Effectiveness of shared medical appointments delivered in primary care for improving health outcomes in patients with long-term conditions: a systematic review of randomised controlled trials.

OBJECTIVES: To examine the effectiveness of shared medical appointments (SMAs) compared with one-to-one appointments in primary care for improving health outcomes and reducing demand on healthcare services by people with one or more long-term conditions (LTCs). DESIGN: A systematic review of the published literature. DATA SOURCES: Six databases, including MEDLINE and Web of Science, were searched 2013-2023. Relevant pre-2013 trials identified by forward and backward citation searches of the included trials were included. ELIGIBILITY CRITERIA: Randomised controlled trials of SMAs delivered in a primary care setting involving adults over 18 years with one or more LTCs. Studies were excluded if the SMA did not include one-to-one patient-clinician time. All countries were eligible for inclusion. DATA EXTRACTION AND SYNTHESIS: Data were extracted and outcomes narratively synthesised, meta-analysis was undertaken where possible. RESULTS: Twenty-nine unique trials were included. SMA models varied in terms of components, mode of delivery and target population. Most trials recruited patients with a single LTC, most commonly diabetes (n=16). There was substantial heterogeneity in outcome measures. Meta-analysis showed that participants in SMA groups had lower diastolic blood pressure than those in usual care (d=-0.086, 95% CI=-0.16 to -0.02, n=10) (p=0.014). No statistically significant differences were found across other outcomes. Compared with usual care, SMAs had no significant effect on healthcare service use. For example, no difference between SMAs and usual care was found for admissions to emergency departments at follow-up (d=-0.094, 95% CI=-0.27 to 0.08, n=6, p=0.289). CONCLUSIONS: There was a little difference in the effectiveness of SMAs compared with usual care in terms of health outcomes or healthcare service use in the short-term (range 12 weeks to 24 months). To strengthen the evidence base, future studies should include a wider array of LTCs, standardised outcome measures and more details on SMA components to help inform economic evaluation. PROSPERO REGISTRATION NUMBER: CRD42020173084.

Identifying the active ingredients of training interventions for healthcare professionals to promote and support increased levels of physical activity in adults with heart failure: a systematic review.

Heart failure (HF) is characterised by breathlessness and fatigue that impacts negatively on patients' intentions to prioritise physical activity (PA). Healthcare professionals (HCPs) experience challenges when motivating patients to increase PA. It is essential to develop an understanding of how to support HCPs to deliver PA interventions. We aimed to identify active ingredients of HCP training interventions to enable delivery of PA interventions to HF patients. Nine databases were searched. Data were extracted on study characteristics, active ingredients, outcomes, and fidelity measures. Data were synthesised narratively, and a promise analysis was conducted on intervention features. Ten RCTs, which reported a training intervention for HCPs were included (N = 22 HCPs: N = 1,414 HF patients). Two studies reported the use of theory to develop HCP training. Seven behaviour change techniques (BCTs) were identified across the 10 training interventions. The most 'promising' BCTs were 'instruction on how to perform the behaviour' and 'problem solving'. Two studies reported that HCP training interventions had been formally evaluated. Fidelity domains including study design, monitoring and improving the delivery of treatment, intervention delivery, and provider training were infrequently reported. Future research should prioritise theory-informed development and robust evaluation of training interventions for HCPs to enable faithful and quality delivery of patient interventions.

Using the precaution adoption process model to understand decision-making about the COVID-19 booster vaccine in England.

