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Social media use and young adult mental health: NIHR Three Schools’ workshop

By Abigail Woodward, on 1 July 2022

This post is written by Dr Patricia Schartau (GP at Hampstead Group Practice; Academic Clinical Lecturer in Primary Care at the UCL Department of Primary Care and Population Health) and Dr Ruth Plackett (NIHR Three schools’ Mental Health Programme Fellow at the UCL Department of Primary Care and Population Health)

On 16th May 2022 we conducted a workshop about social media use and young adult mental health funded by the NIHR Three Schools Programme. We focused on young adults aged 16-25 years.

The online workshop was hosted by the Research Department of Primary Care and Population Health (PCPH) at UCL. A total of 27 people attended, including representatives from charities (e.g., McPin, Mental Health Foundation), young adults with lived experiences, parents and educators, healthcare professionals, students, and researchers with backgrounds in public health, social care and primary care research.

What were the aims of the workshop?

We aimed to:
a) learn about research on social media use and young people’s mental health;
b) share ideas and discuss future research questions;
c) build our networks.

Why was this topic chosen?

Mental health in young adults is as a real concern. Young people’s mental health problems are increasing over time and GPs are looking after and/or referring more young people to mental health services, mostly with long waiting times.
Many newspaper articles have reported on how social media use is related to mental health problems. The articles call for the need to address the emerging ‘social media’ epidemic, as social media use is becoming ubiquitous among young people and has increased during the Covid-19 pandemic. As a GP (Patricia), I have seen a recent increase of young adults with mental health problems, with many reporting social media as a cause or a contributing factor.

What is the evidence base?

There are benefits to using social media, as it can improve social support, strengthen bonds, and reduce loneliness. On the other hand, social media use is related to feelings of depression and anxiety in young adults, but there is limited evidence to suggest social media itself causes these issues.
We had the privilege to welcome Dr Lizzy Winstone and Dr Lucy Biddle from the University of Bristol to present at the workshop. Lizzy discussed her research that found that the effects of social media on mental health differ depending on how we use it and how long we use it for. Lucy discussed ideas and challenges around developing guidelines to assist mental health practitioners to talk to young people about online activities. Some guidelines on social media use exist but they are general, hard to apply, and not tailored towards different healthcare professions, such as GPs.

What did we do in the workshop?

In groups we discussed two key areas of research:
1. How can we improve social media campaigns to help young adults access mental health services/information? (Padlet questions 1 and 2)
2. How can we improve primary care experiences for young adults who seek help for mental health issues that might be related to social media use? (Padlet questions 3 and 4)

Padlet questions:

Key messages from discussion of the first set of questions:

Reach

  • Social media could reach people who are unsure about seeking help.
  • Not all young adults have access to social media: we need to be careful not to widen health inequalities.

Support

  • Signposting towards resources and advice on where to seek help.
  • Empowering young adults by providing information.

Content of campaigns

  • Delivered by key influencers or young adults with lived experience.
  • Balance between normalising and glamourising mental health problems.

Key messages from discussion of the second set of questions:

What should primary care clinicians ask young adults and how?

  • Be open minded and non-judgmental: Ask about whether a young adult is using social media, what makes them feel good or bad about using it.
  • Questions about social media use need to be incorporated dynamically into the consultation rather than delivering a ‘screening’ question.

Who should ask it?

  • Anyone in the community healthcare team who has contact with young adults with mental health problems
  • Time constraints: Follow-up consultations may be required with the GP and/or other professionals, such as social prescribers.
  • Schools and community groups could provide more support.

Further support for young adults

  • What are the best resources that GPs can signpost to?
  • Provide advice about managing privacy settings.

Training for clinicians

  • Practical and tailored guidance is needed on how to discuss social media use with young adults.
  • Training in social media literacy is needed.


What’s next?

As a result of the workshop, we have connected with researchers, charities, young adults with lived experience and clinicians across the country. We are applying for further funding to explore what guidance and training we can develop and provide to primary care clinicians for them to support young adults with mental health concerns.

The workshop was a rewarding experience and it helped us to understand these issues from different perspectives. Our attendees provided positive feedback, and many requested to stay involved with the research.

“Eye opening workshop! very tricky issues, great to talk about them thank you”

Ruth will lead on this research going forward as part of her NIHR Three Schools’ Mental Health Fellowship and Ruth and Patricia plan to apply for further funds.

For further information please contact Ruth ruth.plackett.15@ucl.ac.uk or Patricia patricia.schartau@ucl.ac.uk. Or follow us on Twitter: @ruthplackett or @DrPatriciaES.

International co-design study focuses on supporting people after a diagnosis of dementia when people can feel overwhelmed

By Megan Armstrong, on 10 June 2022

This post is written by Greta Rait (Clinical Professor of Primary Care and Health Services Research) and Jane Wilcock (Senior Research Fellow) who have played a lead role in an international collaboration aimed at supporting people after a diagnosis of dementia.

By 2050, the World Health Organisation has estimated that 139 million people world-wide will have dementia. There is currently no treatment for the disease and no cure. We know that people living with dementia and those who care for them often have negative experiences of the dementia diagnostic process.

People tell us that they receive insufficient information after a dementia diagnosis, there is a pervasive view that little can be done and that you are given are a diagnosis and told to go to home and get on with it. This has been exacerbated by pandemic restrictions on services and community-based supports.

Most dementia post-diagnostic support does not consider quality of life and is reactive and not proactive, it is also very patchy in terms of provision at an international and national level. Health care professionals can find communication of a dementia diagnosis difficult. They can find it tricky to get supports and care packages in place. They report variations in service availability and a lack of integration of services.

What was our approach?

We are part of an international consortium led by the University of New South Wales with colleagues in Canada, The Netherlands and Poland partnering with people living with dementia, those who care for them and healthcare professionals to improve dementia support.

The UK team (Greta Rait, Jane Wilcock at UCL and Louise Robinson and Marie Poole at Newcastle University) undertook a review and thematic analysis of global National dementia strategies and guidelines and public health campaigns.  It became clear from this review and workshop discussions with our partners that there were multiple areas requiring attention but for this ambitious study we wanted to focus on doing one thing and one thing well. From this it became clear that we would focus on the need for support during the first 12 months post diagnosis.

Our work highlighted:

  • the uncertainty following a diagnosis about what the future holds and who can help
  • how accessing good support at the right time is key to living positively with dementia
  • concerns among healthcare professionals that they don’t always know enough about dementia, or the organisations and services that can offer practical or emotional support
  • ongoing issues during the Covid-19 pandemic with finding and providing good dementia support

Through an iterative and collaborative process of co-design workshops and user testing refinement we have developed Forward with Dementia  a website and personalised toolkit to help people with dementia, their families, and professionals providing support, to access the right information and support at the right time. For free and on any device. Each partner country has translated and culturally adapted the intervention to their own regions. The site is available in Polish, Dutch and French Canadian.

