Capacity development

One of the main objectives of the study is to explore how lockdowns impacted individuals from different deprivation and ethnicity groups - hence the exploration of the unequal impact of lockdowns on maternal and neonatal morbidity is an integral aspect of this project. The topic is explored through a number of different methodological approaches. 

• Systematic Review and Meta-analysis: a systematic review of all the literature which explores the impact of lockdowns on birth outcomes in high income countries and are now in the midst of conducting a meta-analysis. A meta-analysis of each key outcome including preterm birth, postpartum depression, readmission rates for mothers and Newborns, etc. Then we will conduct a meta-analysis specifically looking at studies which have data stratified according to deprivation level and ethnicity group. In this stratified meta-analysis, an exploration of how rates of key outcomes changed per group and if inequalities increased or increased in high income countries.  
• NHS Hospital data analysis:  approved access to a large amount of Hospital Episode Statistics Data from the NHS, ranging from the present to 2018 with data on all information related to pregnancy and birth admissions. The plan of analysis is to explore which key birth outcomes changed significantly over lockdowns - by conducting an interrupted time series regression. Followed by a stratified analysis to explore which socio-economic and ethnic groups experienced which changes. Finally, to pinpoint key regions in which outcomes worsened and where outcomes improved. This will inform which social and demographic groups experienced adverse outcomes due to lockdowns and whether or not inequalities were substantially affected. 
• Finally, - between 15-30 interviews with women who were pregnant over lockdown will be conducted. A key aspect of questions in the interviews relate to inequality directly - for example asking about experiences of discrimination or racial abuse, as well as the housing environment, financial insecurity, and employment insecurity. Through these interviews it is hoped to elucidate the lived experiences of lockdown for a variety of individuals and explore how lockdown impacted different groups of people very in various and inconsistent ways. 

Targets to reduce inequality, mortality and morbidity

• This project investigates how key perinatal outcomes were impacted by the COVID-19 lockdowns. We will explore key maternal and neonatal morbidity and mortality outcomes, such as stillbirth, preterm birth, neonatal mortality, maternal length of stay & readmission, perineal tears, Caesarean section, and maternal mental health. 
•  Analyze the inequalities in the outcomes between ethnic groups and deprivation levels, and how lockdowns may have exacerbated or alleviated these inequalities.
• To gain understand of how lifestyle changes that occurred during lockdowns could have impacted perinatal health, through qualitative research on mothers who were pregnant in lockdowns. 

Summary

The study of households with children with obesity will help to understand how people’s beliefs and actions about being ‘good’ and doing the ‘right’ thing affect their conversations, decisions and routines in the home.

Concerned with ordinary ethics, the research will consider the different ways, or practices, of ‘doing’ health and happiness.  This will include a focus on weight, but will also include all the other ways of ‘doing good’ and ‘being good’ that families care about.   The research will take into account the external pressures households have faced during the pandemic that influence decisions and actions about health.

Meredith will spend a year with twelve diverse families and households in East London. She will use a variety of methods to understand the daily practices and priorities of parents/carers and children:

• online interviews and a focus group with parents/carers
• ‘walk through’ videos of the household
• voice notes for parents/carers to record their reflections and thoughts about the decisions they have to make throughout a normal day
• children’s drawings of their household and their favourite activities

The approach will pay attention to practices, moments of decision, conversation and compromise, and descriptions of daily activities in people’s accounts. The research will identify new ways for helping households with children in their journey towards a healthier weight for the future. This in turn will inform local childhood obesity strategies in East London.

Summary

Background Informal carers find their role in medication management is challenging. This can affect adherence and may negatively impact relationships between carer, cared-for and clinicians. Medicines are prescribed (and sometimes stopped) within clinical consultations. Carers’ experiences of these consultations, and the extent to which their priorities are considered is an important aspect of managing caregiver burden.  

The COVID-19 pandemic has dramatically changed consulting practices with more consultations conducted remotely. There is concern that patients have difficulty accessing face-to-face consultations to discuss ‘non urgent’ chronic disease management. It is unclear whether, how, and to what extent these changes have impacted carers’ partnerships with their healthcare providers.  

