Public Health - Doctoral Theses
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Item The potential impact of atrial fibrillation screening in Ireland(University College Cork, 2023) Callanan, Aileen; Buckley, Claire; Bradley, Colin; Kearney, Patricia M.; Quinlan, Diarmuid; Health Service ExecutiveBackground Atrial fibrillation (AF) is the most commonly diagnosed cardiac arrhythmia globally (1-4)and is a major risk factor for ischaemic stroke (5, 6), with stroke risk increasing five-fold in the presence of AF (6). However, AF is frequently asymptomatic, and this coupled with its intermittent nature, makes diagnosis difficult (5). If identified, treatment is available which reduces stroke risk by up to two thirds (7, 8). The two primary treatment options for AF are electrical cardioversion or cardioversion with anti-arrhythmic medication or rate control drugs (9). Guidelines also recommend the use of OAC based on individual thromboembolic risk (9, 10). AF screening meets many of the World Health Organisation (WHO) criteria for screening (11) and is recommended nationally (12) and internationally (2). However, to date there is no national screening programme for AF in Ireland. A community setting such as general practice has been identified as a potential location to conduct AF screening and mobile ECG devices have been reported as the preferred screening tools (13). In Ireland, opportunistic AF case finding via pulse palpation was introduced as part of a new chronic disease management programme in January 2020 to a proportion of the population ≥ 75 years, it is available to those who are covered under the national health insurance scheme (14). Studies have reported increased morbidity and mortality associated with AF related stroke compared to non-AF related stroke (1, 15). Previously, there are no robust estimates of the burden (disability and death) associated with AF related stroke and non-AF related stroke in Ireland. This thesis (i) estimates the burden (disability and death) of AF and non-AF related strokes in the Irish context, (ii) identifies facilitators and barriers to AF screening from the perspectives of general practitioners (GPs) in primary care, and (ii) quantifies the yield and feasibility of a pilot AF screening programme in primary care in the south of Ireland. Aims The overall aim of this thesis was to explore the feasibility of opportunistic AF screening in primary care in Ireland with one-lead ECG technology. Specific aim 1: to estimate the burden of AF by investigating the association between AF related and non-AF related stroke with severe stroke outcomes and death in Ireland. Specific aim 2: to identify facilitators and barriers to AF screening in primary care in Ireland from the perspectives of GPs. Specific aim 3: to implement a pilot AF screening programme in primary care in Ireland using one-lead ECG technology. Methods A multiphase mixed method design including quantitative research conducted concurrently with an exploratory sequential design was adopted for this thesis. Three studies were conducted during the three-year research period: • Study 1 – a secondary data analysis of the Irish National Audit of Stroke (INAS). • Study 2 –a qualitative descriptive study of GPs in primary care. • Study 3 – a pilot AF screening programme in primary care in the south of Ireland. The secondary data analysis of the Irish National Audit of Stroke provides robust evidence regarding the burden of AF related stroke in Ireland and highlights the need for further stroke prevention efforts based on the magnitude of morbidity and mortality associated with AF related stroke. Data from the qualitative study was used to inform the pilot AF screening programme. Facilitators and barriers which were identified in this study were incorporated into the design of the pilot AF screening programme. The pilot AF screening study provides real world evidence regarding the implementation of an AF screening programme using one-lead ECG technology. Data from INAS were analysed using Stata SE version 17.0 statistical package. The modified Rankin scale (mRS) was used as a measure of disability. Students t-test was used to analyse difference in numeric variables, displayed as mean, minimum, maximum, range and standard deviation, Chi-square tests were used to analyse categorical variables, reported as numbers and proportions. Logistic regression was used to investigate the association between AF related stroke and non-AF related stroke, disability and death. Study 2 was a qualitative descriptive study of GPs in primary care to identify facilitators and barriers to AF screening from their perspectives. A total of 58 GPs were invited from the north Cork region to participate in individual interviews at their practices, rural and urban, with a view to recruiting a sample of up to 12 GPs. The interviews were audio-recorded, transcribed verbatim and analysed using framework analysis. Study 3 was a pilot AF screening programme in primary care in the south of Ireland using a one-lead ECG device, KardiaMobile. General practitioners (GPs) were recruited from Cork and Kerry and invited patients ≥65 years to undergo a stroke prevention initiative compromising AF screening, blood pressure check and identification of smoking status. Descriptive statistics were carried out using Stata SE 17.0 statistical package. Results Quantitative study; the association between AF related stroke and stroke severity, disability and death. During the three-year study period, 10,528 ischaemic strokes were recorded by INAS, 4489 (43%) were female with a mean age of 74 (SD 13) years. AF related strokes were found to account for approximately 31% of ischaemic strokes. Patients with AF related stroke were on average older 78 (SD 9.9) than those without AF 70 (SD14), (p<0.001) and a higher proportion were females 1433 (45%) (p 0.008). Having a severe stroke (modified Rankin scale measuring disability) was more likely in the AF related stroke group in the univariate model, OR 2.1 (1.9-2.3, p<0.001), and the multivariate model