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The attributes of public health leadership.
Get PDFThe COVID-19 pandemic highlighted the importance of public health leadership. Yet, while there were many inspirational examples, too often, it was lacking. This personal perspective reflects on the experience of the pandemic, drawing on previous reflections on the role of public health professionals. It identifies eight key attributes that a public health leader should have. These are an ability to take the initiative, a sense of curiosity, a broad perspective on health threats, a recognition that there are those who are opposed to health, a willingness to speak truth to power, confidence, and the ability to engage with leaders in other sectors, a commitment to values, and an ability to communicate. In each case, it asks whether these attributes were apparent during the pandemic and why they might be needed in the future
Cognitive Authority Theory: Reframing health inequity, disadvantage and privilege in palliative and end-of-life care.
Get PDFBackground: There persist disparities in access to quality palliative and end-of-life care, often based on avoidable injustice. Research and theory to explain this health inequity focuses on structural or individual-based factors, overlooking important relational factors between health professionals, patients and families.
Aim: To apply Cognitive Authority Theory in palliative and end-of-life care to explain neglected relational drivers of inequity in access and experience.
Methods: Cognitive Authority Theory, a middle-range theory of power relations between individuals and authority over knowledge, was developed from empirical and review data. This paper demonstrates its utility in explaining an overlooked component of inequity in palliative care: interactions between health professionals and patients/caregivers.
Results: Using examples from the palliative care literature, we characterise how people who are socially disadvantaged have fewer resources to exploit during consultations with health professionals which makes it difficult for them to have their voices heard, their choices prioritised by others, and to express their expertise. We examine the implications of health professionals' judgements of expertise for care access, experience, involvement and appropriateness. We offer a fresh perspective on the mechanisms by which stereotypes, bias and power imbalances between health professionals and patients reinforce existing health inequities, drawing on the role of social privilege in shaping inequity in palliative care.
Conclusion: This paper provides a new language to articulate relational drivers of inequity in palliative care. It explains how to use Cognitive Authority Theory to design and interpret research to determine how healthcare interactions reinforce both social privilege and social disadvantage at end-of-life
HIV in Latin American migrants in the UK: A neglected population in the 95-95-95 targets.
Get PDFBACKGROUND: The UK has reached the UNAIDS 2025 targets (of 95% of those living with HIV to be diagnosed, 95% to be on treatment and 95% of those on treatment to be virally suppressed). However, it is not known whether this target is met in subgroups such as migrant populations. Latin Americans are a fast-growing migrant group in the UK and have low engagement with healthcare services, yet little is known about the HIV profile in this population. This study aimed to explore the profile of Latin American migrants under HIV care in the UK, and to identify any gaps in the 95-95-95 target in this population. METHODS: Country of birth- and gender- stratified prevalence of HIV in Latin American migrants in the UK (as of December 2022) was estimated using data from the HIV and AIDS Reporting System and the Office for National Statistics. UNAIDS (2024) estimates from Latin American countries were used as proxies for expected prevalences and applied to Latin American demography in England to calculate expected cases. The ratio of the observed (or diagnosed) cases to the expected cases was calculated to estimate potential underdiagnosis. RESULTS: A total of 2482 migrants born in Latin American countries were diagnosed with (and under care for) HIV in the UK (observed prevalence 841 per 100 000 population) by the end of 2022. The highest observed prevalence was in men born in Country 3 (2431 per 100 000 population) and the lowest in women born in Country 13 (30 per 100 000 population). Some 89% (n = 2219) of Latin American migrants under care for HIV were men, with 263 women under care with HIV in the whole of the UK. For women born in five of the countries of the region, it was estimated that only 14%, 17%, 25%, 26% and 33% of women living with HIV were under care. CONCLUSIONS: There may be a significant burden of underdiagnosis of HIV among Latin American women in the UK. Although based on some assumptions (notably the application of national HIV estimates to migrant populations which have a different risk profile), the gender disparity is striking. Community engagement and culturally appropriate targeted awareness raising and testing campaigns are recommended
Tissue Doppler echocardiography predicts long-term cardiovascular mortality: the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) legacy 20-year follow-up study.