Objectives 

1. To explore carers’ experience of consultations where medications are prescribed and stopped. 
2. To consider how carers’ relationships with healthcare providers may have changed with the shift to remote consulting during the COVID-19 pandemic. 
3. To engage carers in a process of co-design to inform processes of medication management that better meet the needs of patients with complex health conditions. 

Methods 

This qualitative study will begin with in-depth narrative interviews with 12 carers recruited from carers support groups. Analysis of this data will inform the development of two ‘trigger’ films of ‘triadic’ doctor-patient-carer consultations that involve prescribing. These films will be used to stimulate a process of co-production, in which carers recount real-life stories of experience in the process of creating fictive stories about the carers’ journey through this process to improve service design. 

Analysis will be informed by the Burden of Treatment theory. This model describes a framework through which medical, social and emotional factors, combine to form the carer’s workload of demands. If the burden exceeds the carer’s capacity to cope, then the result may be poor carer engagement, non-adherence and poor mental and physical wellbeing for both carer and cared-for.   Discourse analysis and narrative techniques will be used to analyse the data.   

Summary

Many people presenting to primary care with memory concerns are given a diagnosis of mild
cognitive impairment (MCI). Only around 10-15% of these people develop dementia each year. Up to
480,000 people in the UK develop MCI annually. There is currently no clinical strategy that GPs or
secondary care physicians can use to identify MCI patients at high risk of progressing to dementia.
Patients seen in primary care with memory concerns are usually referred to secondary care,
however following a diagnosis of MCI they are usually discharged back into primary care without follow up.

Methodological approach 

 A key theme is that knowledge gaps about MCI lead to patients feeling let down by primary care. They stated that the “GP should comprehend the concerns of the patient” and “make sure the GP takes us seriously and sends for future tests”. The ABATED study (chief investigator primary supervisor Dr Marshall) began in June 2022, with 2-year follow up due to be completed in early 2025. Rifah aims to embed and lead an observational longitudinal cohort study within this imaging-focused project. She will gain skills in clinical epidemiology, statistics and predictive modelling, as well as building on her previous experience in neuroscience, clinical recruitment and PPIE.

Background: The number of people who are living with and beyond cancer is increasing in the UK and worldwide. Cancer recurrence causes 67% of cancer deaths (Dillekås et al, 2019) and preventing cancer recurrence is an important research priority for people living with and beyond cancer. Existing research on cancer recurrence predominantly focuses on two areas: (i) tumour characteristics and treatment regimes, (ii) lifestyle/behavioural factors limited to diet and physical exercise. It is unclear if wider demographic factors contribute to risk of cancer recurrence. Socio-economic status and ethnicity could be risk factors for cancer recurrence. Techniques of early identification in at risk groups could help design approaches to detect recurrence early for all people living with and beyond cancer. These factors overarch traditional ‘lifestyle’ factors, such as diet and exercise, that are associated with lower risk of cancer recurrence.

Aim: To identify if people from lower socio-economic backgrounds or from ethnic minorities are at increased risk of cancer recurrence compared to those from higher socio-economic backgrounds and the white population, respectively. 

Methods: I propose two pieces of work: (a) a systematic review on the socio-economic and racial inequalities in recurrence across all cancer types; (b) an exploration of the potential of local and national datasets to examine socio-economic and racial inequalities in cancer recurrence, accompanied by training in quantitative data analysis.

Potential impact: This work will provide a basis for a mixed methods doctoral research application in cancer recurrence and health inequalities. Such an application will lead to future research identifying who is at risk of cancer recurrence and, potentially, developing targeted interventions to detect, treat and prevent recurrence earlier. This could improve outcomes for people in at-risk marginalised groups.

Empirical determination of targeted treatment of hypertension mining longitudinal primary-care data for treatment inequity identification & treatment optimisation

Summary

Hypertension is estimated to affect approximately 1 in 4 adults in the UK and poorly control hypertension is a major (but manageable) factor in cardiovascular events such as strokes and heart attacks.

Stuart and colleagues have already completed work on a cohort of almost 220,000 adult patients with hypertension in North East London (NEL) followed from January 2019 to October 2022 and identified higher risk groups prior to and through the pandemic.  This work identified poorer control of hypertension in groups such as younger patients, patients of Black/Black British ethnicity, and patients from more affluent areas.