How Forward with Dementia can help?

The online guide brings together practical advice, personal experiences from people with dementia and those who care for them, and topical news stories.  You can find information on key issues: Hearing (and giving) a diagnosis; Coming to terms with dementia; Managing symptoms and changes; Supporting health and wellbeing; and Making plans and decisions.  The site is designed to simplify navigation, ensure accessibility, and written in a friendly non-scientific language either for a person with dementia, family carer or healthcare professional.

A personalised toolkit lets people choose and save information that is relevant to them and create actions to take positive steps to living life with dementia,  without having to remember a password and log-in name.  The toolkit can be shared with others such as family, friends, professionals though sharing a unique URL.

Bill has been part of the UK co-design group.  He cares for his wife Jo and is a passionate advocate of improving understanding of dementia and living positively. As well as being involved in the development of the guide, Bill continues to use it for support as their circumstances change:

“My wife Jo was given her diagnosis during lockdown and I, like many others had no experience of what to do next. Who do I turn to? What help is available? Where can I find out everything I need to know? The realisation that I didn’t know what I didn’t know was overwhelming. now. If only Forward with Dementia had been around then my life would have been so much easier. As the research and website developed so, sadly, did Jo’s journey. I was able to contribute from real time life experience and also gain insights from others into both my journey and Jo’s, all at the right time for me. I have and will continue to use this resource as a valuable part of my dementia toolkit.”

 Join us to find out more

We are trying to reach out to as many people as possible who would benefit from accessing Forward with Dementia.

  • You can explore the site and create a toolkit
  • Share the guide with family and friends
  • Consider using this with patients or clients to start difficult conversations
  • Help us with our evaluation and to improve the site by completing the short website survey via the homepage or reach out and speak to us. We would love to hear your feedback.
  • You can request our leaflets and posters to help raise awareness

Follow us on social media for regular updates and information about promotional events.

Facebook: @ForwardDementiaGB

Twitter: @ForwardDementia

Instagram: forwardwithdementia_gb

YouTube: Forward with dementia International

What next? We have been awarded a research grant from the NIHR Three Schools’ Dementia Research Programme to produce and deliver a tailored supportive guide to social care after a diagnosis of dementia.

Jane will lead on this research across the NIHR Schools of Primary Care, Public Health and Social Care Research partnering with colleagues at Newcastle University and King’s College NIHR Policy Research Unit in Health and Social Care Workforce.

For further information about Forward with Dementia, or to request resources such as leaflets or posters contact Jane Wilcock at j.wilcock@ucl.ac.uk

Forward with Dementia in the UK are funded by the Alzheimer’s Society.

 

“Diverse Voices” A UCL Community Engagement Project on diversity in health research participation

By Megan Armstrong, on 4 March 2022

This blog is written by Shoba Poduval (Clinical lecturer) & Chandrika Kaviraj (Expert by Experience).

Shoba Poduval (project lead):

We have known for some time that people from ethnic minority backgrounds suffer from poorer health outcomes, but are less likely to be included in health and social care research studies (1). The Covid-19 pandemic has exacerbated inequalities and multiple studies have shown that people from ethnic minority backgrounds have an increased risk of infection, Intensive Therapy Unit (ITU) admission, and death (2-4).

These data plus the fact that two thirds of my NHS colleagues who lost their lives to Covid-19 were from ethnic minority backgrounds (5) has had a profound impact on me, which has resonated every time I have completed a Covid-19 workplace risk assessment that has scored me at higher risk than my white counterparts due to my ethnicity. We often talk about research impact, but rarely does it cause us to reflect not only on our own personal identities, but also our professional commitment to diversity and inclusion. My idea for this project was borne out of a need to explore this and my sense of connection to the communities affected by these issues. “You have to use your privilege and your strength to make a difference, otherwise it’s worth nothing.” (Asma Khan, leading female chef, entrepreneur and activist).

I knew that in order to be accessible and generate rich discussions, the project required imagination and innovation, beyond the methods traditionally used in academia. I therefore worked with Kois Miah, a photographer based in east London specialising primarily on projects that combine photography with community participation for social change. We successfully gained UCL Community Engagement seed funding (https://www.ucl.ac.uk/ucl-east/news/2021/jul/community-engagement-seed-fund-2021-grants-announced) to collaborate with members of east London’s diverse communities in online workshops sharing our experiences of illness, healthcare, and Covid-19. We used visual storytelling through images created with smartphone cameras.

 

The photos generated by participants formed a catalyst for discussion in co-design workshops to address barriers to engagement with research. Professional portraits taken by Kois supplemented the participant-generated works.

 

Chandrika Kaviraj (project participant):

This project was unique in that it combined listening and photography to discover insights. It was by far the best health research and health engagement project I have taken part in. And yes, I’ve been on a few.

The individuals gained photography skills and tapped into potential we didn’t know we possessed. We expressed ourselves creatively and through discussions as a group, when we hadn’t been listened to before. People often turn their noses up at a therapeutic approach but this did so in a subtle yet powerful way. We felt confident sharing our life experiences and our passions in 2021.  It was slap bang in the middle of the Covid-19 pandemic. We were made to feel comfortable because Shoba and Kois shared of themselves first.

As a carer, although I am vocal and advocate loudly for my elderly parents, I hide behind that aspect of my life.  There are some carers who feel invisible but we also feel vulnerable.  Added to that, being a woman of colour – many assumptions are made. Dealing with this, as well as assumptions made about the people I care for, with immigrant backgrounds has been challenging and “Diverse Voices” gave me the space to express it verbally and creatively.

Chandrika and Shoba (along with the rest of the “Diverse Voices” team) have the following recommendations for those of you who wish to engage participants from different backgrounds:

  1. Seek out unique and creative ways to encourage collaboration- drawing and photography are examples of accessible ways of doing this which don’t require language skills or general/IT literacy;
  2. How will participants benefit from being involved? The funding criteria for this project was two-way exchange of knowledge and skills. This can be applied to research approaches also. Acknowledge your participants’ investment in your project’s aims and objectives. This doesn’t just mean financial compensation through vouchers, but also offers of training and opportunities to engage at every stage and with other projects of interest.
  3. Respect participants’ lived experience and the value and insight this brings to your work;
  4. Consider the impact of your work not just in terms of scientific publications and presentations but also engaging with communities to discuss how change can be brought about “on the ground”.

