Natalie King

Objective This scoping review aimed to identify evidence on the barriers and enablers influencing engagement in behavioural weight management interventions among women from underserved communities living with and beyond cancer. Background Managing weight after a cancer diagnosis is complex, but may improve outcomes. However behavioural weight management interventions often fail to reach underserved women with cancer. Inclusion criteria : Sources were included if they reported barriers and/or enablers of, female adults with cancer from ethnic minority and/or lower socioeconomic status backgrounds, engaging in weight management interventions. Methods The Joanna Briggs Institute and PRISMA-ScR guidelines were followed. Database searches conducted in December 2024 were updated in January 2026. Study, participant and intervention characteristics, and engagement barriers and enablers were narratively summarised. Results Twenty-nine studies were identified; most conducted in the United States (n = 26), used qualitative methods (n = 12),engaged African American or Black women (n = 11) and focused on breast cancer (n = 19). Structural, cultural, and contextual barriers to engagement in weight management interventions were identified. Social support, flexible delivery, and culturally-tailored, holistic approaches enabled engagement. Conclusions Research in this area is growing but remains concentrated in specific populations. Future research should co-design strategies to enhance equitable access and sustained engagement, and explore barriers and enablers across more diverse populations.

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.

Purpose We systematically reviewed published and ongoing physical activity (PA) trials in women with metastatic breast cancer (MBC). We examined: i) the effectiveness of PA interventions on key outcomes, and identified: ii) the type of interventions being evaluated, iii) how they were delivered; iv) their theoretical basis. Methods Seven databases and two trial registries were searched in August 2024 for; randomised controlled trials, testing any PA intervention in people with MBC, reporting a PA outcome. The Joanna Briggs Institute (JBI) handbook was followed, including quality assessment using the JBI Critical Appraisal Checklist for RCTs. Data were summarised narratively. Intervention details were extracted using the TIDieR framework. Results 1687 records were screened and 96 assessed for eligibility. 28 reports were included (13 full reports, 4 protocols, 11 trial registries). Sample sizes ranged from 21-357 participants. 21/28 reports were phase II, pilot, or feasibility trials. Most interventions did not cover all types of recommended PA. Methodological quality of studies was moderate. Intervention adherence was moderate to high (≥50% in 10 studies). Among studies reporting on safety (9), only one recorded any serious events (two events) related to the intervention. Evidence indicates that PA can improve fatigue, health-related QoL, physical fitness and functioning over the short and medium-term (≤6 months). Conclusions Physical activity is safe, well adhered to, and improves physical function and QoL in MBC. Future trials could clarify the optimal PA type, duration, delivery mode, frequency, and long-term effectiveness. Women with MBC should be supported by healthcare professionals to be active.

Background: Information on the quality of life of people hospitalised with COVID-19 is important, both in assessing the burden of disease and the cost-effectiveness of treatments. However, there were potential barriers to collecting such evidence. Objective: To review the existing evidence on quality of life for people hospitalised with COVID-19, with a focus on the amount of evidence available and methods used. Design: A scoping review with systematic searches. Results: A total of 35 papers were selected for data extraction. The most common study type was economic evaluation ( N = 13), followed by cross-sectional ( N = 10). All economic evaluations used published utility values for other conditions to represent COVID-19 inpatients’ quality of life. The most popular quality-of-life survey measure was the Pittsburgh Sleep Quality Index ( N = 8). There were 12 studies that used a mental health-related survey and 12 that used a sleep-related survey. Five studies used EQ-5D, but only one collected responses from people in the acute phase of COVID-19. Studies reported a negative impact on quality of life for people hospitalised with COVID-19, although many studies did not include a formal comparison group. Limitations: Although it used systematic searches, this was not a full systematic review. Conclusion: Quality-of-life data were collected from people hospitalised with COVID-19 from relatively early in the pandemic. However, there was a lack of consensus as to what survey measures to use, and few studies used generic health measures. Economic evaluations for COVID-19 treatments did not use utilities collected from people with COVID-19. In future health crises, researchers should be vigilant for opportunities to collect quality-of-life data from hospitalised patients but should try to co-ordinate as well as ensuring generic health measures are used more. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR132254.