BACKGROUND: COVID-19 continues to pose a threat to public health. Booster vaccine programmes are critical to maintain population-level immunity. Stage theory models of health behaviour can help our understanding of vaccine decision-making in the context of perceived threats of COVID-19. PURPOSE: To use the Precaution Adoption Process Model (PAPM) to understand decision-making about the COVID-19 booster vaccine (CBV) in England. METHODS: An online, cross-sectional survey informed by the PAPM, the extended Theory of Planned Behaviour and Health Belief Model administered to people over the age of 50 residing in England, UK in October 2021. A multivariate, multinomial logistic regression model was used to examine associations with the different stages of CBV decision-making. RESULTS: Of the total 2,004 participants: 135 (6.7%) were unengaged with the CBV programme; 262 (13.1%) were undecided as to whether to have a CBV; 31 (1.5%) had decided not to have a CBV; 1,415 (70.6%) had decided to have a CBV; and 161 (8.0%) had already had their CBV. Being unengaged was positively associated with beliefs in their immune system to protect against COVID-19, being employed, and low household income; and negatively associated with CBV knowledge, a positive COVID-19 vaccine experience, subjective norms, anticipated regret of not having a CBV, and higher academic qualifications. Being undecided was positively associated with beliefs in their immune system and having previously received the Oxford/AstraZeneca (as opposed to Pfizer/BioNTech) vaccine; and negatively associated with CBV knowledge, positive attitudes regarding CBV, a positive COVID-19 vaccine experience, anticipated regret of not having a CBV, white British ethnicity, and living in East Midlands (vs London). CONCLUSIONS: Public health interventions promoting CBV may improve uptake through tailored messaging directed towards the specific decision stage relating to having a COVID-19 booster.

Shared medical appointments in English primary care for long-term conditions: a qualitative study of the views and experiences of patients, primary care staff and other stakeholders.

BACKGROUND: Shared medical appointments (SMAs) or group consultations have been promoted in primary care to improve workload pressures, resource-use efficiency and patient self-management of long-term conditions (LTCs). However, few studies have explored stakeholders' perspectives of this novel care delivery model in the English NHS context, particularly patients' views and experiences of SMAs. METHOD: Semi-structured interviews were used to explore the perspectives of stakeholders (21 patients, 17 primary care staff, 2 commissioners and 2 SMA training providers) with and without SMA experience from a range of geographical and socio-economic backgrounds in the North East and North Cumbrian region of England. Thematic analysis was conducted to examine perceptions around impact on patient care and outcomes and barriers and facilitators to implementation. RESULTS: Three main themes were identified: 'Value of sharing', 'Appropriateness of group setting', 'Implementation processes'. Patients experiences and perceptions of SMAs were largely positive yet several reported reservations about sharing personal information, particularly in close-knit communities where the risk of breaching confidentiality was perceived to be greater. SMAs were considered by patients and staff to be inappropriate for certain personal conditions or for some patient groups. Staff reported difficulties engaging sufficient numbers of patients to make them viable and having the resources to plan and set them up in practice. Whilst patients and staff anticipated that SMAs could deliver high quality care more efficiently than 1:1 appointments, none of the practices had evaluated the impact SMAs had on patient health outcomes or staff time. CONCLUSION: Stakeholder experiences of SMA use in English primary care are largely similar to those reported in other countries. However, several important cultural barriers were identified in this setting. Further work is needed to better understand how patient and staff perceptions, experiences and engagement with SMAs change with regular use over time. Concerns regarding staff capacity, additional resource requirements and numbers of eligible patients per practice suggest SMAs may only be feasible in some smaller practices if facilitated by primary care networks. Further mixed-method evaluations of SMAs are needed to inform the evidence base regarding the effectiveness, efficiency and feasibility of SMAs long-term and subsequently their wider roll-out in English primary care.

A comparison of seasonal influenza and novel Covid-19 vaccine intentions: A cross-sectional survey of vaccine hesitant adults in England during the 2020 pandemic.