Final words from Chandrika:

“This outstanding project allowed each participant to explore our experiences and feelings, not just about Covid-19 but the health systems we encounter on a daily basis. With “Diverse Voices”, I feel I have been encouraged and allowed to express, been inspired to be creative and have hopefully, found a way to make changes in health and social care research. I have made six potential collaborations in future projects, but also wonderful friends, I hope, for life.”

This project is dedicated to those fighting the systemic inequalities that lead to the alienation of many people, not just due to their race, but also gender, disability, and wealth.

““Be the change you want to see in the world” is one my favourite quotes and something I’m trying to live by. If we can look at music and culture in the same way, people won’t be told “you can’t do that”, they will chase bigger dreams and be free to express themselves how they want. The arts can be the most powerful vehicle for change and should be respected as such.” (Jamal Edwards, pioneer music entrepreneur and philanthropist).

 

With many thanks to:

Kois Miah & the “Diverse Voices” team

Briony Fleming, Sam Wilkinson, Jordan Abankwah and the UCL Public Engagement/UCL East teams

Jeshma Mehta, Bijal Parmar & the UCL research administrators

Niccola Hutchinson & the Co-Production Collective

The Bloomsbury Theatre

Karen Hubbard, Rebecca Chester & The Brady Art Gallery

Raheel Nabi, Phil Mason & UCL Media

Further information:

The images (as well as a recording of the private view with panel discussions) will be shared online (details TBC) and represent a legacy by and for east London’s ethnic minority communities.

REFERENCES

  1. Treweek S, Forouhi NG, Narayan KMV, Khunti K. COVID-19 and ethnicity: who will research results apply to? The Lancet. 2020;395(10242):1955-7.https://doi.org/10.1016/S0140-6736(20)31380-5
  2. Sze S, Pan D, Nevill CR, Gray LJ, Martin CA, Nazareth J, et al. Ethnicity and clinical outcomes in COVID-19: A systematic review and meta-analysis. EClinicalMedicine. 2020;29-30:100630.https://doi.org/10.1016/j.eclinm.2020.100630
  3. Williamson EJ, Walker AJ, Bhaskaran K, Bacon S, Bates C, Morton CE, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature. 2020;584(7821):430-6.10.1038/s41586-020-2521-4
  4. Public Health England. Beyond the data: Understanding the impact of COVID-19 on BAME groups. 2020.
  5. Rimmer A. Covid-19: Two thirds of healthcare workers who have died were from ethnic minorities. BMJ. 2020;369:m1621.10.1136/bmj.m1621

 

Researcher Tips for Conducting Remote Research in Older Populations

By Megan Armstrong, on 16 December 2021

Tasmin Rookes

This blog is written by Tasmin Rookes, Research Assistant for the PD-Care programme. Tasmin also runs a Research Assistant group – if you’d like more information about this group please email Tasmin here: t.rookes@ucl.ac.uk

Since the COVID-19 pandemic research activity, such as identifying, consenting, and assessing participants has been conducted online and remotely. With many clinical populations being older adults, without consistent levels of technology knowledge, this has introduced some challenges. Reflecting on the PD-Care feasibility study, I share our experience and learnings of conducting remote research with people with Parkinson’s.

Identifying potential participants

On the morning of clinics, send reminder emails to the clinical teams to remind them to approach potentially eligible participants with a copy of the participant information sheet.

When following up with a phone call to discuss further, have a loose script with the key information points participants need to know, including the next steps involved to get them enrolled.

Where relevant, recruit or include participants carers or family members to assist with explaining the study, setting up technology or assisting with future research activity, particularly if the person has mild cognitive impairment.

Consenting participants

If obtaining consent online, follow-up with phone calls or emails to reminder people to complete the consent form and keep it at the forefront of their mind. Older people often aren’t used to managing an email inbox, so sometimes resending the link to the consent form can help.

If obtaining written consent, via the post, follow-up after one week of posting to determine if it has arrived and if they have any questions. Be prepared for postal delays and always offer to resend out if participants have waited a long time.

If obtaining verbal consent, ensure you have posted or emailed a copy of the consent form, so participants can follow along. Ensure they are engaged by asking them to state their name and date for the recording. Read through each statement clearly, asking participants to confirm they consent to each statement. Be prepared for questions and consider that your answers are being audio recorded. Save audio recording in a secure location and complete a consent form stating verbal consent was obtained, to send a copy to participants, GPs, and upload to patient notes.

Completing assessments

Be aware of potential risk and safeguarding. If a participant discloses something concerning, follow the guidance in the study protocol and ask for advice from senior colleagues. Keep records of all decision making and collect the participants GP and clinical team contact details for future use.

Completing assessments can be lengthy and is more tiring when completed on a screen. Be transparent about how long they will take and offer comfort breaks or break into shorter sessions where appropriate. Also, providing a written copy of the assessments to participants can help them to follow along with the questions as they are being asked. Allow plenty of time for the assessment and give participants time to think and respond.

Consider whether the assessments you want to do can be completed remotely. If not, consider self-report measures or look for measures that have been adapted to be delivered remotely.

It is inevitable that some assessment appointments will be missed by participants. Send reminder letters, emails, or phone calls to prevent this from happening and provide them with your contact details, so they can inform you if they can no longer attend. Try to reschedule as soon as possible, particularly for follow-up assessments where timelines can be tight.

Be prepared for technical issues and understand how to talk someone through joining calls using the chosen software. Get an understanding of how confident they are, so you can support them and factor this into the time allocated.

Key messages

Most people are happy to conduct research remotely and on the whole older populations are comfortable using technology if they are supported.

Have a clear process in place and test with the team or PPI members before starting to recruit, to iron out any potential issues.

Allow plenty of time at every step, being patient, friendly and calm. You may be the only person they speak to that day, or they may be anxious about using the technology or completing the assessments, so this may help put them at ease.

Consider all potential impairments participants may have, including vision, hearing and speech, and have strategies in place to overcome these and be inclusive. These include, offering study documents in large print, providing contact through email or letter, and having a carer or family member present to support.

Be organised, keep logs of what has been done and what is still to do, so recruitment and follow-up schedules are adhered to.

As we develop more digital interventions and conduct research activity remotely, adapting our approach and using the tips outlined above, successful research conducted remotely with older populations is not only feasible, but can be successful and beneficial.

Health and social care access for people experiencing homelessness and lessons for primary care

By Megan Armstrong, on 29 October 2021

This blog is written by Caroline Shulman and Megan Armstrong. Caroline has worked as a GP for people experiencing homelessness in primary care and as a clinical lead in a hospital homeless team. Caroline is principal investigator (PI) on a range of projects on palliative care, frailty and homelessness. Megan was the senior research fellow on this project and currently is the Programme Manager of PD-Care and the PI of exploring self-management in those experiencing low socioeconomic deprivation. 

