Edward J. D. Webb

Background: Due to rapid urbanization, in many low- and middle-income countries (LMICs), urban primary healthcare (PHC) systems are not compatible with meeting the growing need for healthcare services. However, limited research exists on what patients consider important when seeking PHC services from various types of providers in LMICs like Bangladesh. This study aimed to identify and prioritise attributes to develop a discrete choice experiment (DCE) intended to elicit PHC preferences among people living in the slums of Dhaka, Bangladesh. Methods: To identify and prioritise key attributes for developing choice sets for DCE in a local context, we followed a two-phase process. In the first phase, attributes were identified through: (a) a systematic review of relevant literature, (b) four focus group discussions with community members who had and had not utilised PHC services in the past year, and (c) eight key informant interviews with supply-side stakeholders. In the second phase, the attributes were reduced and refined through (d) a ranking exercise with 15 community participants, (e) one-to-one consultations with four urban health experts, and (f) pretesting the draft DCE instrument. Results: The systematic review, FGDs, and KIIs together yielded a long list of 25 attributes, which was reduced to 12 for the community ranking exercise. Six attributes were finally selected for the DCE: travel time to reach a healthcare centre, waiting time, type of healthcare provider, recommendation from neighbours/relatives, consultation fee, and medicine expenditure. Attribute levels reflected the range of experiences identified in the qualitative data analysis and were refined through expert consultation and pretesting. During pretesting, comprehension of attributes and levels was found to be difficult for people with low literacy and these difficulties were addressed through revising the wording and introducing graphical Q-cards. Conclusions: This study contributes to the existing literature on the development of attributes and levels for a DCE. By documenting a transparent, replicable process, this study offers researchers a practical worked example of developing DCE attributes in understudied low-income urban settings.

Chronic hepatitis B virus (HBV) infection is a global public health problem, and many regions of Sub‐Saharan Africa are disproportionately affected, including Cameroon, where prevalence has previously been shown to be high. This study aimed to provide up‐to‐date estimates of HBV prevalence in Cameroon. We searched Medline, Global Health, Embase, Web of Science, Cochrane Library, Africa Index Medicus and the Journal of Health Science and Disease at the University of Yaounde. We included studies reporting HBV surface antigen (HBsAg) prevalence in the general population and subpopulations. A random‐effects meta‐analysis was used to generate pooled estimates of HBsAg prevalence, overall and for population subgroups including those considered at relatively higher‐risk and relatively lower‐risk of HBV infection. Heterogeneity was assessed using the index of heterogeneity ( I ² ). Quality was assessed using the Joanna Briggs Institute critical appraisal tool. Out of 1236 records, 92 papers with 100 studies were included in the meta‐analysis. Overall prevalence of HBV in Cameroon was 9.98% (95% confidence interval [CI] 9.00–11.02) with high heterogeneity ( I ² = 98.10% ) . The prevalences for relatively lower‐risk and higher‐risk populations were8.94% (95% CI 7.84–10.11) and 12.70% (95% CI 10.28–15.32), respectively. In subgroup analyses, we found that sex, geographical area (regions), population risk groups and study design were the main sources of heterogeneity. Overall, HBV prevalence remains high in Cameroon. Our findings suggest an urgent need for health interventions to halt the spread of the disease, with particular attention needed for males and regions with the highest prevalence.

