A narrative review of course evaluation methods for continuing professional development: The case of paediatric and neonatal acute-care in-service courses in low and lower-middle income countries: BEME Guide No. 76.

BACKGROUND: Training a skilled healthcare workforce is an essential part in reaching the United Nations Sustainable Development Goal to end preventable deaths in children and neonates. The greatest burden of mortality lies in low and lower-middle income countries (LLMIC). Short term, in-service courses have been implemented in many LLMIC to improve the quality of care delivered, but the evaluation methods of these courses are inconsistent. METHOD: Studies describing evaluations of course and outcome measures were included if the course lasted seven days or less with postgraduate participants, included paediatric or neonatal acute or emergency training and was based in a LLMIC. This narrative review provides a detailed description of evaluation methods of course content, delivery and outcome measures based on 'Context, Input, Process and Product' (CIPP) and Kirkpatrick models. RESULTS: 5265 titles were screened with 93 articles included after full-text review and quality assessment. Evaluation methods are described: context, input, process, participant satisfaction, change in learning, behaviour, health system infrastructure and patient outcomes. CONCLUSIONS: Outcomes, including mortality and morbidity, are rightly considered the fundamental aim of acute-care courses in LLMIC. Course evaluation can be difficult, especially with low resources, but this review outlines what can be done to guide future course organisers in providing well-conducted courses with consistent outcome measures for maximum sustainable impact.

Measuring differential attainment: a longitudinal analysis of assessment results for 1512 medical students at four Scottish medical schools.

OBJECTIVE: To measure Differential Attainment (DA) among Scottish medical students and to explore whether attainment gaps increase or decrease during medical school. DESIGN: A retrospective analysis of undergraduate medical student performance on written assessment, measured at the start and end of medical school. SETTING: Four Scottish medical schools (universities of Aberdeen, Dundee, Edinburgh and Glasgow). PARTICIPANTS: 1512 medical students who attempted (but did not necessarily pass) final written assessment. MAIN OUTCOME MEASURES: The study modelled the change in attainment gap during medical school for four student demographical categories (white/non-white, international/Scottish domiciled, male/female and with/without a known disability) to test whether the attainment gap grew, shrank or remained stable during medical school. Separately, the study modelled the expected versus actual frequency of different demographical groups in the top and bottom decile of the cohort. RESULTS: The attainment gap grew significantly for white versus non-white students (t(449.39)=7.37, p=0.001, d=0.49 and 95% CI 0.34 to 0.58), for internationally domiciled versus Scottish-domiciled students (t(205.8) = -7, p=0.01, d=0.61 and 95% CI -0.75 to -0.42) and for male versus female students (t(1336.68)=3.54, p=0.01, d=0.19 and 95% CI 0.08 to 0.27). International, non-white and male students received higher marks than their comparison group at the start of medical school but lower marks by final assessment. No significant differences were observed for disability status. Students with a known disability, Scottish students and non-white students were over-represented in the bottom decile and under-represented in the top decile. CONCLUSIONS: The tendency for attainment gaps to grow during undergraduate medical education suggests that educational factors at medical schools may-however inadvertently-contribute to DA. It is of critical importance that medical schools investigate attainment gaps within their cohorts and explore potential underlying causes.

The protective effect of SARS-CoV-2 antibodies in Scottish healthcare workers.

BACKGROUND: Healthcare workers (HCWs) are believed to be at increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It is not known to what extent the natural production of antibodies to SARS-CoV-2 is protective against re-infection. METHODS: A prospective observational study of HCWs in Scotland (UK) from May to September 2020 was performed. The Siemens SARS-CoV-2 total antibody assay was used to establish seroprevalence in this cohort. Controls, matched for age and sex to the general local population, were studied for comparison. New infections (up to 2 December 2020) post antibody testing were recorded to determine whether the presence of SARS-CoV-2 antibodies protects against re-infection. RESULTS: A total of 2063 health and social care workers were recruited for this study. At enrolment, 300 HCWs had a positive antibody test (14.5%). 11 out of 231 control sera tested positive (4.8%). HCWs therefore had an increased likelihood of a positive test (OR 3.4, 95% CI 1.85-6.16; p<0.0001). Dentists were most likely to test positive. 97.3% of patients who had previously tested positive for SARS-CoV-2 by reverse transcriptase (RT)-PCR had positive antibodies. 18.7% had an asymptomatic infection. There were 38 new infections with SARS-CoV-2 in HCWs who were previously antibody negative, and one symptomatic RT-PCR-positive re-infection. The presence of antibodies was therefore associated with an 85% reduced risk of re-infection with SARS-CoV-2 (hazard ratio 0.15, 95% CI 0.06-0.35; p=0.026). CONCLUSION: HCWs were three times more likely to test positive for SARS-CoV-2 than the general population. Almost all infected individuals developed an antibody response, which was 85% effective in protecting against re-infection with SARS-CoV-2.