Though everyone’s circumstances are different, to support people experiencing homelessness, it helps to understand some of the underlying causes of homelessness. Systemic factors such as austerity, increase in poverty and inequality, regressive changes to welfare systems, increased job insecurity with more zero hours contracts, lack of affordable housing and a hostile environment for migrants have contributed to significant increases over the last decade. However, in addition, there are individual vulnerabilities that increase the likelihood of becoming homeless. It is estimated 90% of people who are homeless have experienced adverse childhood experiences with 54% experiencing four or more (1). Adverse childhood experiences include abuse (emotional, physical, sexual or neglect) and household dysfunction such as living with domestic violence, or with a family member who has an addiction, is suicidal, mentally ill or in prison. Lack of having needs met and being soothed as a child impacts on cognitive, emotional, and social development and unresolved trauma is associated with an overdevelopment of the emotional and reactive parts of the brain (2).

People experiencing homelessness have some of the worst health outcomes of any group in society with the average age of death being in their early 50s  (see here). They have a much higher rate of most long terms conditions, including heart disease, respiratory disease than even populations in the most deprived sectors of society. Conditions usually found in older populations, such as cognitive impairment, incontinence, poor mobility, and frailty are highly prevalent at a young age in this population. Many people, with a history of sleeping on the streets in London, end up on homeless hostels. Homeless hostels are staffed by support workers who have no training in health or social care. In one hostel (for adults aged 35+), where residents average age was 55, frailty scores were equivalent to a population of people in their late 80s. All had multimorbidity with the average number of conditions per person being seven. Older age conditions such as cognitive impairment, falls and poor mobility were highly prevalent, though only 9% had any form of social services package of care (3).

One reason for the young age of death of people experiencing homelessness is the barriers they often face in accessing health and social care. Our study aimed to explore these barriers and potential facilitators from the perspectives of hostel residents and staff (4). We interviewed 18 homeless hostel managers/support staff and 15 people experiencing homelessness from six homeless hostels in London and Kent.

We found there were service barriers to health and social care access due to:

Stigma of both the residents and the hostel staff (often reporting not being believed):

“We have got one of the local GPs around here, they will not accept our residents unless a keyworker is with them, and they have to attend all appointments with them and register with them. They won’t accept them on their own.” Support worker

Lack of communication and information sharing from services with the hostel:

“I was that upset and annoyed that she’s [social worker] not speaking to anyone else that I’m working with [in the hostel]. I said, “It’s not keeping you up to date.” I speak to you once every three weeks, you don’t know what’s happening. So I could be going through a really difficult time and you’re not aware of it….” Resident

A lack of trust from the residents and a struggle to build relationships beyond the hostel staff:

“I’m still finding I’m having to learn to trust people. I don’t always trust people now, and my confidence is not brilliant. Once I know someone [this is different]…., but I’m not very good coming forward at the beginning.” Resident

Incorrect assumptions around capacity and the role of the hostel:

“I think because a lot of people presume because it’s [the hostel] a 24-hour manned project, they’ve got staff. They [external services] don’t really realise that our job isn’t to be carers…It’s not always practical to see everybody every single day. What people see from the outside is 24-hour staff” Support worker

The impact of lack of health and social care support led to staff going beyond their job role, continuous support needed by the residents, and burnout:

“We also have to go and collect people’s medications. We don’t have to but we’re doing that as well and liaising with GPs to put [medication] in dosette boxes and things like that.” Hostel staff

Overall, the hostel staff and residents had a great, trusting relationship. However, due to the lack of external service support, this can become a huge responsibility for the hostel staff. The quote below highlights the trust in the hostel staff.

“I think she [hostel staff member] cares about me. I’ve never actually asked her, does she care? The staff here are alright, I like them. I like the staff here. I ain’t got a bad word to say about them.”

An example of the causes of burnout for hostel staff include the trauma when a resident dies:

“When he was standing along the walls and he was saying, “I’m feeling pain,” and he just slid into the floor. It was during the night, early morning so there were only two staff. Staff were running up and down. It was quite a traumatic experience.”

See our recent paper and blog on palliative care for people experiencing homelessness.

What does this mean for primary care?

  • Everyone needs to be able to register with a GP. Groundswell have developed ‘My Right to Healthcare’ cards that can be posted for free.
  • Training is available for reception staff including a short 6 minute video: resources here
  • Primary Care Networks should consider having an inequalities lead to explore local solutions. They could also undertake a self-assessment to support improved engagement with inclusion health groups (see here).
  • Services should be person-centred, and trauma informed so that people feel safe, welcome, listened to and understood. Here is a video on trauma informed communication skills and an overview of training available here.
  • Services need to recognise the importance of developing trust and trusting relationships, as these are at the heart of healing and recovery. Ideally with the continuity of care with the same provider.
  • Services should  proactively support people with literacy, language, and cognition difficulties.
  • Primary care services should consider how they can take care to people with the highest need to enable trust to be developed. For example, enhanced services undertaking in-reach into hostels can be highly successful in increasing engagement. Reaching out to frontline staff in homeless services, who often feel stigmatised, can be a first step in acknowledging the support they are providing and explore how they can be better supported.

It is our duty to find and care for those in our community who are excluded and marginalised and advocate for their needs. We need to embed inclusive care and assertive advocacy as core to our work.

References

  1. Liu, M., Luong, L., Lachaud, J., Edalati, H., Reeves, A., & Hwang, S. W. (2021). Adverse childhood experiences and related outcomes among adults experiencing homelessness: a systematic review and meta-analysis. The Lancet Public Health.
  2. Bennet, M.S. (2017), ‘Connecting Paradigms: A Trauma-Informed & Neurobiological Framework for Motivational Interviewing Implementation’, Bennett Innovation Group, Denver.
  3. Rogans-Watson, R., Shulman, C., Lewer, D., Armstrong, M., & Hudson, B. (2020). Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel. Housing, Care and Support.
  4. Armstrong, M., Shulman, C., Hudson, B., Stone, P., & Hewett, N. (2021). Barriers and facilitators to accessing health and social care services for people living in homeless hostels: a qualitative study of the experiences of hostel staff and residents in UK hostels. BMJ open11(10), e053185.

Bridging the gap: diversifying education in primary healthcare

By Megan Armstrong, on 20 October 2021

This blog post is written by Sara Thompson (GP), Morounkeji Ogunrinde (GP), Zenni Emeka-Enechi (Medical student) and Natalie Amavih-Mensah (Medical student).

