Karen Pickett

Are trainee teachers being adequately prepared to promote the health and well-being of school children? A survey of current practice

BACKGROUND Teachers are a key part of the wider public health workforce in England. We conducted a survey to find out how they are trained for this role during their initial teacher education (ITE). METHODS Between 2011 and 2012, we sent an online questionnaire to 220 ITE course managers and conducted semi-structured interviews with a purposive sample of 19 course managers to explore issues in more depth. RESULTS The response rate to the questionnaire was 34% (n = 74). Although most of the course managers felt inclusion of health and well-being training in ITE was important, provision across courses was variable. Topics which are public health priorities [e.g. sex and relationships education (SRE) and drugs, alcohol and tobacco] were covered by fewer courses than other topics (e.g. child protection, emotional health and anti-bullying). Perceived barriers to training included lack of time and a belief that health and well-being were low priorities in educational policy. CONCLUSIONS Not all of tomorrows teachers are being adequately prepared for their role in helping to address public health priorities. Educational policy does not appear to be supporting the priorities of public health policy, and this is a key barrier to health promotion training in ITE. Keywords children, educational settings, health promotion.

Education to improve quality of life of people with chronic inflammatory skin conditions: a systematic review of the evidence.

Patient and carer education has been proposed as a way of improving health‐related quality of life (HRQoL) among people with chronic inflammatory skin conditions. This systematic review aimed to assess the effects of education that specifically addresses HRQoL among people with chronic inflammatory skin conditions. We searched 12 literature databases and other sources (up to July 2014). Seven randomized controlled trials (RCTs) met the review inclusion criteria. Data from these RCTs were extracted and critically appraised. Two RCTs showed that for psoriasis in adults, group‐based and text message education (as adjuncts to usual care) resulted in better HRQoL and disease severity outcomes than comparators, respectively. One RCT found that group‐based education for children with eczema (atopic dermatitis) and their parents resulted in greater improvements in parents’ HRQoL and in the childrens disease severity than no education at 12 months. The remaining RCTs evaluated an educational session for psoriasis, a website for carers of children with eczema, information on skincare and make‐up use given to women with acne, and an itch‐coping programme for a range of conditions, all as adjuncts to usual care. None of these RCTs found statistically significant effects on HRQoL or disease severity compared with usual care. Common features of the effective interventions were long delivery (over 6 weeks to 3 months) and delivery by a multidisciplinary team. Overall, the evidence base is currently limited and generally has an unclear risk of bias. There is a need for more large RCTs evaluating piloted and theory‐based interventions.

Educational interventions to improve quality of life in people with chronic inflammatory skin diseases: systematic reviews of clinical effectiveness and cost-effectiveness

BACKGROUND Inflammatory skin diseases include a broad range of disorders. For some people, these conditions lead to psychological comorbidities and reduced quality of life (QoL). Patient education is recommended in the management of these conditions and may improve QoL. OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of educational interventions to improve health-related quality of life (HRQoL) in people with chronic inflammatory skin diseases. DATA SOURCES Twelve electronic bibliographic databases, including The Cochrane Library, MEDLINE and EMBASE, were searched to July 2014. Bibliographies of retrieved papers were searched and an Advisory Group contacted. REVIEW METHODS Systematic reviews were conducted following standard methodologies. Clinical effectiveness studies were included if they were undertaken in people with a chronic inflammatory skin condition. Educational interventions that aimed to, or could, improve HRQoL were eligible. Studies were required to measure HRQoL, and other outcomes such as disease severity were also included. Randomised controlled trials (RCTs) or controlled clinical trials were eligible. For the review of cost-effectiveness, studies were eligible if they were full economic evaluations, cost-consequence or cost analyses. RESULTS Seven RCTs were included in the review of clinical effectiveness. Two RCTs focused on children with eczema and their carers. Five RCTs were in adults. Of these, two were of people with psoriasis, one was of people with acne and two were of people with a range of conditions. There were few similarities in the interventions (e.g. the delivery mode, the topics covered, the duration of the education), which precluded any quantitative synthesis. Follow-up ranged from 4 weeks to 12 months, samples sizes were generally small and, overall, the study quality was poor. There appeared to be positive effects on HRQoL in participants with psoriasis in one trial, but no difference between groups in another trial in which participants had less severe psoriasis. Carers of children in one RCT of eczema showed improvement in HRQoL; however, in a RCT evaluating a website intervention there were no demonstrable effects on HRQoL. Neither the RCT in those adults with acne nor the RCT in those adults with mixed skin conditions demonstrated an effect on HRQoL. One RCT reported subgroups with atopic dermatitis or psoriasis and education was effective for psoriasis only. Other outcomes also showed mixed results. It is unclear how clinically meaningful any of the observed improvements are. Three studies of cost-effectiveness were included. The interventions, comparators and populations varied across the studies and, overall, the studies provided limited information on cost-effectiveness. The studies did provide detailed information on resources and costs that could be useful to inform a future cost-effectiveness evaluation in this area. LIMITATIONS The application of the inclusion criterion around whether the interventions were aimed at improving HRQoL or the inference that they could improve HRQoL was difficult as information was rarely reported. CONCLUSIONS There is uncertainty regarding whether educational interventions addressing issues that could improve HRQoL in people with chronic skin conditions are effective. Tentative conclusions about the best approach to delivering these kinds of interventions are that face-to-face, group, sessions may be beneficial; however, text messages may also be effective. Delivery over a period of time and by a multidisciplinary team may also be associated with positive outcomes. There is uncertainty over whether or not educational interventions are cost-effective. STUDY REGISTRATION This study is registered as PROSPERO CRD42014007426. FUNDING The National Institute for Health Research Health Technology Assessment programme.