including sex, age, social position (using GMS national health insurance cover as a proxy), marital status and admission to a stroke unit, OR 1.4 (1.3-1.6, p<0.001). The association remained in sensitivity analyses and subgroup analyses providing robust estimates. The increased risk of morbidity and mortality in this study demonstrates the additional burden of AF related stroke and the potential importance of AF screening to identify unknown AF cases who can be assessed for treatment. Qualitative study; identification of facilitators and barriers to AF screening: Eight GPs, four male, four female from five practices participated. Five were from urban practices, three were from rural practices. Facilitators and barriers were sub-categorised into patient facilitators, practice facilitators, GP facilitators, patient barriers, practice barriers, GP barriers, attitudes to AF screening, willingness to facilitate and priority ranking. All eight participants expressed a willingness to engage in AF screening. Time constraints was the barrier discussed most frequently by all participants along with the need for additional staff. Programme structure was the most discussed facilitator by all participants and patient awareness campaigns. These findings were incorporated into the pilot AF screening programme. Cognisant to lack of time identified as a barrier to AF screening, the pilot screening programme used (i) 1-lead ECG device due to its ability to provide an ECG reading in 30 seconds and (ii) a short one-page clinical report form was used for the study to facilitate prompt data collection by participating GPs. Lack of clear onward referral pathways were also identified as a barrier. Thus, a detailed standard operating procedure (SOP) providing guidance on referral to secondary care was provided in the pilot screening programme. The qualitative study identified important data on facilitators and barriers that may be experienced implementing an AF screening programme in primary care and these findings were integrated into the pilot AF screening programme. Pilot AF screening study; implementation of a pilot AF screening programme in primary care in Ireland: The pilot programme was offered to over 400 GP practices. Anonymised data from 3555 eligible patients, across 34 practices (52GPs) was analysed. Of those 1720 (48%) were female, 1698 (48%) were male. The result of the screening intervention, using Kardia Mobile, was 3282 (92%) had normal readings, 101 (3%) had possible AF, 124 (4%) had unreadable or unclassified readings and 48 (1%) missing data. Of the 101 patients who had a possible AF reading, 45 (45%) had AF confirmed as per 12 lead ECG. Uptake from participants was high from both GPs and patients and the yield of the screening was 1.3%. Levels of hypertension were also high in the screened population, and it may be beneficial to incorporate AF screening into an overall stroke prevention programme focusing on a selection of the main cardiovascular risk factors including hypertension. Conclusion AF related stroke accounts for 31% of ischaemic strokes in Ireland and is associated with considerable disability and death. One third of AF related ischaemic stroke patients were diagnosed with AF on presentation with stroke. While a large proportion of those with AF are on OAC, approximately 80%, the findings demonstrate the potential need for screening. The secondary data analysis study identified high levels of morbidity and mortality associated with AF related stroke. This is a significant public health issue. Despite barriers to AF screening identified by GPs in the qualitative study, there was significant willingness to engage in the pilot AF screening programme as demonstrated by high uptake by GPs and patients. Early detection of AF in asymptomatic individuals enabled assessment for treatment. The high levels of high systolic BP detected are notable. It may be beneficial to conduct more comprehensive stroke risk assessments rather than AF screening in isolation.Item From self-stigma to self-worth: understanding self-stigma through developing, implementing and evaluating a selfstigma intervention among people living with HIV and AIDS “Change your thoughts and you change the world”(University College Cork, 2023) Ferris France, Nadine; Arensman, Ella; Matvienko-Sikar, Karen; Byrne, Elaine; Conroy, RonanBackground Stigma is a global public health threat that can have consequences for the epidemiology of HIV and other health conditions. Though research has been conducted examining stigma in the context of HIV and AIDS, disability and illness, mental health and physical deformities, much less is understood about self-stigma. HIV-related self-stigma is the result of complex interactions between social, contextual, and self factors. Self-stigma can have serious negative effects, including feelings of isolation, lower quality of life and mental health status, impaired social interaction, and reduced health service utilisation, treatment compliance and adherence. This thesis aims to better understand self-stigma among people living with HIV, in terms of what it is and how it manifests through developing, implementing and evaluating a self-stigma intervention. Methods This doctoral work adopted a mixed methods research design using an implementation science approach, and is comprised of five studies. Study 1 was an exploratory qualitative study that explored the core beliefs of people living with HIV in Ireland (Chapter 3). Study 2 was an implementation mixed methods study to examine the potential role of an inquiry-based stress reduction (IBSR) intervention in helping adults living with HIV (PLHIV) to overcome self-stigma and associated states in Zimbabwe (Chapter 4). Study 3 was an exploratory qualitative study to explore the beliefs, experiences and impacts of HIV-related self-stigma amongst adolescents and young people living with HIV in Zimbabwe (AYPLHIV) (Chapter 5). Study 4 was a qualitative study to understand the perceived impact and process of an IBSR intervention aimed at increasing self-worth