Racism in healthcare concerns everyone

Racism and racial inequality are deeply rooted in societies and institutions worldwide. Britain is no exception.

For many, 2020 was a clarion call to address various ills plaguing our society. Although the time in isolation and lockdown brought significant emotional stress, it also forced us to confront long-standing systemic concerns based on race and our misconceptions of one another. In 2020, the BMJ published its first special report on racism in healthcare since its inauguration in the 1800s.1 In the UK, racial disparities occur in fields as varied as genetic counselling, artificial intelligence, and medical school admissions.2 These inequalities expose ethnic minorities to a higher risk of chronic conditions.3

Racism, not race, perpetuates health disparities

The NHS is regarded as a fair and equitable tool for distributing health care services, and its accomplishments have been praised worldwide. Yet, despite this, one in five black women in the UK die in and around childbirth.4 Black men are ten times more likely to face discrimination when presenting with a mental health illness.5

Training on microaggressions and implicit bias have minimal effect on outcomes and cannot facilitate change without a corresponding shift in the system.6 Attempts to haphazardly reduce these disparities without addressing the root causes have been problematic e.g. the #NotsoNICE campaign.7 NICE proposed draft guidelines to reduce maternal mortality among Black, Asian and minority ethnic people by encouraging inducing labour.8 The guideline did not address the principal factors of racism and neglect, sparking outcry and disillusionment. Race-based medicine provides crude shortcuts to clinical judgement that is harmful to patients from BAME communities.9

World-renowned science journalist Angela Saini refers to race as a social construct that we should challenge. She reports that we “tailor” clinical decisions about patient treatment considering race without any substantial scientific basis of delineating what terms like “Caucasian” or “Black” mean10; we have created a subjective ‘science’ that is not scientific at all.

The healthcare and minority ethnic groups divide

Patients of colour are disproportionately vulnerable to misdiagnosis and undertreatment. Consequently, patients from ethnic minorities have poorer outcomes in healthcare and fewer opportunities to access healthy living.3

A lack of diverse, inclusive education precipitates insidious doubt and mistrust recently exemplified by the suspicion and hesitation of the ethnic minorities communities towards the COVID-19 vaccine.11

Health Care Professionals (HCPs) and students come to accept racial biases and aggressions as the norm. Some  professionals from ethnic minority groups are reticent to voice concerns for fear of being undermined or receiving backlash. HCPs from ethnic minority groups are more likely to be blamed for errors and are victim to disproportionately more disciplinary action.12

Students from ethnic minority groups may not report racial aggressions because they believe their medical school will not take them seriously.13 There is a performance gap in UK medical schools. Black students are more likely to underperform compared to their white counterparts.14

People from ethnic minority communities are less likely to participate in research studies and initiatives to improve health outcomes. Thus, there is less data available, biasing research and policy.15

Natalie’s experiences as an ethnic minority patient

Feeling unheard and misunderstood is debilitating. I struggled with acne since high school. I was only referred to dermatology after three years. I cannot be sure if my race played a part intentionally, or unintentionally; however, significant distress was caused.

Insecurities, caused by acne, stifled my confidence. I believed that the condition defined me. My GP practice consistently dismissed my concerns making me think that the acne was my fault. I felt powerless and alone. Understanding the variations in presentation among different skin tones is not just about treating a single condition; it is also about preventing and remedying the subsequent destructive psychological thinking patterns.

The Diversifying Dermatology in Primary Care Working Group

Colours of the World Skin Tone Crayons range in 2020 so that “all children can colour themselves”. We need to ensure that our medical education shows the same awareness of skin tones and that dermatological conditions can present differently on different skin colours.

We aim to understand the patient experience and to increase the diversity of educational resources available, we want to raise awareness that conditions as common as acne and eczema present differently on different skin tones and educate on how to better diagnose and manage these conditions on darker skin. We won a “Listen and “Learn” grant, with which we held interviews to understand service users’ experience. Mimms Learning has developed an e-learning module addressing several questions on how and when black skin will look significantly different. 16 Our collaboration with Black & Brown Skin aims to facilitate community members to continue to support each other by creating a forum for shared experiences and a growing image library accessible to clinicians worldwide.

We hope that, by increasing the variety of resources available, the quality of education will improve, leading to higher quality care for patients thus enhancing patients’ trust in the health care service created to treat and serve them.

Conclusion

Reform takes time. We need to overturn and redefine ideas about race that have persisted for centuries. There will be uncomfortable conversations and we will have to overcome indifference and resistance to change.

Decolonising the curriculum is not a fad; it is something that we must continue, even when the world is not watching. With dedication, persistence and unity, there is hope for a better future – for all skin tones.

Additional Information

Quiz on Dermatology in Black and Brown Skin

Bimpe and Zainab: Bimpe (UCL medical student) talking to Zainab about atopic dermatitis.mp4

Zenni and Malone:Zenni (UCL medical student) interviewing Malone Mukwende (Founder of blackandbrownskin.co.uk).MOV

Honey and Natalie:Honey (UCL medical student) talking to Natalie about acne vulgaris.mp4

References

  1. https://www.bmj.com/racism-in-medicine
  2. Adebowale, V., Rao M. Racism in medicine: why equality matters to everyone. BMJ [online] 2020;368:m530 . Available from: doi: https://doi.org/10.1136/bmj.m530
  3. McKenna, H., 2019. Professor David Williams on racism, discrimination and the impact they have on health. [podcast] The King’s Fund. Available from: <https://www.kingsfund.org.uk/audio-video/podcast/david-williams-racism-discrimination-health>
  4. https://www.bmj.com/content/372/bmj.n152
  5. https://www.mind.org.uk/news-campaigns/legal-news/legal-newsletter-june-2019/discrimination-in-mental-health-services
  6. Sharda S, Dhara A. It’s Time To Talk: Gender and Race in Medicine. CMAJ Blogs July 2019
  7. Lewin, L. The #NotSoNice Campaign [online]. The OBS: England; 2021 [Accessed 30th August 2021] Available from: https://the-obs.co.uk/your-doula/
  8. National Institute for Health and Care Excellence. ​​NICE recommends offering women induced labour earlier in new draft guidance [online]. NICE: London; 2021 [Accessed 20th August 2021]. Available from:https://www.nice.org.uk/news/article/nice-recommends-inducing-women-in-labour-earlier-in-new-draft-guidance
  9. Chadha, N., Lim, B., Kane, M., et al. Toward the Abolition of Biological Race in Medicine. UC Berkeley [online] 2020; 4-6, 16-19. Available at: <https://escholarship.org/uc/item/4gt3n0dd>
  10. https://www.angelasaini.co.uk/
  11. Lockyer, B, Islam, S,  Rahman, A, et al;  the Bradford Institute for Health Research Covid-19 Scientific Advisory Group.  Understanding COVID-19 misinformation and vaccine hesitancy in context: Findings from a qualitative study involving citizens in Bradford, UK. [online]. Health Expect.  2021; 24: 1158– 1167. Available from: https://doi.org/10.1111/hex.13240
  12. Majid, A. What lies beneath: getting under the skin of GMC referrals BMJ [online] 2020;368:m338 . Available from: doi: https://doi.org/10.1136/bmj.m338
  13. Kmietowicz, Z. Are medical schools turning a blind eye to racism? BMJ [online] 2020;368:m420 . Available from: doi: https://doi.org/10.1136/bmj.m420
  14. Jones, A. C. , Nichols, A. C. , McNicholas, C. M. & Stanford, F. C. Admissions Is Not Enough: The Racial Achievement Gap in Medical Education. Acad Med [online]  2021;96 (2):176-181. Available from: doi:10.1097/ACM.0000000000003837.
  15. Smart, A., Harrison, E. The under-representation of minority ethnic groups in UK medical research. Ethnicity & Health [online] 2017;22(1): 65-82. Available from: doi: 1080/13557858.2016.1182126
  16. https://www.mimslearning.co.uk/learning-paths/skin-of-colour-disorders-of-pigmentation-and-hair-and-scalp-conditions