Get PDFBackground: Left ventricular diastolic function as assessed by tissue Doppler echocardiography predicts cardiovascular event rates at 4 years of follow-up in patients with hypertension. Our aim was to evaluate whether this extends to predicting cardiovascular mortality after 20 years of follow-up.
Methods: Conventional (E) and tissue Doppler (e') echocardiography was performed on hypertensive participants in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) with long-term follow-up ascertained via linkage to the Office of National Statistics. Cardiovascular mortality was defined as death from coronary heart disease, stroke and other cardiovascular aetiology such as heart failure or peripheral vascular disease. Unadjusted and adjusted Cox regression survival models were constructed to investigate the association between tissue Doppler echocardiography measurements and long-term cardiovascular mortality.
Results: Among 506 hypertensive patients (median age 64, interquartile range (58, 69), 87% male), there were 200 (40%) deaths over a 20-year follow-up period. 60 deaths (12%) were cardiovascular-related.A reduction in e' was independently associated with increased cardiovascular mortality, after adjusting for the ACC/AHA Atherosclerotic Cardiovascular Disease (ASCVD) risk score, with an inverse HR of 1.22 per 1 cm/s decrease (95% CI 1.04-1.43). A higher E/e' ratio was independently associated with increased cardiovascular mortality, after adjusting for the ASCVD risk score, with an HR of 1.12 per 1-unit increase (95% CI, 1.02 to 1.23).
Conclusions: Impaired left ventricular diastolic function, measured using tissue Doppler echocardiography through e' and E/e', independently predicts increased cardiovascular mortality over 20 years in hypertensive patients, highlighting its long-term prognostic significance
Life course trajectories of maternal cardiovascular disease risk factors by obstetric history: a UK cohort study using electronic health records.
Get PDFBACKGROUND: Women who experience adverse pregnancy outcomes (APOs; gestational hypertension, preeclampsia (PE), gestational diabetes (GD), preterm birth (PTB), small or large for gestational age, miscarriage, multiple miscarriages, stillbirth, and offspring with major congenital anomalies) have increased risk of developing cardiovascular disease (CVD). We aimed to compare cardiometabolic health trajectories across the life course between women with and without APOs.
METHODS: We studied 187,186 women with a registered pregnancy in the UK Clinical Practice Research Datalink (CPRD) GOLD linked to Hospital Episode Statistics. Fractional polynomial multilevel models were used to compare trajectories of cardiometabolic risk factors (body mass index [BMI], blood pressure [BP], cholesterol, and glucose) between women with and without a history of APOs (individual APOs in any pregnancy and number of APOs). We explored two underlying time axes: (1) time relative to first pregnancy (from 10 years before first pregnancy to 15 years after) and (2) age. Models controlled for age at first pregnancy, residential area deprivation, non-singleton pregnancy, parity, smoking status, ethnicity, and medications use.
RESULTS: Women with a history of PE, gestational hypertension, or GD had higher BMI, BP, and glucose 10 years before first pregnancy compared to women without these APOs. These differences persisted 15 years post-first pregnancy. Women with a history of GD had a steeper post-partum rise in glucose. Women who experienced multiple (3 +) miscarriage, stillbirth, and/or medically indicated PTB had higher BP and BMI before and after pregnancy, with BP trajectories converging 15 years after first pregnancy. Women who experienced multiple APOs had the most adverse measurements across all cardiometabolic risk factors, with more unfavourable mean levels with each additional APO. There was little difference in cardiometabolic trajectories between women with and without a history of 1 or 2 miscarriages or congenital anomalies.
CONCLUSIONS: Women with APOs had adverse cardiometabolic profiles before first pregnancy, persisting up to 15 years post-pregnancy. Findings highlight the potential for targeted public health interventions to promote good cardiometabolic health in young adults transitioning from contraceptive use to planning pregnancies. APOs may identify young women who could benefit from monitoring CVD risk factors and interventions to improve cardiometabolic health
Contextual factors influencing implementation of tuberculosis digital adherence technologies: a scoping review guided by the RE-AIM framework.
Get PDFINTRODUCTION: Digital adherence technologies (DATs) may enable person-centred tuberculosis (TB) treatment monitoring; however, implementation challenges may undermine their effectiveness. Using the reach, effectiveness, adoption, implementation and maintenance framework, we conducted a scoping review to identify contextual factors informing 'reach' (DAT engagement by people with TB) and 'adoption' (DAT uptake by healthcare providers or clinics).