AMEE Consensus Statement: Planetary health and education for sustainable healthcare.

The purpose of this Consensus Statement is to provide a global, collaborative, representative and inclusive vision for educating an interprofessional healthcare workforce that can deliver sustainable healthcare and promote planetary health. It is intended to inform national and global accreditation standards, planning and action at the institutional level as well as highlight the role of individuals in transforming health professions education. Many countries have agreed to 'rapid, far-reaching and unprecedented changes' to reduce greenhouse gas emissions by 45% within 10 years and achieve carbon neutrality by 2050, including in healthcare. Currently, however, health professions graduates are not prepared for their roles in achieving these changes. Thus, to reduce emissions and meet the 2030 Sustainable Development Goals (SDGs), health professions education must equip undergraduates, and those already qualified, with the knowledge, skills, values, competence and confidence they need to sustainably promote the health, human rights and well-being of current and future generations, while protecting the health of the planet.The current imperative for action on environmental issues such as climate change requires health professionals to mobilize politically as they have before, becoming strong advocates for major environmental, social and economic change. A truly ethical relationship with people and the planet that we inhabit so precariously, and to guarantee a future for the generations which follow, demands nothing less of all health professionals.This Consensus Statement outlines the changes required in health professions education, approaches to achieve these changes and a timeline for action linked to the internationally agreed SDGs. It represents the collective vision of health professionals, educators and students from various health professions, geographic locations and cultures. 'Consensus' implies broad agreement amongst all individuals engaged in discussion on a specific issue, which in this instance, is agreement by all signatories of this Statement developed under the auspices of the Association for Medical Education in Europe (AMEE).To ensure a shared understanding and to accurately convey information, we outline key terms in a glossary which accompanies this Consensus Statement (Supplementary Appendix 1). We acknowledge, however, that terms evolve and that different terms resonate variably depending on factors such as setting and audience. We define education for sustainable healthcare as the process of equipping current and future health professionals with the knowledge, values, confidence and capacity to provide environmentally sustainable services through health professions education. We define a health professional as a person who has gained a professional qualification for work in the health system, whether in healthcare delivery, public health or a management or supporting role and education as 'the system comprising structures, curricula, faculty and activities contributing to a learning process'. This Statement is relevant to the full continuum of training - from undergraduate to postgraduate and continuing professional development.

Exploring threshold concepts in population health.

BACKGROUND: Doctors are increasingly expected to improve the health and well-being of populations, as well as to care for individuals. However, despite extensive efforts to integrate population health into undergraduate programmes, engaging students in such learning is notoriously challenging. Threshold concepts are transformative, integrative, irreversible and fundamental to understanding a discipline. Grasping such concepts requires learners to cross a liminal space, which often involves struggle. METHODS: We employed a form of transactional curriculum enquiry, involving qualitative and quantitative methods, with experienced population health medical educators to identify and explore threshold and troublesome concepts in population health. RESULTS: Attributing causality, inequalities in health and doctors' responsibility for populations not just individuals were the concepts most participants thought were threshold. The value of qualitative research, health as politically and socially determined and not taking evidence at face value were the concepts ranked as most troublesome for learners. Participants found the notions of threshold and troublesome concepts helpful and empowering. They described ways these new ideas would influence how they taught population health. DISCUSSION: Transactional curriculum enquiry can offer insights into which population health concepts may be threshold and troublesome. The number of such concepts identified in this study may help explain why students often struggle to engage in population health learning. Understanding which concepts are threshold and particularly which are troublesome can help teachers to better support learners and can also inform curriculum design. If our students are to … take responsibility for populations as well as individuals … it is vital that they cross these fundamental thresholds in learning.