Working with the AcaMedic students to produce research

By Megan Armstrong, on 8 October 2021

This blog post is written by Melvyn Jones (A Clinical Associate Professor in General Practice), Surinder Singh (a Clinical Senior Lecturer at PCPH), and See Chai Carol Chan and Jack Shi Jie Yuan (both medical students).

This summer a very slowly gestating project came to fruition with the publication in the BMJopen of a study exploring the influences at medical schools on students with respect to GP career choices (see here). Surinder Singh and myself quite a few years ago (2017) thought that an anthropological approach using our students to capture these drivers of student carer choice might be quite a useful addition to the field, on the back of the NHS Wass report “By choice not by chance”.  At the same time the AcaMedics group (a multi institutional collaboration to support students developing research skills) was looking for potential projects. We set our plans and were lucky to be selected by two highly able UCL medical students (Jack Shi Jie Yuan  and See Chai Carol Chan) to work on the project.  Meanwhile across London at Imperial a very similar project was being undertaken.  It took Sophie Park to join the dots and make this a cross institutional project- key to improving the generalisability of our findings.

Getting ethics was tricky though.  Would we need consent to use quotes from someone making pejorative comments about general practice as a career?  Clearly this would never happen, but thankfully the ethics committee agreed that the anonymised observation and reflection occurring away from the clincal setting was acceptable.

Rolling forward via presentations and posters at the UCL Education conference in 2018, the Trainees in the Association for the Study of Medical Education (TASME 2018)  and SAPC Madingley hall conference helped us shape our thinking.  Writing workshops helped refine our argument. However, publication proved much more difficult with a straight rejection and then a very long drawn out peer review, eventually leading to another rejection.   A key motivation for our students was to have something to put in their publication box on their NHS junior doctor Foundation Programme application, but by this stage they had all graduated and moved on.  It took a final push by Ravi Parekh at Imperial assisted by myself and Surinder to have a good fresh look at the manuscript, the data and the peer reviews and to decide it was with another go.  So in the summer 2021 it finally appeared.

What are the messages from the study?   Some of the findings were there before- students feeling a GP career was the default, the fall back position. For students used to competing for everything this seems like defeat. The interesting observation was the student’s perception of the internalised process of being a primary care physician. The fact that the GP sits and the patient comes to them was perceived as being too passive to students used to the swarm of the ward round buzzing around hospitals. The internal process of thinking about clinical decisions such as how to balance treating a patient’s heart failure without worsening their kidney function or making them fall over as their blood pressure drops, was invisible to the students. It was only when the students were sitting in the consulting hot seat did they begin to see the considerable intellectual challenge to many primary care consultations.   But were they exposed to “bad mouthing” of general practice?  Yes to some extent, but interestingly they were also exposed to hospital clinicians who talked up the role of general practice and the challenges to doing it well.

It was always challenging for students to undertake their own research project (see here). However it is a great shame that students appear to be completely marginalised since Covid when it comes to undertaking research projects. Recent new guidance from the NHS Research Authority prevents undergraduates from conducting research.  Thus, perhaps the ultimate conclusion for our study – which has come to light after publication – is that we’re faced with far fewer opportunities to prepare and encourage the next generation of would-be researchers.

Working with students on research projects is a however great experience but the time frame for ethics and sluggish peer review processes can be a real issue when they have fixed deadlines like revising for finals, moving on as junior doctors and the almost complete lack of headspace to think about research when they are enveloped in working as an NHS foundation doctor.  Find a project however, with a realistic outcome and timeframe and you will find a rich seam of motivated talented individuals who are keen to contribute.

Opinion piece: My experiences so far of hybrid working at the PCPH department

By Megan Armstrong, on 1 October 2021

Dr Sarah Griffiths, Senior Research Fellow and Study Manager of
PriDem: Best practice in primary care led dementia support

In this blog, Sarah Griffiths discusses her experiences of beginning the hybrid working at the PCPH department.

Emily Spencer (Research assistant, PriDem) and I have started coming into the department for two days a week.  We have been together in the office twice so far and have seen benefits. Both being new to UCL, it has been an important step in starting to feel a sense of belonging to a department. I think being in-person for some of the time is enhancing the development of an effective working relationship. At the start of each week, we plan weekly goals and have started to prioritise tasks that would work best in-person for office days. Enjoying everyday conversation just for the sake of it, without this being a prelude to a meeting has been a novelty, and the potential for using bodily movement for ‘acting out’ anecdotes or being unaware of what our faces are doing, has created a much-missed sense of communicative freedom. Going for coffee together, airing thoughts as they occur and having spontaneous discussions (rather than having to compose them in an email or wait until the next Teams meeting), are all great benefits of hybrid working and breed creativity. It can also be easier to read and respond to people’s emotions when in person and there is nothing like a co-present giggle for enhancing well-being.

It is early days, and there haven’t been many people around in the department yet, but some chance meetings in the kitchen and corridor have led to spontaneous conversations with new people and a chance to connect with the wider team.

Before the pandemic I loved rare WFH days. To me they were luxury; a chance to switch off distractions and ‘get in the flow’, with all the benefits of being able to get washing done, cuddle the dog and eat whole packets of biscuits unobserved. However, since this became the norm, the enjoyment has gradually faded for me. I’m fortunate that I can find space to work, away from family members, and I don’t have children living at home. Even so, at times I’ve felt trapped by lack of variety. Like many people I’ve been super productive, but have often worked crazy hours, due to a lack of natural breaks to travel to/from work, and no escape from the ‘workplace’.