Initial Teacher Training to Promote Health and Well-Being in Schools--A Systematic Review of Effectiveness, Barriers and Facilitators.

Objectives: To conduct a systematic review of effectiveness, and barriers and facilitators, of initial teacher training to promote health and well-being in schools. Design: Systematic review of the literature. Method: A total of 20 bibliographic databases were searched, including MEDLINE, EMBASE and the Social Science Citation Index. Studies were included if they reported research into the processes and/or outcomes of initial (pre-service) teacher training to promote health. Results: A total of 20 studies met the inclusion criteria, mainly from the UK and Australia. Twelve studies assessed outcomes, commonly using uncontrolled before and after assessment designs. Sixteen studies evaluated the processes of training. Training was diverse in terms of content, format and health topics. The studies demonstrated short-term increases in trainee teachers’ factual knowledge of health issues, a general increase in teachers’ confidence to teach about health and to identify and help children with specific health issues. There was an increase in teachers’ positive beliefs about their role in promoting children’s health. None of the studies assessed changes in pupil outcomes. The training was generally considered acceptable and adequate by trainee teachers. However, some of the trainees felt that they still lacked knowledge and confidence to address sensitive health issues on entering teaching practice. Conclusion: This systematic review identified some evidence for the effectiveness of teacher training for health and highlighted factors which facilitate and inhibit effective training. Further evaluation, using controlled trial designs with long-term follow-up of teacher and pupil outcomes, may enable teachers to effectively address the health and education needs of school pupils.

Systematic review of the empirical investigation of resources to support decision-making regarding BRCA1 and BRCA2 genetic testing in women with breast cancer

OBJECTIVE Identify existing resources developed and/or evaluated empirically in the published literature designed to support women with breast cancer making decisions regarding genetic testing for BRCA1/2 mutations. METHODS Systematic review of seven electronic databases. Studies were included if they described or evaluated resources that were designed to support women with breast cancer in making a decision to have genetic counselling or testing for familial breast cancer. Outcome and process evaluations, using any type of study design, as well as articles reporting the development of decision aids, were eligible for inclusion. RESULTS Total of 9 publications, describing 6 resources were identified. Resources were effective at increasing knowledge or understanding of hereditary breast cancer. Satisfaction with resources was high. There was no evidence that any resource increased distress, worry or decisional conflict. Few resources included active functionalities for example, values-based exercises, to support decision-making. CONCLUSION Tailored resources supporting decision-making may be helpful and valued by patients and increase knowledge of hereditary breast cancer, without causing additional distress. PRACTICE IMPLICATIONS Clinicians should provide supportive written information to patients where it is available. However, there is a need for robustly developed decision tools to support decision-making around genetic testing in women with breast cancer.

A Longitudinal Study to Explore the Impact of Preservice Teacher Health Training on Early Career Teachers’ Roles as Health Promoters

Teachers play a key role in promoting children and young people’s health and therefore require health training during their initial teacher education (ITE). However, little is known about the impact of such training on teachers’ knowledge, attitudes, confidence, and competence toward promoting health in school, especially long term. We report on Phase 1 of an 18-month project examining the long-term impact of an innovative health education program, based on socio-constructivist learning and critical reflection, during preservice teacher training at one ITE university in England. It also explored barriers and facilitators to promoting health in school. We sent a questionnaire to 1,014 primary and secondary school teachers from three consecutive cohorts: preservice teachers (N = 334), newly qualified teachers (N = 334), and early careers teachers (N = 346). Of these, 164 (16%) responded (32% of preservice teachers, 8% of in-service teachers). This low response rate presents limitations but is in accordance with other research following up early career teachers. The majority of the respondents found the training useful, felt confident and knowledgeable teaching and dealing with health issues, and held positive attitudes about promoting health. They indicated that practical experience, supportive colleagues, and a positive school ethos toward children’s health and well-being were important facilitators to teaching health education. We conclude the training is associated with a positive, long-term effect in the minority who responded, and we argue that the socio-constructivist nature of the health education training is a contributor. However, school environment factors might mitigate or support the impact of training provided during ITE.