We compared intention to receive the seasonal influenza vaccine with a prospective coronavirus (COVID-19) vaccine among undecided or COVID-19 vaccine hesitant individuals to better understand the underlying differences and similarities in factors associated with vaccine intention. We delivered a cross-sectional online survey in October-November 2020. We included psychological constructs and sociodemographic variables informed by theory. We conducted pairwise comparisons and multiple linear regression models to explore associations between vaccine intention and psychological constructs. We recruited 1,660 participants, where 47.6% responded that they would likely receive the influenza vaccine, 31.0% that they would probably not accept the vaccination and 21.4% were unsure. In relation to the prospective COVID-19 vaccine, 39.0% responded that they would likely receive the vaccination, 23.7% that they would probably not accept the vaccination and 37.3% were unsure. Unique factors positively associated with COVID-19 vaccine intention were: perceived knowledge sufficiency about vaccine safety, beliefs about vaccine safety, and living in an area of low deprivation. The only unique factor positively associated with influenza intention was past influenza behavior. The strongest common predictors positively associated with intention were: favorable vaccine attitudes, the anticipated regret they may feel following infection if they were not to receive a vaccine, and the expectation from family or friends to accept the vaccine. Despite overall similarities in those factors associated with vaccination intention, we identified unique influences on intention. This additional insight will help support the planning and tailoring of future immunizations programmes for the respective viruses.

Factors associated with vaccine intention in adults living in England who either did not want or had not yet decided to be vaccinated against COVID-19.

Early studies showed that 28-36% of UK adults were unsure or unwilling to be vaccinated against COVID-19. We wanted to identify which socio-demographic, socio-economic, personal health and psychological factors were associated with COVID-19 vaccine intentions (CVI) in adults living in England who did not want, yet to consider, or not sure whether to vaccinate. In October/November 2020, prior to vaccine availability, we surveyed adults stratified by gender, region, and deprivation, with additional purposive sampling of those aged 50 and over and those from an ethnic minority. Two hundred and ten did not want; 407 had yet to consider; and 1,043 were not sure whether to be vaccinated. Factors positively associated with CVI were: favorable vaccine views, trust in institutions associated with vaccine approval, vaccine subjective norms, anticipated regret of not having a vaccine, perceived vaccine benefits, perceived safety knowledge sufficiency, and a history of having an influenza vaccine. Factors negatively associated were: anti-lockdown views, and being a health or social care worker. Whilst showing significant relationships with CVI when analyzed in isolation, neighborhood deprivation and ethnicity did show an independent relationship to intention when all study measures were controlled for. Our findings suggest vaccine promotion focusing on the anticipated regret of not having a vaccine, the benefits of a mass COVID-19 immunization program, and the safety of a vaccine whilst ensuring or engendering trust in those bodies that brand a campaign may be most supportive of COVID-19 vaccine uptake.

What influences people's responses to public health messages for managing risks and preventing infectious diseases? A rapid systematic review of the evidence and recommendations.

BACKGROUND: Individual behaviour changes, such as hand hygiene and physical distancing, are required on a population scale to reduce transmission of infectious diseases such as COVID-19. However, little is known about effective methods of communicating risk reducing information, and how populations might respond. OBJECTIVE: To synthesise evidence relating to what (1) characterises effective public health messages for managing risk and preventing infectious disease and (2) influences people's responses to messages. DESIGN: A rapid systematic review was conducted. Protocol is published on Prospero CRD42020188704. DATA SOURCES: Electronic databases were searched: Ovid Medline, Ovid PsycINFO and Healthevidence.org, and grey literature (PsyarXiv, OSF Preprints) up to May 2020. STUDY SELECTION: All study designs that (1) evaluated public health messaging interventions targeted at adults and (2) concerned a communicable disease spread via primary route of transmission of respiratory and/or touch were included. Outcomes included preventative behaviours, perceptions/awareness and intentions. Non-English language papers were excluded. SYNTHESIS: Due to high heterogeneity studies were synthesised narratively focusing on determinants of intentions in the absence of measured adherence/preventative behaviours. Themes were developed independently by two researchers and discussed within team to reach consensus. Recommendations were translated from narrative synthesis to provide evidence-based methods in providing effective messaging. RESULTS: Sixty-eight eligible papers were identified. Characteristics of effective messaging include delivery by credible sources, community engagement, increasing awareness/knowledge, mapping to stage of epidemic/pandemic. To influence intent effectively, public health messages need to be acceptable, increase understanding/perceptions of health threat and perceived susceptibility. DISCUSSION: There are four key recommendations: (1) engage communities in development of messaging, (2) address uncertainty immediately and with transparency, (3) focus on unifying messages from sources and (4) frame messages aimed at increasing understanding, social responsibility and personal control. Embedding principles of behavioural science into public health messaging is an important step towards more effective health-risk communication during epidemics/pandemics.