Introduction: Avoidable and unfair variation in access to palliative care exists for different groups of people and communities. Primary and community care teams deliver most palliative care and care to people at the end of life at home but the quality of care provided is variable. This is an under-researched area and receives little attention in service design and policy. This study will investigate the key contexts, resources and components required for an integrated approach to palliative care to deliver improved and more equitable outcomes for patients and carers. Methods and analysis: This mixed-methods study adopts a realist methodological approach, and comprises four work packages: A multi-perspective mixed-methods study to understand patient preferences and priorities in palliative care, prioritising recruitment of patients and family members/carers from areas of socioeconomic deprivation. Data collection will comprise: (1) qualitative interviews, (2) review of patient case notes and (3) a discrete choice experiment. Realist analysis will result in the development of theory based on the identification of the key contexts and underlying mechanisms required to achieve beneficial outcomes through an integrated approach to palliative care. A realist evaluation of existing integrated models of palliative care will involve theory-refining interviews and theory-consolidating focus groups with professionals working in three different service areas. Dynamic simulation modelling of the healthcare resources needed to deliver the proposed integrated approach, ensuring quality and equity. The theoretical and economic modelling will be tested out at two expert stakeholder workshops to determine the key enablers to implementation in practice. Patient and public involvement: The study design was informed by patient and public involvement (PPI) with 16 patients and members of the public from diverse and socioeconomically deprived communities for 12 months in a National Institute for Health and Care Research-funded palliative care partnership. PPI will be continuous throughout the study, prioritising inclusivity. Ethics and dissemination: Ethical approval was obtained from the East of Scotland Research Ethics Service Research Ethics Committee 2, on 20 August 2025 (IRAS ID: 354755) and Health Research Authority approval on 1 October 2025. The targeted dissemination strategy will include outputs and resources for key audiences including patients and families, professionals in primary care and specialist palliative care and service commissioners. The results will inform service delivery to reduce inequities and optimise the use of finite resources to maximise impact. Trial registration details: The study is registered with the ISRCTN UK Clinical Study Registry: https://www.isrctn.com/ISRCTN61092011 .

Background: Strengthening urban primary healthcare (PHC) systems in low- and middle-income countries (LMICs) is essential to effectively serve the growing urban poor. Such reforms should incorporate patient opinions to ensure accessible and affordable services. However, there is limited evidence on patient preferences for PHC providers in these settings. We aimed to conduct a systematic review of the evidence on the attributes reported by patients when choosing PHC providers in urban LMICs. Methods: A search was performed across MEDLINE, Embase, Global Health, Web of Science, PsycINFO, and Scopus bibliographic databases, as well as grey literature sources, from their earliest entries until March 30, 2024. Studies examining the revealed or stated preferences of populations for PHC providers in urban LMIC settings were included. We descriptively analysed and compared these studies, assessing their methodological quality using checklists for Conjoint Analysis studies and the Mixed Methods Appraisal Tool. Results: Our findings are reported according to PRISMA guidelines. The search yielded 5,089 citations, of which 28 met the eligibility criteria for this review. We identified 203 attributes across selected studies. The most frequently reported attributes were cost of services ( n = 25) and distance/proximity ( n = 24), followed by provider behaviour/attitude ( n = 19) and quality of care ( n = 17). Most studies identified the availability of medicine/equipment, distance/proximity, healthcare provider type, and quality of care as the most valued attributes. Eighteen studies examined preference heterogeneity, considering socioeconomic factors such as education, gender, age, severity of illness, and income, with severity of illness being the most significant factor. Conclusions: Prioritising patient preferences in health system reforms is essential for equitable and sustainable healthcare in rapidly urbanising LMICs. Our review highlights the most valued attributes in preference studies, which will help policymakers and researchers tailor better PHC interventions to meet urban community needs and guide future studies on PHC preferences in similar settings.