Pre-Service Teacher Training in Health and Well-Being in England: The State of the Nation.

This paper presents findings from a survey of pre-service teacher training institutions in England with regard to the provision of health and well-being education. It examines factors affecting the inclusion of health and well-being, and explores educational implications in light of the changing landscape of pre-service teacher education in England. Provision of health and well-being education is noticeably variable across institutions, and many course leaders are unclear about the coverage in their partner schools. Course leaders regard health and well-being as an important part of the curriculum, but the focus is usually on generic health-related themes such as child protection and behaviour management, which address Government priorities, rather than on specific topics such as education about diet, drugs, alcohol, smoking, sex and relationships and physical activity. The paper argues that these aspects should be addressed for pre-service teachers to have an increased sense of self-efficacy and become capable health promoters.

Peer review of health research funding proposals: A systematic map and systematic review of innovations for effectiveness and efficiency

Objective To investigate methods and processes for timely, efficient and good quality peer review of research funding proposals in health. Methods A two-stage evidence synthesis: (1) a systematic map to describe the key characteristics of the evidence base, followed by (2) a systematic review of the studies stakeholders prioritised as relevant from the map on the effectiveness and efficiency of peer review ‘innovations’. Standard processes included literature searching, duplicate inclusion criteria screening, study keyword coding, data extraction, critical appraisal and study synthesis. Results A total of 83 studies from 15 countries were included in the systematic map. The evidence base is diverse, investigating many aspects of the systems for, and processes of, peer review. The systematic review included eight studies from Australia, Canada, and the USA, evaluating a broad range of peer review innovations. These studies showed that simplifying the process by shortening proposal forms, using smaller reviewer panels, or expediting processes can speed up the review process and reduce costs, but this might come at the expense of peer review quality, a key aspect that has not been assessed. Virtual peer review using videoconferencing or teleconferencing appears promising for reducing costs by avoiding the need for reviewers to travel, but again any consequences for quality have not been adequately assessed. Conclusions There is increasing international research activity into the peer review of health research funding. The studies reviewed had methodological limitations and variable generalisability to research funders. Given these limitations it is not currently possible to recommend immediate implementation of these innovations. However, many appear promising based on existing evidence, and could be adapted as necessary by funders and evaluated. Where feasible, experimental evaluation, including randomised controlled trials, should be conducted, evaluating impact on effectiveness, efficiency and quality.

Etelcalcetide for Treating Secondary Hyperparathyroidism: An Evidence Review Group Evaluation of a NICE Single Technology Appraisal

The manufacturer of the calcimimetic drug etelcalcetide was invited to make an evidence submission as part of the National Institute for Health and Care Excellence (NICE) Single Technology Appraisal (STA) programme. Within this submission, they reported evidence on the clinical and cost effectiveness of etelcalcetide for the treatment of secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) on haemodialysis. The Southampton Health Technology Assessments Centre (SHTAC), part of the Wessex Institute at the University of Southampton, was the independent Evidence Review Group (ERG) commissioned to appraise the company’s submission. This article describes the ERG’s review and critique of the company’s submission and summarises the NICE Appraisal Committee’s subsequent guidance (issued in June 2017). The clinical-effectiveness evidence submitted by the company consisted of two double-blind, randomised controlled trials (RCTs) comparing etelcalcetide with placebo, one RCT comparing etelcalcetide with cinacalcet, two single-arm extension studies of the above trials, and one single-arm study evaluating the effect of switching from cinacalcet to etelcalcetide. No study specifically examined the population specified in the NICE appraisal scope: patients refractory to standard therapy with phosphate binders and vitamin D (PBVD). None of these trials were designed to collect long-term efficacy data for outcomes such as mortality, bone fractures, cardiovascular events, or parathyroidectomies. Instead, biomarker data from the trials were mapped to long-term outcomes by an assumed linear relationship between the trial outcome, reduction of parathyroid hormone (PTH) by > 30%, and the log-hazard ratios for the occurrence of clinical events derived from a large, long-term RCT of cinacalcet (the EVOLVE trial). After submission of a confidential Patient Access Scheme (PAS) discount reducing etelcalcetide drug costs, the incremental cost-effectiveness ratio (ICER) for etelcalcetide versus cinacalcet was £14,778 per quality-adjusted life-year (QALY) gained in the company’s base case. While this value is lower than the NICE threshold range of £20,000 and £30,000 per QALY gained, it was the opinion of the ERG that the ICER was highly uncertain due to efficacy data limitations for etelcalcetide, inadequate synthesis of clinical-effectiveness evidence, and strong assumptions connecting short-term biomarker data with long-term clinical outcomes. The ERG produced an alternative base case for etelcalcetide versus cinacalcet, with an ICER of £22,400 per QALY gained, also subject to uncertainty. The NICE Appraisal Committee recommended etelcalcetide as an option for the treatment of SHPT in adults with CKD only if treatment with a calcimimetic is indicated and cinacalcet is not suitable, subject to the company’s provision of the agreed PAS discount.

