twenty-six responses were received, nominating 40 different people. Twelve semi-structured interviews were conducted. Thematic analysis, based on 'grounded theory', was conducted. RESULTS: Five leadership 'talents' for public health were identified: mentoring-nurturing, shaping-organizing, networking-connecting, knowing-interpreting and advocating-impacting. CONCLUSIONS: Talent-based approaches have been effective for leadership development in other sectors. These talents are the first specific to the practice of public health and align with some aspects of existing frameworks. An increased focus on identifying and developing talents during public health training, as opposed to 'competency'-based approaches, may be effective in strengthening public health leadership. Further research to understand the combination and intensity of talents across a larger sample of public health leaders is required.

Mind the public health leadership gap: the opportunities and challenges of engaging high-profile individuals in the public health agenda.

BACKGROUND: Public health leadership has been criticized as being ineffective. The public health profession is relatively small. Critics have argued that there is over-emphasis on technical aspects and insufficient use of the 'community as a source of public health actions'. METHODS: The paper analyses the resources, motivations and skills utilized by high-profile individuals who have made contributions to the public health agenda. The phenomenon of celebrity diplomacy is critiqued. Two exemplars are discussed: Jamie Oliver and Michael Bloomberg. The risks of involving celebrities are also considered. RESULTS: Leaders for public health demonstrate 'a paradoxical blend of personal humility and professional will' to make the 'right decisions happen'. While they may have ego or self-interest, in this context, at least, they channel their ambition for the public health cause, not themselves. CONCLUSIONS: Leaders from outside public health may have no understanding of what public health is nor consider their work as part of a wider public health agenda. It is important to understand why they become leaders for public health. This will inform a strategy for how others may be encouraged to collaborate for public health causes. Some key points for working with high-profile leaders for public health are identified.