Barriers and facilitators to implementation of shared medical appointments in primary care for the management of long-term conditions: a systematic review and synthesis of qualitative studies.

OBJECTIVE: To synthesise the published literature on practitioner, patient and carer views and experiences of shared medical appointments (SMAs) for the management of long-term conditions in primary care. DESIGN: Systematic review of qualitative primary studies. METHODS: A systematic search was conducted using MEDLINE (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), Web of Science, Social Science Premium Collection (Proquest) and Scopus (SciVerse) from database starting dates to June 2019. Practitioner, patient and carer perspectives were coded separately. Deductive coding using a framework approach was followed by thematic analysis and narrative synthesis. Quality assessment was conducted using the Critical Appraisal Skills Programme for qualitative studies. RESULTS: We identified 18 unique studies that reported practitioner (n=11), patient (n=14) and/or carer perspectivs(n=3). Practitioners reported benefits of SMAs including scope for comprehensive patient-led care, peer support, less repetition and improved efficiency compared with 1:1 care. Barriers included administrative challenges and resistance from patients and colleagues, largely due to uncertainties and unclear expectations. Skilled facilitators, tailoring of SMAs to patient groups, leadership support and teamwork were reported to be important for successful delivery. Patients' reported experiences were largely positive with the SMAs considered a supportive environment in which to share and learn about self-care, though the need for good facilitation was recognised. Reports of carer experience were limited but included improved communication between carer and patient. CONCLUSION: There is insufficient evidence to indicate whether views and experiences vary between staff, medical condition and/or patient characteristics. Participant experiences may be subject to reporting bias. Policies and guidance regarding best practice need to be developed with consideration given to resource requirements. Further research is needed to capture views about wider and co-occurring conditions, to hear from those without SMA experience and to understand which groups of patients and practitioners should be brought together in an SMA for best effect. PROSPERO REGISTRATION NUMBER: CRD42019141893.

Effectiveness of personal letters to healthcare professionals in changing professional behaviours: a systematic review protocol.

BACKGROUND: Letters are regularly sent by healthcare organisations to healthcare professionals to encourage them to take action, change practice or implement guidance. However, whether letters are an effective tool in delivering a change in healthcare professional behaviour is currently uncertain. In addition, there are currently no evidence-based guidelines to support health providers and authorities with advice on how to formulate the communication, what information and behaviour change techniques to include in order to optimise the potential effect on the behaviour of the receivers. To address this research gap, we seek to inform such guidance through this systematic review, which aims to provide comprehensive evidence of the effectiveness of personal letters to healthcare professionals in changing their professional behaviours. METHODS/DESIGN: A comprehensive literature search of published and unpublished studies (the grey literature) in electronic databases will be conducted to identify randomised controlled trials (RCTs) that meet our inclusion criteria. We will include RCTs evaluating the effectiveness of personal letters to healthcare professionals in changing professional behaviours. The primary outcome will be behavioural change. The search will be conducted in five electronic databases (from their inception onwards): MEDLINE, Embase, PsycINFO, the Cochrane Library and CINAHL. We will also conduct supplementary searches in Google Scholar, hand search relevant journals, and conduct backward and forward citation searching for included studies and relevant reviews. A systematic approach to searching, screening, reviewing and data extraction will be applied in accordance with the process recommended by the Cochrane Collaboration. Two researchers will examine titles, abstracts, full-texts for eligibility independently. Risk of bias will be assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for randomised controlled trials. Disagreements will be resolved by a consensus procedure. DISCUSSION: Health policy makers across government are expected to benefit from being able to increase compliance in clinical settings by applying theories of behaviour to design of policy communications. The synthesised findings will be disseminated through peer-reviewed publication. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020167674.