METHODS: We searched eight databases from 1 January 2000 to 25 April 2023 to identify all TB DAT studies. After extracting qualitative and quantitative findings, using thematic synthesis, we analysed common findings to create meta-themes informing DAT reach or adoption. Meta-themes were further organised using the Unified Theory of Acceptance and Use of Technology, which posits technology use is influenced by perceived usefulness, ease of use, social influences and facilitating conditions.
RESULTS: 66 reports met inclusion criteria, with 61 reporting on DAT reach among people with TB and 27 reporting on DAT adoption by healthcare providers. Meta-themes promoting reach included perceptions that DATs improved medication adherence, facilitated communication with providers, made people feel more 'cared for' and enhanced convenience compared with alternative care models (perceived usefulness) and lowered stigma (social influences). Meta-themes limiting reach included literacy and language barriers and DAT technical complexity (ease of use); increased stigma (social influences) and suboptimal DAT function and complex cellular accessibility challenges (facilitating conditions). Meta-themes promoting adoption included perceptions that DATs improved care quality or efficiency (perceived usefulness). Meta-themes limiting adoption included negative DAT impacts on workload or employment and suboptimal accuracy of adherence data (perceived usefulness); and suboptimal DAT function, complex cellular accessibility challenges and insufficient provider training (facilitating conditions). Limitations of this review include the limited studies informing adoption meta-themes.
CONCLUSION: This review identifies diverse contextual factors that can inform improvements in DAT design and implementation to achieve higher engagement by people with TB and healthcare providers, which could improve intervention effectiveness
The good, the bad, and the ugly: Compliance of e-pharmacies serving India and Kenya with regulatory requirements and best practices.
Get PDFAs with most technology-driven change, e-pharmacy markets have expanded faster than the pace of regulation, particularly in low- and middle-income countries. We developed and applied a checklist to assess compliance with best practices and regulations by e-pharmacies serving clients in India and Kenya, two countries with contrasting regulatory environments. We defined e-pharmacies as businesses selling prescription-only medicines directly to consumers through websites or apps. We identified the universe of e-pharmacies through online searches, and captured data using a structured questionnaire (Jan-May 2023). We then assessed e-pharmacies against a set of global 'best practice' standards, as well as national regulations (for Kenya) and 'proposed requirements' from local guidelines and draft bills (for India, which had no e-pharmacy-specific regulations). We identified 61 websites and 37 apps serving India, and 26 websites and 3 apps serving Kenya. Regarding best practices, a facility to upload prescriptions was provided by 90% of websites serving India and 58% serving Kenya. Only 16% (India) and 42% (Kenya) provided complete drug information. On average, websites serving Kenya met 8.9 of the 12 (74%) Kenyan regulatory requirements, while those serving India met 7.5 of the 14 (54%) 'proposed requirements'. Only 31% serving Kenya and none serving India displayed required registration numbers. Contrary to regulations/guidelines, many e-pharmacies serving Kenya (62%) and India (34%) listed narcotic/controlled drugs for sale. In both countries, high-traffic websites and e-pharmacies located within the study country had higher mean compliance to regulation and best practices compared to the others. These findings can be leveraged to strengthen enforcement in Kenya and inform the development of a comprehensive regulatory framework in India. We recommend a risk-based regulatory approach, where regulators work with the largely compliant ("good") e-pharmacies, improve enforcement among the partially compliant ("bad"), and eliminate the largely non-compliant ("ugly") from the market
What do people do in the aftermath of healthcare-related harm? A qualitative study on experiences and factors influencing decision-making.