Impact of socioeconomic status on disease phenotype, genomic landscape and outcomes in myelodysplastic syndromes.

Genetic and epigenetic alterations contribute to the biological and clinical characteristics of myelodysplastic syndromes (MDS), but a role for socioeconomic environment remains unclear. Here, socioeconomic status (SES) for 283 MDS patients was estimated using the Scottish Index of Multiple Deprivation tool. Indices were assigned to quintile categorical indicators ranked from SES1 (lowest) to SES5 (highest). Clinicopathological features and outcomes between SES quintiles containing 15%, 20%, 19%, 30% and 16% of patients were compared. Prognostic scores identified lower-risk MDS in 82% of patients, with higher-risk disease in 18%. SES quintiles did not associate with age, gender, cytogenetics, International Prognostic scores or, in sub-analysis (n = 95), driver mutations. The odds ratio of a diagnosis of refractory anaemia was greater than other MDS sub-types in SES5 (OR 1·9, P = 0·024). Most patients (91%) exclusively received supportive care. SES did not associate with leukaemic transformation or cause of death. Cox regression models confirmed male gender (P < 0·05), disease-risk (P < 0·0001) and age (P < 0·01) as independent predictors of leukaemia-free survival, with leukaemic transformation an additional determinant of overall survival (P = 0·07). Thus, if access to healthcare is equitable, SES does not determine disease biology or survival in MDS patients receiving supportive treatment; additional studies are required to determine whether outcomes following disease-modifying therapies are influenced by SES.

Teaching public health in UK medical schools: 'things have improved: teaching no longer feels like an expensive hobby'.

BACKGROUND: Recent policy initiatives in the UK have underlined the importance of public health education for healthcare professionals. We aimed to describe teaching inputs to medical undergraduate curricula, to identify perceived challenges in the delivery of public health teaching and make recommendations that may overcome them. METHODS: We undertook a cross-sectional survey; questionnaires were sent electronically to 32 teaching leads in academic departments of public health in UK medical schools and followed up by telephone interviews. RESULTS: We obtained a 75% response rate; 13 public health teaching leads were interviewed. We found much variability between schools in teaching methods, curricular content and resources used. Concerns regarding the long-term sustainability of teaching focus on: staffing levels and availability, funding and the prioritization of research over teaching. We give examples of integration of public health with clinical teaching, innovative projects in public health and ways of enabling students to witness public health in action. CONCLUSIONS: There is a need to increase the supply of well-trained and motivated teachers and combine the best traditional teaching methods with more innovative approaches. Suggestions are made as to how undergraduate public health teaching can be strengthened.

Contemporary risk of hip fracture in type 1 and type 2 diabetes: a national registry study from Scotland.

The purpose of this study was to compare contemporary risk of hip fracture in type 1 and type 2 diabetes with the nondiabetic population. Using a national diabetes database, we identified those with type 1 and type 2 diabetes who were aged 20 to 84 years and alive anytime from January 1, 2005 to December 31, 2007. All hospitalized events for hip fracture in 2005 to 2007 for diabetes patients were linked and compared with general population counts. Age- and calendar-year-adjusted incidence rate ratios were calculated by diabetes type and sex. One hundred five hip fractures occurred in 21,033 people (59,585 person-years) with type 1 diabetes; 1421 in 180,841 people (462,120 person-years) with type 2 diabetes; and 11,733 hip fractures over 10,980,599 person-years in the nondiabetic population (3.66 million people). Those with type 1 diabetes had substantially elevated risks of hip fracture compared with the general population incidence risk ratio (IRR) of 3.28 (95% confidence interval [CI] 2.52-4.26) in men and 3.54 (CI 2.75-4.57) in women. The IRR was greater at younger ages, but absolute risk difference was greatest at older ages. In type 2 diabetes, there was no elevation in risk among men (IRR 0.97 [CI 0.92-1.02]) and the increase in risk in women was small (IRR 1.05 [CI 1.01-1.10]). There remains a substantial elevation relative risk of hip fracture in people with type 1 diabetes, but the relative risk is much lower than in earlier studies. In contrast, there is currently little elevation in overall hip fracture risk with type 2 diabetes, but this may mask elevations in risk in particular subgroups of type 2 diabetes patients with different body mass indexes, diabetes duration, or drug exposure.