Public understanding of COVID-19 antibody testing and test results: A qualitative study conducted in the U.K. early in the pandemic.

BACKGROUND: During the COVID-19 pandemic, antibody testing was proposed by several countries as a surveillance tool to monitor the spread of the virus and potentially to ease restrictions. In the UK, antibody testing originally formed the third pillar of the UK Government's COVID-19 testing programme and was thought to offer hope that those with a positive antibody test result could return to normal life. However, at that time scientists and the public had little understanding of the longevity of COVID-19 antibodies, and whether they provided immunity to reinfection or transmission of the virus. OBJECTIVE: This paper explores the UK public's understanding of COVID-19 testing, perceived test accuracy, the meaning of a positive test result, willingness to adhere to restrictive measures in response to an antibody test result and how they expect other people to respond. METHODS: On-line synchronous focus groups were conducted in April/May 2020 during the first wave of the pandemic and the most stringent period of the COVID-19 restrictive measures. Data were analysed thematically. RESULTS: There was confusion in responses as to whether those with a positive or negative test should return to work and which restrictive measures would apply to them or their household members. Participants raised concerns about the wider public response to positive antibody test results and the adverse behavioural effects. There were worries that antibody tests could create a divided society particularly if those with a positive test result were given greater freedoms or chose to disregard the restrictive measures. CONCLUSION: Should these tests be offered more widely, information should be developed in consultation with the public to ensure clarity and address uncertainty about test results and subsequent behaviours.

A Rapid Systematic Review of Public Responses to Health Messages Encouraging Vaccination against Infectious Diseases in a Pandemic or Epidemic.

Public health teams need to understand how the public responds to vaccination messages in a pandemic or epidemic to inform successful campaigns encouraging the uptake of new vaccines as they become available. A rapid systematic review was performed by searching PsycINFO, MEDLINE, healthevidence.org, OSF Preprints and PsyArXiv Preprints in May 2020 for studies including at least one health message promoting vaccine uptake of airborne-, droplet- and fomite-spread viruses. Included studies were assessed for quality using the Mixed Methods Appraisal Tool (MMAT) or the Assessment of Multiple Systematic Reviews (AMSTAR), and for patient and public involvement (PPI) in the research. Thirty-five articles were included. Most reported messages for seasonal influenza (n = 11; 31%) or H1N1 (n = 11; 31%). Evidence from moderate to high quality studies for improving vaccine uptake included providing information about virus risks and vaccination safety, as well as addressing vaccine misunderstandings, offering vaccination reminders, including vaccination clinic details, and delivering mixed media campaigns across hospitals or communities. Behavioural influences (beliefs and intentions) were improved when: shorter, risk-reducing or relative risk framing messages were used; the benefits of vaccination to society were emphasised; and beliefs about capability and concerns among target populations (e.g., vaccine safety) were addressed. Clear, credible, messages in a language target groups can understand were associated with higher acceptability. Two studies (6%) described PPI in the research process. Future campaigns should consider the beliefs and information needs of target populations in their design, including ensuring that vaccine eligibility and availability is clear, and messages are accessible. More high quality research is needed to demonstrate the effects of messaging interventions on actual vaccine uptake.

How effective are social norms interventions in changing the clinical behaviours of healthcare workers? A systematic review and meta-analysis.