Background: High medicine prices contribute to increasing cost of healthcare worldwide. Many patients with limited resources in sub-Saharan Africa (SSA) are confronted with out-of-pocket charges, constraining their access to medicines. Different medicine pricing policies are implemented to improve affordability and availability; however, evidence on the experiences of implementations of these policies in SSA settings appears limited. Therefore, to bridge this knowledge gap, we reviewed published evidence and answered the question: what are the key determinants of implementation of medicines pricing policies in SSA countries? Methods: We identified policies and examined implementation processes, key actors involved, contextual influences on and impact of these policies. We searched five databases and grey literature; screening was done in two stages following clear inclusion criteria. A structured template guided the data extraction, and data analysis followed thematic narrative synthesis. The review followed best practices and reported using PRISMA guidelines. Results: Of the 5595 studies identified, 31 met the inclusion criteria. The results showed thirteen pricing policies were implemented across SSA between 2003 and 2020. These were in four domains: targeted public subsides, regulatory frameworks and direct price control, generic medicine policies and purchasing policies. Main actors involved were government, wholesalers, manufacturers, retailers, professional bodies, community members and private and public health facilities. Key contextual barriers to implementation were limited awareness about policies, lack of regulatory capacity and lack of price transparency in external reference pricing process. Key facilitators were favourable policy environment on essential medicines, strong political will and international support. Evidence on effectiveness of these policies on reducing prices of, and improving access to, medicines was mixed. Reductions in prices were reported occasionally, and implementation of medicine pricing policy sometimes led to improved availability and affordability to essential medicines. Conclusions: Implementation of medicine pricing policies in SSA shows some mixed evidence of improved availability and affordability to essential medicines. It is important to understand country-specific experiences, diversity of policy actors and contextual barriers and facilitators to policy implementation. Our study suggests three policy implications, for SSA and potentially other low-resource settings: avoiding a ‘one-size-fits-all’ approach, engaging both private and public sector policy actors in policy implementation and continuously monitoring implementation and effects of policies. Systematic review registration: PROSPERO CRD42020178166

Adjusting dosing regimens based on measurements of carbapenem levels may improve carbapenem exposure in patients. This systematic review aims to describe the effect carbapenem therapeutic drug monitoring (TDM) has on health outcomes, including the emergence of antimicrobial resistance (AMR). Four databases were searched for studies that reported health outcomes following adjustment to dosing regimens, according to measurements of carbapenem concentration. Bias in the studies was assessed with risk of bias analysis tools. Study characteristics and outcomes were tabulated and a narrative synthesis was performed. In total, 2 randomised controlled trials (RCTs), 17 non-randomised studies, and 19 clinical case studies were included. Significant variation in TDM practice was seen; consequently, a meta-analysis was unsuitable. Few studies assessed impacts on AMR. No significant improvement on health outcomes and no detrimental effects of carbapenem TDM were observed. Five cohort studies showed significant associations between achieving target concentrations and clinical success, including suppression of resistance. Studies in this review showed no obvious improvement in clinical outcomes when TDM is implemented. Optimisation and standardisation of carbapenem TDM practice are needed to improve intervention success and enable study synthesis. Further suitably powered studies of standardised TDM are required to assess the impact of TMD on clinical outcomes and AMR.