Risk of cardiovascular disease and total mortality in adults with type 1 diabetes: Scottish registry linkage study.

BACKGROUND: Randomized controlled trials have shown the importance of tight glucose control in type 1 diabetes (T1DM), but few recent studies have evaluated the risk of cardiovascular disease (CVD) and all-cause mortality among adults with T1DM. We evaluated these risks in adults with T1DM compared with the non-diabetic population in a nationwide study from Scotland and examined control of CVD risk factors in those with T1DM. METHODS AND FINDINGS: The Scottish Care Information-Diabetes Collaboration database was used to identify all people registered with T1DM and aged ≥20 years in 2005-2007 and to provide risk factor data. Major CVD events and deaths were obtained from the national hospital admissions database and death register. The age-adjusted incidence rate ratio (IRR) for CVD and mortality in T1DM (n = 21,789) versus the non-diabetic population (3.96 million) was estimated using Poisson regression. The age-adjusted IRR for first CVD event associated with T1DM versus the non-diabetic population was higher in women (3.0: 95% CI 2.4-3.8, p<0.001) than men (2.3: 2.0-2.7, p<0.001) while the IRR for all-cause mortality associated with T1DM was comparable at 2.6 (2.2-3.0, p<0.001) in men and 2.7 (2.2-3.4, p<0.001) in women. Between 2005-2007, among individuals with T1DM, 34 of 123 deaths among 10,173 who were <40 years and 37 of 907 deaths among 12,739 who were ≥40 years had an underlying cause of death of coma or diabetic ketoacidosis. Among individuals 60-69 years, approximately three extra deaths per 100 per year occurred among men with T1DM (28.51/1,000 person years at risk), and two per 100 per year for women (17.99/1,000 person years at risk). 28% of those with T1DM were current smokers, 13% achieved target HbA(1c) of <7% and 37% had very poor (≥9%) glycaemic control. Among those aged ≥40, 37% had blood pressures above even conservative targets (≥140/90 mmHg) and 39% of those ≥40 years were not on a statin. Although many of these risk factors were comparable to those previously reported in other developed countries, CVD and mortality rates may not be generalizable to other countries. Limitations included lack of information on the specific insulin therapy used. CONCLUSIONS: Although the relative risks for CVD and total mortality associated with T1DM in this population have declined relative to earlier studies, T1DM continues to be associated with higher CVD and death rates than the non-diabetic population. Risk factor management should be improved to further reduce risk but better treatment approaches for achieving good glycaemic control are badly needed. Please see later in the article for the Editors' Summary.

Factors associated with uptake of pandemic influenza vaccine among general practitioners and practice nurses in Shropshire, UK.

BACKGROUND: At the time of the 2009-10 influenza pandemic there was considerable unease about vaccination. Early surveys suggested that the intention to be vaccinated amongst healthcare workers was low. AIMS: To determine what influenced vaccination uptake among general practice healthcare workers in Shropshire County Primary Care Trust in the UK. METHODS: A cross-sectional survey was distributed to all frontline healthcare workers in Shropshire County's general practices in June 2010. All 45 practices participated. Questionnaires were distributed by practice managers to frontline staff and returned by post. Practices with the lowest return rates were reminded by telephone after 3 months. RESULTS: 205 valid replies were received, giving a response rate of 48.0%. 10.0% reported being infected with the pandemic H1N1 strain by the time they received the questionnaire. 172 (83.9%) respondents reported that they had been vaccinated against H1N1. Influenza infection prior to vaccination had a negative impact on uptake (adjusted OR 0.17, 95% CI 0.05 to 0.56) and previous vaccination against seasonal influenza was associated with increased uptake (adjusted OR 4.07, 95% CI 1.62 to 10.24). Those who received the pandemic vaccine were seven times more likely to accept future vaccines (adjusted OR 7.04, 95% CI 2.70 to 18.37). CONCLUSIONS: Vaccination uptake was significantly higher than the national (40.3%), regional (40.9%), and county averages (49.3%). Motivation for and against vaccination was very similar to that for seasonal vaccination, with previous vaccination having the greatest influence. Ensuring healthcare workers receive vaccination early in their career is likely to set a precedent for future vaccination. This is the first detailed study purely in general practice in England.