BACKGROUND: Healthcare workers perform clinical behaviours which impact on patient diagnoses, care, treatment and recovery. Some methods of supporting healthcare workers in changing their behaviour make use of social norms by exposing healthcare workers to the beliefs, values, attitudes or behaviours of a reference group or person. This review aimed to evaluate evidence on (i) the effect of social norms interventions on healthcare worker clinical behaviour change and (ii) the contexts, modes of delivery and behaviour change techniques (BCTs) associated with effectiveness. METHODS: Systematic review and meta-analysis of randomised controlled trials. Searches were undertaken in seven databases. The primary outcome was compliance with a desired healthcare worker clinical behaviour and the secondary outcome was patient health outcomes. Outcomes were converted into standardised mean differences (SMDs). We performed meta-analyses and presented forest plots, stratified by five social norms BCTs (social comparison, credible source, social reward, social incentive and information about others' approval). Sources of variation in social norms BCTs, context and mode of delivery were explored using forest plots, meta-regression and network meta-analysis. RESULTS: Combined data from 116 trials suggested that social norms interventions were associated with an improvement in healthcare worker clinical behaviour outcomes of 0.08 SMDs (95%CI 0.07 to 0.10) (n = 100 comparisons), and an improvement in patient health outcomes of 0.17 SMDs (95%CI 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I2 of 85.4% (healthcare worker clinical behaviour) and 91.5% (patient health outcomes). Credible source was more effective on average, compared to control conditions (SMD 0.30, 95%CI 0.13 to 0.47, n = 7). Social comparison also appeared effective, both on its own (SMD 0.05, 95%CI 0.03 to 0.08, n = 33) and with other BCTs, and seemed particularly effective when combined with prompts/cues (0.33, 95%CI 0.22 to 0.44, n = 5). CONCLUSIONS: Social norms interventions appeared to be an effective method of changing the clinical behaviour of healthcare workers and have a positive effect on patient health outcomes in a variety of health service contexts. Although the overall result is modest and variable, there is the potential for social norms interventions to be applied at large scale. TRIAL REGISTRATION: PROSPERO CRD42016045718 .

The impact of social norms interventions on clinical behaviour change among health workers: protocol for a systematic review and meta-analysis.

BACKGROUND: Health workers routinely carry out clinical behaviours, such as prescribing, test-ordering or hand-washing, which impact on patient diagnoses, care, treatment and recovery. Social norms are the implicit or explicit rules that a group uses to determine values, beliefs, attitudes and behaviours. A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. This study aims to find out whether or not social norms interventions are effective ways of encouraging health workers to carry out desired behaviours and to identify which types of social norms intervention, if any, are most effective. METHODS: A systematic review will be conducted. The inclusion criteria are a population of health professionals, a social norms intervention that seeks to change a clinical behaviour, and randomised controlled trials. Searches will be undertaken in MEDLINE, EMBASE, CINAHL, British Nursing Index, ISI Web of Science, PsycINFO and Cochrane trials. Titles and abstracts will be reviewed against the inclusion criteria to exclude any that are clearly ineligible. Two reviewers will independently screen all the remaining full texts to identify relevant papers. For studies which meet our inclusion criteria, two reviewers will extract data independently, code for behaviour change techniques and assess quality using the Cochrane risk of bias tool. The primary outcome measure will be compliance with desired behaviour. To assess the effect of social norms on the behaviour of health workers, we will perform fixed effects meta-analysis and present forest plots, stratified by behaviour change technique. We will explore sources of variation using meta-regression and may use multi-component-based network meta-analysis to explore which forms of social norms are more likely to be effective, if our data meet the necessary requirements. DISCUSSION: The study will provide evidence regarding the effectiveness of different methods of applying social norms to change the clinical behaviour of health professionals. We will disseminate the research to academics, health workers and members of the public and use the findings from the review to plan future research on the use of social norms with health workers. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016045718. Future protocol changes will be clearly stated in PROSPERO.

Behavior Change Techniques Associated With Changes in Postintervention and Maintained Changes in Self-Efficacy For Physical Activity: A Systematic Review With Meta-analysis.