Virtual chromoendoscopy for the real-time assessment of colorectal polyps in vivo: a systematic review and economic evaluation

BACKGROUND Current clinical practice is to remove a colorectal polyp detected during colonoscopy and determine whether it is an adenoma or hyperplastic by histopathology. Identifying adenomas is important because they may eventually become cancerous if untreated, whereas hyperplastic polyps do not usually develop into cancer, and a surveillance interval is set based on the number and size of adenomas found. Virtual chromoendoscopy (VCE) (an electronic endoscopic imaging technique) could be used by the endoscopist under strictly controlled conditions for real-time optical diagnosis of diminutive (≤ 5 mm) colorectal polyps to replace histopathological diagnosis. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of the VCE technologies narrow-band imaging (NBI), flexible spectral imaging colour enhancement (FICE) and i-scan for the characterisation and management of diminutive (≤ 5 mm) colorectal polyps using high-definition (HD) systems without magnification. DESIGN Systematic review and economic analysis. PARTICIPANTS People undergoing colonoscopy for screening or surveillance or to investigate symptoms suggestive of colorectal cancer. INTERVENTIONS NBI, FICE and i-scan. MAIN OUTCOME MEASURES Diagnostic accuracy, recommended surveillance intervals, health-related quality of life (HRQoL), adverse effects, incidence of colorectal cancer, mortality and cost-effectiveness of VCE compared with histopathology. DATA SOURCES Electronic bibliographic databases including MEDLINE, EMBASE, The Cochrane Library and Database of Abstracts of Reviews of Effects were searched for published English-language studies from inception to June 2016. Bibliographies of related papers, systematic reviews and company information were screened and experts were contacted to identify additional evidence. REVIEW METHODS Systematic reviews of test accuracy and economic evaluations were undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Meta-analyses were conducted, where possible, to inform the independent economic model. A cost-utility decision-analytic model was developed to estimate the cost-effectiveness of VCE compared with histopathology. The model used a decision tree for patients undergoing endoscopy, combined with estimates of long-term outcomes (e.g. incidence of colorectal cancer and subsequent morbidity and mortality) derived from University of Sheffield School of Health and Related Researchs bowel cancer screening model. The model took a NHS perspective, with costs and benefits discounted at 3.5% over a lifetime horizon. There were limitations in the data on the distribution of adenomas across risk categories and recurrence rates post polypectomy. RESULTS Thirty test accuracy studies were included: 24 for NBI, five for i-scan and three for FICE (two studies assessed two interventions). Polyp assessments made with high confidence were associated with higher sensitivity and endoscopists experienced in VCE achieved better results than those without experience. Two economic evaluations were included. NBI, i-scan and FICE are cost-saving strategies compared with histopathology and the number of quality-adjusted life-years gained was similar for histopathology and VCE. The correct surveillance interval would be given to 95% of patients with NBI, 94% of patients with FICE and 97% of patients with i-scan. LIMITATIONS Limited evidence was available for i-scan and FICE and there was heterogeneity among the NBI studies. There is a lack of data on longer-term health outcomes of patients undergoing VCE for assessment of diminutive colorectal polyps. CONCLUSIONS VCE technologies, using HD systems without magnification, could potentially be used for the real-time assessment of diminutive colorectal polyps, if endoscopists have adequate experience and training. FUTURE WORK Future research priorities include head-to-head randomised controlled trials of all three VCE technologies; more research on the diagnostic accuracy of FICE and i-scan (when used without magnification); further studies evaluating the impact of endoscopist experience and training on outcomes; studies measuring adverse effects, HRQoL and anxiety; and longitudinal data on colorectal cancer incidence, HRQoL and mortality. STUDY REGISTRATION This study is registered as PROSPERO CRD42016037767. FUNDING The National Institute for Health Research Health Technology Assessment programme.