Seedcorn Bridging funding will fund time to:

1. Complete a “proof of concept” analysis using existing data collected from the NEL cohort of patient with hypertension including algorithms for the generation of the longitudinal trajectories dataset and the identification of the most appropriate machine learning (ML) methodologies for their analysis.
2. Develop a network of collaborators including academics and clinicians working in the fields of Bioinformatics, diabetes, biostatistics and health data science. 
3. Apply for fellowships and project grants for future funding.
4. Attend appropriate CPD events such as the UKRI-MRC’s RADIANCE (Rigorous Training In Longitudinal Data Science) free online course.

Background to study 

Assistive technology (AT) comprising home modifications, digital technology or innovative digital infrastructure solutions is being given priority by the UK government as a cost-effective way of supporting independence, health and wellbeing for people living with disability or long-term conditions. NHS England has recently recognised chronic obstructive pulmonary disease (COPD) as one of five priority long term conditions to reduce health inequalities. Around 1.3 million people have COPD in the UK costing the NHS £1.9 billion each year and the prevalence is rising. The condition is physically and psychologically disabling and commonly associated with multimorbidity. COPD is an important example where there is great potential for benefit from AT. People with COPD have highlighted the need for AT to support independent living at home, however the evidence to support implementation of AT is lacking. 

This mixed methods study aims to synthesise the evidence on the effectiveness and cost-effectiveness of AT to improve the wellbeing, quality of life and independence of people with COPD, and to understand the experience of AT service provision, uptake and use to support long term independent living in people with COPD. 

Internship experience

'I was a little apprehensive going into this internship with no prior experience of conducting systematic reviews or primary care research, but Dr Ratna was really supportive in guiding me and providing me with useful resources while also giving me the independence to carry out tasks on my own. During my internship, I was exposed to different stages of the systematic review process; and was especially involved in screening studies and drafting the inclusion/exclusion criteria and search strategy. In addition, I was given the opportunity to carry out a pilot interview as part of the qualitative study, which allowed me to put into practice relevant skills in understanding a patient's experience of their health conditions. Overall, I have learnt a lot and am really thankful to have been given this opportunity to work with the research team.'

Do primary care quality improvement frameworks consider equity? 

Introduction  

Quality Improvement (QI) is a cornerstone of the NHS’ drive to continually improve care. However, it does not often consider inequalities and the distribution of benefits across disadvantaged groups. Numerous QI frameworks are used by the NHS. We aimed to explore the extent to which these frameworks consider health equity.    

Methods  

We conducted a search of MEDLINE, EMBASE and key websites to compile a list of the quality improvement frameworks used in primary care. This list was then refined by a consultation with an expert panel using an online survey. Guidance documents for each of the QI frameworks were identified from national NHS websites or QI organisations (e.g. Health Foundation). We undertook a document analysis of the guidance using NVIVO.    

Results    

We identified 18 guidance documents. We found the following themes: 1) There was a limited discussion of equity or targeted QI for disadvantaged groups in the documents. 2) There were indirect considerations of inequalities via social determinants of health or patient involvement. 3) There was a lack of clarity between equity and inequality.    

Discussion   

There is limited consideration of equity in QI frameworks used in primary care. Where equity is discussed, it is implicit and open to interpretation. The most commonly used frameworks are those derived from industry e.g. Plan, Do, Study, Act, where there is the least consideration of equity. This research demonstrates a need for frameworks to be revised with an explicit equity focus to ensure the distribution of benefits from QI is equitable.

Personal experience of internship

I am a third-year medical student at the University of Cambridge, and I decided to apply for the internship for the opportunity to learn more about how research can form part of a career in primary care. During my internship, I started research into the extent to which health inequalities are considered in quality improvement projects used in primary care. I learned how to search for literature, code using NVIVO, peer review, and write a research article. I have received brilliant support by Dr John Ford and Lucy Johnson at QMUL, who have inspired me for the future. I would definitely recommend applying for a SPCR internship to anyone who wants to gain an insight into research in primary care, and have the chance to work towards a publication.