BACKGROUND: Self-efficacy is an important determinant of physical activity but it is unclear how best to increase self-efficacy for physical activity and to maintain these changes. PURPOSE: This systematic review aimed to identify which specific behavior change techniques (BCTs), BCT clusters, and number of BCTs were associated with changes in postintervention and maintained changes in self-efficacy for physical activity across all adult populations. METHODS: A systematic search yielded 180 randomized trials (204 comparisons) which reported changes in self-efficacy. BCTs were coded using the BCT Taxonomy v1. Hierarchical cluster analysis explored the clustering of BCTs. Meta-analyses and moderator analyses examined whether the presence and absence of individual BCTs in interventions were associated with effect-size changes for self-efficacy. RESULTS: Small intervention effects were found for postintervention self-efficacy for physical activity (d = 0.26; 95% CI: [0.21, 0.31]; I2 = 75.8 per cent). "Information about social, environmental, and emotional consequences" was associated with higher effect sizes, whereas "social support (practical)" was associated with lower effect sizes. Small and nonsignificant effects were found for maintained changes in self-efficacy for physical activity (d = 0.08; CI: [-0.05, 0.21]; I2 = 83.8 per cent). Lack of meaningful clustering of BCTs was found. A significant positive relationship was found between number of BCTs and effect sizes for maintained changes in self-efficacy for physical activity. CONCLUSIONS: There does not appear to be a single effective approach to change self-efficacy for physical activity in all adults: different approaches are required for different populations. Interventions with more BCTs seem more effective at maintaining changes in self-efficacy for physical activity.

Using patient and public involvement to improve the research design and funding application for a project aimed at fostering a more collaborative approach to the NHS health check: the CaVIAR project (better Care Via Improved Access to Records).

BACKGROUND: Following an initial NHS Health Check appointment, the National Institute for Health and Care Excellence (NICE) suggest patients with QRISK2 scores of ≥10% should be offered advice on lifestyle and the risks and benefits of starting a statin. NICE recommend GPs should ascertain patients' pre-existing knowledge of cardiovascular disease risk, explore health beliefs, assess readiness to change, offer support, and engage family members. Condensing this complex discussion into a short consultation may result in inadequate patient understanding of the benefits of preventive measures. An alternative approach is needed. We propose a digital adjunct giving patients the opportunity to interact with their health check results from home before returning to see their GP. Before embarking on funding applications we sought the views of patients and members of the public. METHODS: We consulted the Primary Care Research in Manchester Engagement Resource (PRIMER), an established departmental Patient and Public Involvement (PPI) group (N = 9) and then ran a workshop with 19 members of the public, co-facilitated by 4 members of PRIMER. Following a brief presentation on the background to the project, attendees were split into four groups and introduced to Ketso, a toolkit for creative engagement. Ketso was used to encourage group discussions regarding the project idea. RESULTS: This PPI work improved the study design and proposed intervention. Discussions focussed on three themes: 1) positive feedback, 2) challenges and solutions, and 3) improvements/alternatives. Positive feedback included benefits to the NHS and patients. Challenges identified related to: 1) access, 2) data security, 3) engagement, and 4) negative consequences. Workshop members generated various solutions to these challenges and made additional suggestions for improvement relating to: 1) population (e.g. also including those with QRISK2 scores ≤10%), 2) duration (e.g. ongoing access to provide continued feedback), and 3) platform content (e.g. signposting to relevant services). CONCLUSIONS: This PPI work helped identify potential challenges and solutions not previously considered by the research team. Findings have informed the subsequent intervention design and strengthened the bid for funding. We aim to ensure ongoing patient and public involvement in all future stages.

Are parents more willing to vaccinate their children than themselves?

Risk perception studies have focused on personal risks; yet many decisions are taken for others. Some studies have suggested that parents are especially sensitive to risks to their children. We compared 245 parents' willingness to vaccinate their child versus themselves in nine hypothetical scenarios relating to influenza strains. Scenarios varied according to non-vaccination risk (low, medium and high) and 'risk target' (oneself, one's child or, as a comparator, one's elderly parent). Participants were more willing to vaccinate their child (61% acceptance) than themselves (54%) or their parent (56%). Parents may be more risk-sensitive when deciding for their child than for themselves.