I live in Cornwall! It takes me three and a half hours to get to London and I’m lucky because I have accommodation when I am there. I am working out ways of working on a train when the internet is poor, saving tasks for travel times that don’t require online connection. Having a snooze and recharging my batteries has also been on my to-do list.  I have noticed that coming back to Cornwall after my London stint has led to appreciating and enjoying home working all over again.

However, there are issues to overcome to optimise the hybrid working experience, and everyone’s situation is unique. Although currently Emily and I have started fulfilling the UCL guidance of aiming for 40% embodiment, this guidance is somewhat ambiguous and has been variously interpreted. It will not be possible in the literal sense once recruitment starts. Our working practices will vary week to week, in terms of where we need to be and how we approach interactions. Some research activities will be in-person and some remote. However, the challenges of background noise and confidentiality mean remote activity will not necessarily work when carried out in a shared office. We are going to have to negotiate how we do this, building in flexibility and ensuring that we have the right equipment and office ventilation. Headphones and suitable microphones can help with confidentiality and researchers keeping their own vocal volume to a minimum, although many of our participants will have reduced hearing and/or find background noise highly distracting.  The current requirement to wear masks in shared offices adds to the challenge of video calls, especially as people living with dementia and those with hearing difficulties gain communication support from seeing people’s faces.

These challenges have led us discuss future arrangements for hybrid working within our team. The 40% embodiment guidance includes discussing individual circumstances with line managers. We hope that this can be highly flexible, with clearer guidance around managers using discretion and trust; monitoring how well research staff are engaging in remote versus in-person working. Importantly, this will entail balancing efficiency with wellbeing and maintaining a sense of belonging. Fatigue is one to keep an eye on as people return to the world of commuting. Depending on the person, the team and the tasks at hand, researchers may want to be embodied for a whole week at time, but then balance this with a week of working from home. I hope that we can continue this conversation about how we enter the new phase of hybrid working.

 

Developing educational leadership skills as an early career academic

By Megan Armstrong, on 24 September 2021

Dr Danielle Nimmons, GP and NIHR In-Practice Fellow

I am a GP, researcher and educationalist at UCL and I thought I would document some of the milestones in my early academic development. As part of my training I was fortunate to be awarded an NIHR Academic Clinical Fellowship (ACF), which has been an amazing opportunity to develop my research and teaching skills.

My research has included studies on frailty, dementia and Parkinson’s, for example conducting reviews. However, I knew at the start of my ACF that as well as research, I wanted to gain teaching experience and achieve outputs, such as accreditation as Fellow of the Higher Education Academy / HE Advance (FHEA). At UCL we are very fortunate to be encouraged to develop both research and educational skills. Below I outline the main teaching I was involved in, what I got out of it and suggestions/tips for others who may be interested in developing educational leadership skills as an early career academic.

Teaching experience at UCL

As a GP registrar in my 3rd year (ST3) I became a module lead for Preparation for Practice (PfP), part of the Year 4 MBBS programme. My roles included designing simulated patient cases for the students, direct teaching, supporting other GP tutors and administration staff, course evaluation and quality assurance. I also led the transition from face-to-face delivery to online as Covid hit, developing recorded (asynchronous) and live webinar (synchronous) material.

In my 4th year of training  (ST4) I decided to get experience of small group teaching in my GP practice as a Medicine in the Community (MIC) tutor, for two UCL medical students over the academic year. Students spent 10 days in my GP practice in total, and I got to see them improve clinically while I gained personal tutoring skills. Sessions included an interactive workshop on a disease /condition, formative assessment in the shape of MCQs, role play and patient interactions between students and my NHS patients who gave up their time to help.

What I got out of it

I love teaching and find it incredibly rewarding! The variety of teaching experiences helped break up my academic time and focus when working on different project. These experiences included:

  • Face to face teaching,
  • Online teaching,
  • Developing teaching material,
  • Evaluation teaching activities and
  • Quality assurance

These experiences also contributed to my successful fellowship applications and being awarded a UCL Excellence in Medical Education award (EMEA) (see here).

I was also fortunate to get some outputs, including presentations, awards and publications: Medical student mentoring programs: current insights and The UCL ‘Preparation for Practice’ teaching programme. 

Reflections

Balancing GP training (exams and completing my compulsory training portfolio), research and teaching can be challenging, at times I definitely felt like I was juggling many balls and just about managing not to drop any! The extra academic day in my 4th year helped but only because I taught less on the PfP programme, which gave me more time do practice based (MIC) teaching. Having boundaries and recognising when my plate was full also helped. For example, during my final GP (MRCGP) exams I tried not to do too much else.

Teaching was most enjoyable when I linked it to my research. This included selecting patients from under-represented groups for students to interact with in their GP teaching sessions, which complemented my clinical research project exploring how people from under-represented groups self-manage Parkinson’s disease. As my teaching was informed by the research I was doing, it also saved time when it came to lesson planning.

Finally, most of my academic time was during the pandemic and teaching not only helped me network with other academics within the department but also with hospital registrars doing acute medicine and acting as teaching fellows, academic pharmacists and academic clinicians from a range of specialties based at the medical school main campus.

Tips

Tips for other early career academics:

  1. Say ‘Yes’ to opportunities
  2. Recognise limitations; i.e., Time! It is impossible to do everything but you can make a real impact to programmes if you focus on a select few.
  3. Look for a variety of educational experiences. For example, online vs in person teaching, design teaching vs evaluation
  4. Try and get some outputs, e.g., presentations, higher education fellowships like the FHEA
  5. Link it to your research!
  6. Discuss with current ACFs and module leads to get an idea of what is best for you.

I would encourage all early career academics to gain teaching experience and hope this has inspired some to do so!

References

  1. Nimmons D, Hatter L, Davies N, Sampson EL, Walters K, Schrag A. Experiences of advance care planning in Parkinson’s disease and atypical parkinsonian disorders: a mixed methods systematic review. Eur J Neurol. 2020 Oct;27(10):1971-1987. doi: 10.1111/ene.14424. Epub 2020 Jul 30. PMID: 32603525.
  2. Nimmons D, Giny S, Rosenthal J. Medical student mentoring programs: current insights. Adv Med Educ Pract. 2019 Mar 4;10:113-123. doi: 10.2147/AMEP.S154974. PMID: 30881173; PMCID: PMC6404673.
  3. Nimmons D, Jones MM. The UCL ‘Preparation for Practice’ teaching programme. Med Educ. 2020 Nov;54(11):1077-1078. doi: 10.1111/medu.14326. Epub 2020 Sep 3. PMID: 32885435.

