What are the expectations and experiences of a GMH research programme delivered in Bosnia-Herzegovina, Colombia and Uganda? A prospective longitudinal qualitative study.

OBJECTIVES: Global health research collaborations between partners in high-income countries and low-income and middle-income countries (LMICs) aim to generate new evidence, strengthen research capacity, tackle health inequalities and improve outcomes. Previous evaluations of such programmes have identified areas for improvement but consisted only of retrospective experiences. We conducted the first prospective study to assess the initial expectations as well as the final experiences of participants of a global health research programme. DESIGN, SETTINGS AND PARTICIPANTS: This study adopted a prospective longitudinal qualitative study, 38 participants of a global mental health research programme with partners in Bosnia-Herzegovina, Colombia, Uganda and the (UK). The interviewees included senior investigators, coordinators and researchers. Framework analysis was used to analyse the data. OUTCOME MEASURES: Participants were interviewed about their initial expectations at the inception of the research programme and their final experiences at the end. RESULTS: Many of the original expectations were later reported as met or even exceeded. They included experiences of communication, relationships, developed research expertise, further research opportunities and extending networks. However, other expectations were not met or only partially met, mainly on developing local leadership, strengthening institutional research capacity and opportunities for innovation and for mutual learning. Around equity of partnership and ownership of research the views of participants in the UK tended to be more critical than those of partners in LMICs. CONCLUSIONS: The findings suggest that global health research programmes can achieve several of their aims, and that partners in LMICs feel equity has been established in the partnership despite the imbalance of the funding arrangement. Aims of global health research projects should have a realistic focus and be proportionate to the parameters of the funding arrangement. More resources and longer time scales may be required to address sustainable structural capacity and long-standing local leadership sufficiently.

Understanding global mental health: a conceptual review.

BACKGROUND: Mental health disorders are viewed as a global concern requiring globally led approaches to address them. Since the publication of the 2007 Lancet series on global mental health (GMH), the term has become widespread. Over the last two decades, GMH has become increasingly affiliated with policy reform, academic courses, funding bodies and research. However, it is not always obvious how those working in the field of GMH are using the term, resulting in a lack of clarity. Therefore, work is needed to synthesise the current understanding(s) of GMH to help characterise its meaning. AIM: To synthesise the literature and identify the different ways GMH is understood. METHOD: A conceptual review, using a systematic search and a content analysis, was conducted to develop a conceptual framework of the different conceptual understandings of GMH. RESULTS: We developed a conceptual framework of four understandings of GMH. These understandings of GMH are as follows: an area of research generating findings to establish a GMH evidence-base; implementation of research into practice; improving the mental health environment; learning from and supporting low-and-middle-income countries (LMICs). CONCLUSION: Our review proposes a simple framework, clarifying the key characteristics of the GMH landscape. The findings highlight the diversity of usage of the term in the literature, as well as present the wide scope that comprises the field of GMH. Referring to this framework may help those engaged with GMH to be more specific with which aspect of the field they are concerned with.

Using chronic kidney disease trigger tools for safety and learning: a qualitative evaluation in East London primary care.

BACKGROUND: An innovative programme to improve identification and management of chronic kidney disease (CKD) in primary care was implemented across three clinical commissioning groups (CCGs) in 2016. This included a falling estimated glomerular filtration rate (eGFR) trigger tool built from data in the electronic health record (EHR). This tool notifies GP practices of falling eGFR values. By alerting clinicians to patients with possible CKD progression the tool invites clinical review, a referral option, and written reflection on management. AIM: To identify practitioner perceptions of trigger tool use from interviews, and compare these with reflections on clinical management recorded within the tools. DESIGN AND SETTING: A qualitative analysis set in 136 practices across East London during 2016-2018. METHOD: Eight semi-structured interviews with GPs and practice staff were recorded, and thematic analysis was undertaken using framework analysis. The reflective comments recorded in the trigger tools of 1921 cases were categorised by age group, referral status, and by the drop in eGFR (>15 or >25 ml/min). RESULTS: Three themes emerged from the interviews: getting started, patient safety, and trigger tools for learning. Well-organised practices found the tool was readily embedded into workflow and expressed greater motivation for using it. The tool was seen to support patient safety, and was used for learning about CKD management, both individually and as a practice. Reflective comments from 1921 trigger tools were reviewed. These supported the theme of patient safety. The free-text data, stratified by age, challenged the expectation that younger cases, at higher risk of progressive CKD, would have higher referral rates. CONCLUSION: Building electronic trigger tools from the EHR can identify patients with a falling eGFR, prompting review of the eGFR trajectory and management plan. Interview and reflective data illustrated that practice use of the tool supports the patient safety agenda and encourages learning about CKD management.

Improving coding and primary care management for patients with chronic kidney disease: an observational controlled study in East London.

BACKGROUND: The UK national chronic kidney disease (CKD) audit in primary care shows diagnostic coding in the electronic health record for CKD averages 70%, with wide practice variation. Coding is associated with improvements to risk factor management; CKD cases coded in primary care have lower rates of unplanned hospital admission. AIM: To increase diagnostic coding of CKD (stages 3-5) and primary care management, including blood pressure to target and prescription of statins to reduce cardiovascular disease risk. DESIGN AND SETTING: Controlled, cross-sectional study in four East London clinical commissioning groups (CCGs). METHOD: Interventions to improve coding formed part of a larger system change to the delivery of renal services in both primary and secondary care in East London. Quarterly anonymised data on CKD coding, blood pressure values, and statin prescriptions were extracted from practice computer systems for 1-year pre- and post-initiation of the intervention. RESULTS: Three intervention CCGs showed significant coding improvement over a 1 year period following the intervention (regression for post-intervention trend P<0.001). The CCG with highest coding rates increased from 76-90% of CKD cases coded; the lowest coding CCG increased from 52-81%. The comparison CCG showed no change in coding rates. Combined data from all practices in the intervention CCGs showed a significant increase in the proportion of cases with blood pressure achieving target levels (difference in proportion P<0.001) over the 2-year study period. Differences in statin prescribing were not significant. CONCLUSION: Clinically important improvements to coding and management of CKD in primary care can be achieved by quality improvement interventions that use shared data to track and monitor change supported by practice-based facilitation. Alignment of clinical and CCG priorities and the provision of clinical targets, financial incentives, and educational resource were additional important elements of the intervention.

Seasonal fluctuation of lung function in cystic fibrosis: A national register-based study in two northern European populations.

BACKGROUND: Many risk factors for lung disease in cystic fibrosis (CF) display a seasonal pattern yet it is unclear whether this is reflected in seasonal fluctuations in lung function. METHODS: We conducted a longitudinal study using CF registries in Denmark and the UK. 471 individuals with a median of 104 FEV1 measurements per person and 7586 individuals with a median of nine FEV1 measures per person were included from Denmark and the UK respectively. We estimated the effect of seasonality on percent predicted FEV1 trajectories using mixed effects models whilst adjusting for clinically important covariates. RESULTS: We found no significant cyclical seasonal variation in lung function in either country. The maximum variation in percent predicted FEV1 around the yearly average was estimated to be 0.1 percentage points (95%CI 0 to 0.21) and 0.14 percentage points (95%CI 0 to 0.29) in Denmark and the UK, respectively. When considering possible step-like changes between the four seasons, we found that lung function was higher in spring compared to winter in the UK (0.34 percentage points, 95%CI 0.1 to 0.59) though the difference was not of clinical significance. CONCLUSION: In both the UK and Denmark there may be small seasonal changes in lung function but this effect is not of clinical importance.