Optimization of arterial spin labeling MRI for quantitative tumor perfusion in a mouse xenograft model.

Perfusion is an important biomarker of tissue function and has been associated with tumor pathophysiology such as angiogenesis and hypoxia. Arterial spin labeling (ASL) MRI allows noninvasive and quantitative imaging of perfusion; however, the application in mouse xenograft tumor models has been challenging due to the low sensitivity and high perfusion heterogeneity. In this study, flow-sensitive alternating inversion recovery (FAIR) ASL was optimized for a mouse xenograft tumor. To assess the sensitivity and reliability for measuring low perfusion, the lumbar muscle was used as a reference region. By optimizing the number of averages and inversion times, muscle perfusion as low as 32.4 ± 4.8 (mean ± standard deviation) ml/100 g/min could be measured in 20 min at 7 T with a quantification error of 14.4 ± 9.1%. Applying the optimized protocol, heterogeneous perfusion ranging from 49.5 to 211.2 ml/100 g/min in a renal carcinoma was observed. To understand the relationship with tumor pathology, global and regional tumor perfusion was compared with histological staining of blood vessels (CD34), hypoxia (CAIX) and apoptosis (TUNEL). No correlation was observed when the global tumor perfusion was compared with these pathological parameters. Regional analysis shows that areas of high perfusion had low microvessel density, which was due to larger vessel area compared with areas of low perfusion. Nonetheless, these were not correlated with hypoxia or apoptosis. The results suggest that tumor perfusion may reflect certain aspect of angiogenesis, but its relationship with other pathologies needs further investigation.

Improving the management of obesity in adults: a pilot of a method to identify important barriers to change and tailor interventions to address them.

BACKGROUND: A tailored approach to implementation can facilitate the routine use of best evidence, and so improve the quality of care delivered. Tailored implementation involves investigating the context and barriers to change before selecting appropriate interventions. However, there is little evidence on the methods of tailoring. This study investigated the tailoring undertaken by two implementation groups as part of a study to improve adherence to NICE guidelines on adult obesity in primary care. METHODS: Data were collected from interviews with healthcare professionals and patients on barriers and enablers to implementing NICE guidelines on adult obesity along with practice performance data on body mass index (BMI) recording and use of interventions for obesity. Findings were presented to medical practitioners, university and NHS staff (n = 12) who formed two implementation groups to independently identify the most important barriers and enablers, and to suggest interventions to facilitate the implementation of the NICE guidelines. Each group had a facilitator and were observed by researchers whose notes were used to understand the group processes and assess the usefulness of this method. RESULTS: Within the time available both implementation groups reached consensus on the most important barriers and enablers and, led by those who had personal experience of managing patients with weight problems, made practical proposals for interventions to improve the implementation of the NICE guidelines. The role of the facilitator was crucial in ensuring barriers, enablers and interventions were all discussed and agreed upon in the time available. CONCLUSIONS: The facilitated implementation groups method succeeded in identifying appropriate and similar barriers, enablers and implementation interventions, which suggests some justification for this approach to tailoring. However, further research into methods of tailoring is required. Improvements to the implementation group approach may be realised by careful selection of group members and provision of sufficient preparation time prior to group discussions.

The role of research in helping general practice commission efficient healthcare.

The new commissioning consortia face a major challenge in improving the efficiency of the NHS. They are new organisations, and at the same time as establishing themselves they need to overcome significant obstacles to reforming services. Research evidence about the value of care can help consortia achieve efficiencies, but there are often delays between the provision of evidence and its routine use in policy and practice. The National Institute for Health Research (NIHR) has invested substantial funding in providing evidence for the NHS, and in this article we discuss how consortia can make sure they obtain and apply relevant evidence as quickly as possible, and also generate evidence on practical questions such as the impact of redesigned services. Partnership with NIHR research organizations, particularly the Collaborations for Leadership in Applied Research and Care (CLAHRCs), offer one approach to helping consortia commission efficient health care.