Primary care in the COVID-19 era: do we still practice preventive care?

By Megan Armstrong, on 14 September 2021

Alaa Alghamdi is a GP who is undertaking a PhD at UCL

This blog is by Alaa Alghamdi and tackles the practice of preventive care during the COVID-19.

To begin this blog, I have shared a medical case study that clearly addresses the topic at hand:

A 55-year-old male Saudi professor, married with five children, unknown to have any medical illness and not on medications. He presented to the emergency department (ED) complaining of unintentional weight loss of 10 kg in the last six months associated with fatigue. Initially, he attributed his symptoms to the psychological impact of the pandemic. Because of the fear of risk exposure to COVID-19 alongside lockdown restrictions of visiting health facilities for non-emergency, he avoided seeking medical help until he remarked jaundice. In the ED, a CT scan with IV contrast was performed. It showed circumferential wall thickening involving the short segment of the ascending colon with pericolonic enlarged lymph nodes and numerous hepatic lesions indicating metastasis. He was diagnosed with stage 4 colon cancer and referred to a tertiary specialist hospital. Unfortunately, palliative care was the only option in his late presentation, and he passed within two months of his diagnosis.

This case might be one of many other cases that have been affected by disrupted healthcare during the pandemic that prioritised COVID-19 cases. Cancer could be one of the preventable deaths through appropriate screening and early detection (1). Screening is effective for both early detection and prevention in 80% of colorectal cancers (2) and has the potential to reduce colorectal cancer deaths by 60% (3).

Preventive screening is a vital part of primary healthcare practice (PHC). As with many other countries, Saudi Arabia (SA) has started preventive care services early with various programmes delivered through PHC (4). However, like many other countries, the Saudi Ministry of Health (MOH) has diverted resources to healthcare facilities to be able to manage the high numbers of COVID-19 patients. Although SA’s response to the pandemic places it at the highest ranks on international indexes (5) and the second at NIKKEI COVID-19 recovery index (6), the WHO showed that COVID-19 significantly impacts health services for non-communicable diseases (NCDs) globally, including SA (7).

My PhD project aims to explore the patient experience with PHC to provide the appropriate engagement and utilisation of PHC in SA. One of the key issues I have been exploring is the influence of COVID-19 on patient engagement with PHC. An important emerging point is the preventive screening during this pandemic for non-COVID conditions. There are growing concerns that have been arisen by using the online health services, which might have an indirect impact on health providers’ practices towards preventive care. In SA, many online health services have emerged throughout the pandemic, including telemedicine, online appointments and medication delivery. Although most participants expressed their appreciation of the unusual and massive use of online health services, the GPs’ practices towards regular screening are questionable. In my research position as a clinician interviewing a diabetic patient, I asked about the last time that haemoglobin A1c has been tested, the response was startling:

“I had it last year, but the coronavirus pandemic delayed tests appointments. They only care about dispensing the medications.” (P7)

Screening for diabetes complications such as retinopathy, diabetic nephropathy and diabetic foot, which are supposed to be done annually, has been postponed for most of the participants.

The children’s regular vaccination programme also has been affected. Some participants who attended a PHC regularly complained about the delay in completing their children’s vaccines due to difficulties in obtaining a vaccine appointment.

“They told me that the vaccinations were over and I have to wait for a new appointment. This is the reason why my children did not get their vaccinations until now, even though they are to join the school this year. My daughter still has to get one vaccination and my son still has to get two vaccinations.” (P15)

COVID-19 impact on care for patients with non-COVID conditions and the concern around preventive screening is not restricted to Saudi healthcare. A UK survey found that access to health services for people with long-term health conditions was 20% lower during the COVID-19 peak period. Some of the most significant falls in the use of health services are for mental health, heart disease, diabetes and cancer (8). According to the latest records by WHO (April 2021), 41 million people each year die from NCDs, including diabetes and chronic cardiovascular and lung diseases, which is equivalent to 71% of all deaths globally. In addition, each year, more than 15 million people die from NCDs between the ages of 30 and 69 years (9). Primary prevention is a vital component of the response to NCDs (1)(9), and reduces over one-third of all cancer cases (10). Moreover, people living with NCDs are at a higher risk of severe COVID-19-related illness and death (7)(11).

This reveals how preventive care is required at an alarming pace and emphasises the need for the urgent implementation of efficient prevention strategies during COVID-19. GPs’ efforts must be focused on adhering to evidence-based screening guidelines. Health system policymakers also need to recognise that prioritising COVID cases for pandemic control have other health consequences and demand responses to all health needs. This does not minimise the important measures taken to reduce the risk of COVID-19, but it is an opportunity to build a resilient recovery and emerge stronger from the pandemic.

References

  1. Burke CA. Colorectal Neoplasia [Internet]. 2017. Available from: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/colorectal-neoplasia/#bib1
  2. Cunningham D, Atkin W, Lenz H-J, Lynch HT, Minsky B, Nordlinger B, et al. Colorectal cancer. 2010;375:18.
  3. He J, Efron JE. Screening for Colorectal Cancer. Advances in Surgery. 2011 Sep;45(1):31–44.
  4. Sebai ZA, Milaat WA, Al-Zulaibani AA. Health care services in saudi arabia: past, present and future. Journal of family & community medicine, 8(3), 19–23. 2001;
  5. Saudi Arabia’s response to the COVID-19 pandemic places it at the highest ranks on international indexes [Internet]. ARABNEWS. 2021. Available from: https://www.arabnews.com/node/1880171/saudi-arabia
  6. GRACE L. Nikkei COVID-19 Recovery Index. 2021.
  7. Brunier A. COVID-19 significantly impacts health services for noncommunicable diseases [Internet]. Available from: https://www.who.int/news/item/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-diseases
  8. Charlesworth. Shock to the system: COVID-19’s long-term impact on the NHS [Internet]. 2020. Available from: https://www.health.org.uk/news-and-comment/blogs/shock-to-the-system-covid-19s-long-term-impact-on-the-nhs
  9. WHO. Noncommunicable diseases [Internet]. 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases
  10. Vineis P, Wild CP. Global cancer patterns: causes and prevention. The Lancet. 2014 Feb;383(9916):549–57.
  11. Bashir S, Moneeba S, Alghamdi A, Alghamdi F, Niaz A, Anan H, et al. Comorbidities in Patients with COVID-19 and Their Impact on the Severity of the Disease. Journal of Health and Allied Sciences NU. 2021 Jan;11(01):01–7.