Background: Early in the COVID-19 pandemic, there was concern about potentially unnecessary antibiotic prescribing in the National Health Service. Procalcitonin testing was being used in some hospitals to guide antibiotic use. This study aimed to investigate the impact of procalcitonin testing on United Kingdom’s antibiotic prescribing and health outcomes. Methods: Mixed-methods study comprising quantitative, qualitative and health economic work packages, including a: survey of National Health Service hospitals to understand procalcitonin use retrospective, controlled, interrupted time series analysis of aggregated, organisation-level data, including antibiotic dispensing, hospital activity and procalcitonin testing from acute hospital trusts/hospitals in England/Wales. Primary outcome: change in level and/or trend of antibiotic prescribing rates following introduction of procalcitonin multicentre, retrospective, cohort study of 5960 patients using patient-level clinical data from 11 trusts/health boards to determine the difference in early antibiotic prescribing between COVID-19 patients who did/did not have baseline procalcitonin testing by using propensity score matching. Primary outcome: days of early antibiotic therapy qualitative study exploring the decision-making process around antibiotic use for inpatients with COVID-19 pneumonia to identify the contextual factors, feasibility and acceptability of procalcitonin testing algorithms health economic analysis evaluating the cost-effectiveness of baseline procalcitonin testing using the matched data within a decision-analytic model. Setting: Acute hospital trusts/health boards in England/Wales. Participants: Inpatients ≥ 16 years, admitted to participating trusts/health boards and with a confirmed positive COVID-19 test between 1 February 2020 and 30 June 2020, National Health Service healthcare workers. Results: Early in the COVID-19 pandemic, procalcitonin use was expanded/introduced in many National Health Service hospitals, with variation in guidance and interpretation of results. The number of hospitals using procalcitonin in emergency/acute admissions rose from 17 (11%) to 74/146 (50.7%), and its use in intensive care unit increased from 70 (47.6%) to 124/147 (84.4%). Introduction of procalcitonin testing in emergency departments/acute medical admission units was associated with a statistically significant decrease in antibiotic use, which was not sustained. Patient-level data showed that baseline procalcitonin testing was associated with an average reduction in early antibiotic prescribing of 0.43 days (95% confidence interval: 0.22 to 0.64 days, p < 0.001) and a reduction of 0.72 days (95% confidence interval: 0.06 to 1.38 days, p = 0.03) in total antibiotic prescribing, with no increased mortality/hospital length of stay. Interviews revealed concerns about secondary bacterial infections that led to increased antibiotic prescribing in COVID-19 patients. As experience increased, clinician’s ability to distinguish between COVID-19 alone and bacterial coinfections increased. Antibiotic prescribing decisions were influenced by factors such as senior support, situational factors and organisational influences. The health economic analysis concluded that baseline procalcitonin testing was more likely to be cost-effective than not, albeit with some uncertainty. Conclusion: Baseline procalcitonin testing appears to have been an effective antimicrobial stewardship tool during the first wave of the pandemic, reducing antibiotic prescribing without evidence of harm. Limitations: The retrospective, hospital record-based studies were limited by missing data, incorrectly recorded information and lack of randomisation. Interviews with clinicians were conducted more than a year after the first wave, potentially resulting in recall bias. Future work: This study highlights the need for adaptive, inclusive, wide-reaching trials of infection diagnostics and implementation research to assess clinical utility before routine introduction into clinical practice. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR132254.

Background: Improving support for unpaid carers is a policy priority internationally, yet there are few reliable population estimates on numbers of end of life carers, and little is known about the demographic characteristics of this group. Aim: (1) Estimate the number of unpaid end of life carers in the UK; (2) Describe demographic characteristics of this group. Design: An observational study using data from the UK Household Longitudinal Survey (Understanding Society), Health Survey for England and the Office for National Statistics to estimate the number of end of life carers in the UK. Understanding Society was used to explore characteristics of end of life carers including poverty before and after bereavement. Participants: Understanding Society collects annual data on around 40,000 households in the UK, including carers. Results: Data from Understanding Society suggests there are 150,000–180,000 unpaid end of life care in the UK each year, while data from Health Survey for England suggests a higher estimate at 570,000–775,000 carers. End of life carers are more likely to be older and female. There is an increase in the percentage of carers falling into poverty one year after they provided care. Conclusions: These analyses have provided the first estimate of the number of end of life carers in the UK, using methods which are replicable in other countries. Our data provide a useful benchmark both for the UK and for other comparable high income countries. Many end of life carers are living in poverty, including after bereavement, showing a need for policy initiatives to provide support.