Dosing regimens guided by therapeutic drug monitoring (TDM) may be able to improve penicillin exposure in patients. Improved penicillin exposure could result in improved patient health outcomes. This systematic review aims to describe the impact TDM in penicillin treatment has on health outcomes, including the emergence of antimicrobial resistance (AMR). A search of four databases was conducted and supplemented with a hand search of the literature. Studies that measured concentrations of penicillins in patients, adjusted dosing regimens according to the result and reported health outcomes were selected. The risk of bias was assessed according to study type: randomized controlled trials (RCTs) were assessed with the revised Cochrane risk-of-bias tool for randomized trials (RoB2) assessment tool, the risk of bias in non-randomized studies (ROBINS-1) assessment tool was used to assess observational studies, and the Office of Health Assessment and Translation (OHAT) tool was used to assess case studies. The study characteristics were tabulated and described using a narrative synthesis. Three RCTs, 16 observational cohort studies and 9 case studies were included. None of the studies showed statistically significant improvements in health outcomes, when comparing groups receiving TDM and standard care. Five observational studies showed improvement in at least one health outcome statistically significantly associated with target attainment: mortality,^1–5 bacterial persistence,^1,4,5 ICU length of stay,⁴ treatment efficacy,^1,4,6 and suppression of AMR.⁴ However there was a high risk of bias in all of these studies for health outcomes. Most had pharmacological primary outcomes and were underpowered to detect health outcomes. All three RCTs and four (25%) observational studies found that the use of penicillin TDM was associated with improved pharmacological target attainment. Only one study was found that assessed the impact of β-lactams TDM on AMR and found that target attainment of 100% ƒT>_4×MIC was significantly associated with suppression of resistance. No studies found a detrimental effect of penicillin TDM on health outcomes. A meta-analysis was not performed due to the heterogeneity of the included studies. There is little evidence to suggest that TDM improves health outcomes, however neither health outcomes nor reductions in emergence of AMR were adequately addressed by currently published studies. The evaluation of health outcomes was not the primary aim of the majority of the included studies, consequently those that did include these outcomes were underpowered to detect a difference. Observational studies often did not take into account co-interventions, or confounding factors, resulting in a high risk of bias. Large variations in how TDM of penicillins was implemented and the different populations used meant that a quantitative synthesis of results was not suitable. Recommendations to standardize penicillin TDM are a challenge currently, as there is no clear evidence of optimal conditions. Suitably powered studies designed to assess clinical outcomes are required to resolve the ambiguity surrounding the impacts of TDM on clinical outcomes, and to address the gap of the impacts on AMR. Further, appropriate standardized protocols and concentration targets for penicillin TDM in humans need to be identified for it to be implemented successfully.

Despite the availability of several commercial rapid diagnostic tests (RDTs) developed to detect typhoid fever, the cost-effectiveness in resource-limited settings is unclear. This review aimed to ...

Rapid urbanisation presents multiple opportunities, but also poses challenges for equitable distribution of gains from socio-economic developments. This systematic review explored the role of social inclusion within the urban sustainability agenda. Sustainable urban developments were conceptualised as comprising environmental, spatial, social and economic perspectives; and social inclusion as entailing access to core services (healthcare) and resources (food). A search of five databases and grey literature returned 1,015 articles; 26 papers were included following screening using pre-determined criteria. Data was analysed thematically. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations were followed. Most included studies were from North America and few were from Africa and Asia. More empirical than conceptual studies were found, and more focused on food than healthcare. Social inclusion was generally included within the urban sustainability but was often an autonomous component, rather than mainstreamed, within urban sustainability. Social inclusion was mostly related to multiple elements of sustainability, with the greatest focus on combinations of environmental, social and economic opportunities for under privileged groups. However, less consideration was given to gender, ethnicity and other aspects of intersectionality. Multiple theories contributed to transferability of lessons. Key policy implications include prioritising the most vulnerable socially excluded populations, ensuring equal representation in urban planning, designing people-centred systems, building partnerships with communities, considering socio-cultural-political-economic contexts, and recognising both intended and unintended effects. More research is needed in low and middle-income countries (LMICs) on the role of social inclusion in achieving sustainable development, using cross-disciplinary approaches.