Get PDFOBJECTIVES: To capture experiences of people self-reporting harm and contrast responses and actions between those who do or do not take formal action. DESIGN: Semi-structured qualitative interview study. SETTING: People self-reporting harm experienced in the National Health Service (NHS) or their family/friends identified from a general Great British population survey. PARTICIPANTS: 49 participants. RESULTS: There were commonalities in experiences after harm whether formal action (including making a formal complaint or litigation) was taken or not. Many participants reported raising concerns informally with NHS staff, trying to access explanations or support, but were usually unsuccessful. Decision-making on action was complex. There were multiple reasons for not pursuing formal action, including fears of damaging relationships with clinicians, being occupied coping with the consequences of the harm or not wanting to take action against the NHS. NHS advocacy services were not regarded as helpful. Knowledge of how to proceed and feeling entitled to do so, along with proactive social networks, could facilitate action, but often only after people were spurred on by anger and frustration about not receiving an explanation, apology or support for recovery from the NHS. Those from marginalised groups were more likely to feel disempowered to act or be discouraged by family or social contacts, which could lead to self-distancing and reduced trust in services. CONCLUSIONS: People actively seek resolution and recovery after harm but often face multiple barriers in having their needs for explanations, apologies and support addressed. Open and compassionate engagement, especially with those from more marginalised communities, plus tailored support to address needs, could promote recovery, decrease compounded harm and reduce use of grievance services where other provision may be more helpful
Health impact and economic evaluation of the Expanded Program on Immunization in China from 1974 to 2024: a modelling study.
Get PDFBACKGROUND: The Expanded Program on Immunization (EPI), initiated by WHO in 1974, is a cornerstone of public health. China's EPI covers more than a sixth of the world's population and includes eight routine vaccines with high coverage rates. This study aimed to estimate health and economic impacts of China's EPI over the past 50 years (1974-2024). METHODS: This study mathematically modelled the impact of all eight routine vaccines in China's EPI against eight pathogens (measles, pertussis, hepatitis B, tuberculosis, hepatitis A, Japanese encephalitis, meningitis A, and poliomyelitis) based on data availability and their substantial disease burden, particularly accounting for non-linearities in vaccine impact. Health and economic outcomes were determined using mathematical models between a counterfactual scenario without vaccination (vaccine coverage set to zero) and the current vaccination scenario (routine vaccination scheduled at age 0-6 years), based on calendar year and birth cohort approaches. The health impact of China's EPI from 1974 to 2024 was measured in the number of cases, deaths, and disability-adjusted life-years (DALYs) averted. FINDINGS: We estimated that China's EPI averted 703·02 million cases (95% credible interval 699·51-722·80) and 2·48 million deaths (2·14-2·97) in 1974-2024 based on the calendar year approach, equivalent to averting an estimated 160·22 million DALYs (145·05-196·99). Using the birth cohort approach, we predicted 707·41 million cases (703·93-727·03) and 7·01 million deaths (6·95-7·87) averted over the lifetime, corresponding to 279·02 million DALYs (265·78-316·12). From a societal perspective, the aggregated cost of vaccination was estimated to be US2417·85 billion (2359·38-2710·35). China's EPI yielded an aggregate benefit-cost ratio of 19·48 (18·82-22·08) from the societal perspective and 8·02 (7·64-8·80) from the provider's perspective. INTERPRETATION: China's EPI has shown remarkable health and economic achievements, contributing to worldwide EPI success in the past 50 years. Further investment in EPI is warranted to sustain coverage and expand vaccine inclusion in China and globally. FUNDING: Beijing Natural Science Foundation. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section
Application of mobile health (mHealth) in the field of eye care: A scoping review of interventions used by individuals and health services to communicate.
Get PDFMobile health (mhealth) has the potential to become a powerful tool to support healthcare delivery in various ways, but there is a gap in the understanding on the impact of mHealth interventions used in eyecare. The aim of this scoping review is to collate, synthesise and describe the types of mHealth interventions in eye care. We searched MEDLINE, Embase and Global Health on 2 March 2021, July 13th 2023 and August 8th 2024 for any mHealth intervention that is available within an eyecare service and involves communication between patients and health professionals. Fifty-nine studies were included in the scoping review. The results highlight the extensive areas in eye health where mHealth is currently being applied, including a range of settings, modalities and intervention types. Predominantly, mHealth is used for multiple eye conditions and interventions aiming to increase adherence to treatments, improve appointment attendance, and raise awareness of eyecare. However, the specific modes of delivery and types of interventions (simple or complex) that are most effective remain unclear. This scoping review highlights there is significant interest and potential for mHealth interventions to improve communication between eye care professionals and patients across various settings and modalities. Despite the promising applications of mHealth to eye care, the effectiveness of these interventions can vary widely across different settings. To maximise the benefits of mHealth in eye care, future research should aim to address these gaps, especially within diverse socio-economic contexts