With a disproportionate burden of chronic diseases and severe shortage of health workers in sub-Saharan Africa, the region implicitly relies on informal caregivers (ICGs) to support the patients both within and outside the health facilities. The aim of this review is to systematically summarise evidence on the health and economic impact of caregiving on informal caregivers of patients with chronic diseases in sub-Saharan Africa. Medline (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Embase (Ovid), Global Health, and Web of Science databases were systematically searched to identify original articles that considered the economic and/or health impacts of caregiving in sub-Saharan Africa. The results from the included studies were synthesised narratively. After screening 4,951 records, 47 studies were included for synthesis. The articles were from all sub-regions of sub-Saharan Africa with more than half (25/47) of the studies focussing on caregivers for patients with cancer. Although the primary motivation for becoming caregivers was love and responsibility, the caring responsibilities described in twenty studies, had profound effects on the caregiver’s lives. Healthwise, the informal caregivers experienced changes in their physical and mental health like developing musculoskeletal problems and depression. Economically, caregiving was expensive, and financially draining. The opportunity cost of caregiving included loss of jobs, loss of income, foregoing planned important activities and missed education opportunities. Informal caregivers reported a range of mainly negative health and economic effects of the work they do. Health care systems should consider how to better support caregivers in terms of their own physical and mental wellbeing. Also, governments should develop strategies to financially support informal caregivers.

Background: Many hospitals introduced procalcitonin (PCT) testing to help diagnose bacterial coinfection in individuals with COVID-19, and guide antibiotic decision-making during the COVID-19 pandemic in the UK. Objectives: Evaluating cost-effectiveness of using PCT to guide antibiotic decisions in individuals hospitalized with COVID-19, as part of a wider research programme. Methods: Retrospective individual-level data on patients hospitalized with COVID-19 were collected from 11 NHS acute hospital Trusts and Health Boards from England and Wales, which varied in their use of baseline PCT testing during the first COVID-19 pandemic wave. A matched analysis (part of a wider analysis reported elsewhere) created groups of patients whose PCT was/was not tested at baseline. A model was created with combined decision tree/Markov phases, parameterized with quality-of-life/unit cost estimates from the literature, and used to estimate costs and quality-adjusted life years (QALYs). Cost-effectiveness was judged at a £20 000/QALY threshold. Uncertainty was characterized using bootstrapping. Results: People who had baseline PCT testing had shorter general ward/ICU stays and spent less time on antibiotics, though with overlap between the groups’ 95% CIs. Those with baseline PCT testing accrued more QALYs (8.76 versus 8.62) and lower costs (£9830 versus £10 700). The point estimate was baseline PCT testing being dominant over no baseline testing, though with uncertainty: the probability of cost-effectiveness was 0.579 with a 1 year horizon and 0.872 with a lifetime horizon. Conclusions: Using PCT to guide antibiotic therapy in individuals hospitalized with COVID-19 is more likely to be cost-effective than not, albeit with uncertainty.

Background: Long-term health conditions can affect labour market outcomes. COVID-19 may have increased labour market inequalities, e.g. due to restricted opportunities for clinically vulnerable people. Evaluating COVID-19’s impact could help target support. Aim: To quantify the effect of several long-term conditions on UK labour market outcomes during the COVID-19 pandemic and compare them to pre-pandemic outcomes. Methods: The Understanding Society COVID-19 survey collected responses from around 20,000 UK residents in nine waves from April 2020-September 2021. Participants employed in January/February 2020 with a variety of long-term conditions were matched with people without the condition but with similar baseline characteristics. Models estimated probability of employment, hours worked and earnings. We compared these results with results from a two-year pre-pandemic period. We also modelled probability of furlough and home-working frequency during COVID-19. Results: Most conditions (asthma, arthritis, emotional/nervous/psychiatric problems, vascular/pulmonary/liver conditions, epilepsy) were associated with reduced employment probability and/or hours worked during COVID-19, but not pre-pandemic. Furlough was more likely for people with pulmonary conditions. People with arthritis and cancer were slower to return to in-person working. Few effects were seen for earnings. Conclusion: COVID-19 had a disproportionate impact on people with long-term conditions’ labour market outcomes.