and wellbeing by reducing selfstigma among AYPLHIV in Zimbabwe (Chapter 6). Finally, Study 5 was a systematic review to identify, assess and summarise the extant literature to explore what interventions exist to reduce and measure self-stigma among PLHIV (Chapter 7). Results The first study (Chapter 3) identified core beliefs and functions of self-stigma, categorising them into four main areas: disclosure; sexuality and sexual pleasure; self-perception and body; and illness and death. Findings also indicate coping strategies such as community involvement, personal development, and positive attitude. The community-based intervention using IBSR developed and evaluated in the second study, (Chapter 4) demonstrated significant reductions in self-stigma, depression, and fears around disclosure. The third study (Chapter 5), found that selfstigma is frequently experienced by AYPLHIV in Zimbabwe, leading to negative self-perceptions, impact on relationships, and isolation. The fourth study (Chapter 6) built on the findings of the previous studies to develop and evaluate a peer-led intervention for AYPLHIV, combining IBSR with creative techniques and mindfulness, resulting in improvements in self-worth, self-agency, and communication. Findings of the fifth study (Chapter 7), a systematic review of interventions to reduce self-stigma among people living with HIV, identified 31 studies using various intervention approaches, the majority of which showed promise for self-stigma reduction. Conclusion Overall, this doctoral work makes a unique and valuable contribution to the existing gaps in that it increased understanding of the causes, impacts and core-beliefs of self-stigma as well as developed and evaluated an IBSR-based intervention that demonstrates improvement in wellbeing and self-worth among adults and adolescents living with HIV. A number of recommendations for research, policy and future practice are made.Item Implementation of health and social care standards in health and social care services: development and feasibility testing of an implementation support tool(University College Cork, 2023) Kelly Daly, Yvonne; Hegarty, Josephine; O'Rourke, Niamh; Keyes, Laura M.; Health Information and Quality Authority (HIQA); Health Research BoardIntroduction Health and social care standards are complex quality improvement interventions. Standards are typically made up of evidence-based statements that describe safe, high-quality, person-centred care as an outcome or process of care delivery. They involve multiple stakeholders from multiple levels in the health system and apply to diverse services. There is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. There is a need to apply evidence-based, rigorous and transparent methods when selecting strategies to support the implementation of standards. Researchers have consistently highlighted a research-to-practice gap in this area. This PhD research aimed to develop and test an evidence- and theory-informed intervention to guide the identification of appropriate implementation strategies and the selection of tailored support tools and actions for use when implementing a set of standards. Methods The Medical Research Council (MRC) framework for developing and evaluating complex interventions guided a multi-methods sequential approach. A) Standards were conceptualised by narratively synthesising 12 definitions of standards used by standard-setting bodies internationally. B) The evidence-base was gathered by conducting: a systematic review (n=35 included studies) to identify and describe enablers and barriers to implementing (inter)nationally endorsed standards; and C) a qualitative exploration (focus groups (n=6), individual interviews (n=8)) of individuals’ (n=38) experiences, enablers and barriers to implementing nationally endorsed standards in Ireland. D) These enablers and barriers were used alongside implementation science theory, tools and methodologies to develop a digital intervention. Programme theory guided the development process. The Consolidated Framework for Implementation Research (CFIR), CFIR-ERIC (Expert Recommendations for Implementing Change) matching tool and the Behaviour Change Wheel (BCW) were used to develop a prototype of the content and interactive logic within a digital intervention. E) Co-design workshops (n=3) were held to refine the digital intervention with intended users (n=7). F) A feasibility study was undertaken with end-users (n=14) using a survey that measured acceptability, appropriateness and feasibility. Results A) There was variation in how standard-setting bodies define standards. The commonalities among definitions included the terms ‘quality’, ‘statements’ and ‘performance.’ B) Thematic statements describing enablers (n=22) and barriers (n=24) were created. The most frequently reported enablers related to available support tools, education and shared learning. The most frequently reported barriers related to a lack of knowledge of standards, staffing issues and insufficient funds. C) Six themes were generated from qualitative interviews. Key enablers identified related to teamwork, support tools, leadership and inspections. Key barriers related to workforce issues, a lack of awareness of standards and fear of inspection outcomes. D) Twenty-three enablers and barriers were prioritised using set criteria. E) Iterative feedback led to refinements of the intervention, creating the prototype for the feasibility study. The intervention was entitled SITAS (Selecting Implementation Tools and Actions for Standards). F) SITAS was perceived as acceptable and feasible in preliminary feasibility testing. Conclusion A feasible intervention was developed, enhanced by user involvement. SITAS is a practical digitally enabled intervention that can facilitate bridging the research-to-practice gap. SITAS aims to guide the process of selecting and tailoring implementation strategies to specific contexts, using core concepts of implementation science. Further research is required to undertake formal piloting on SITAS using a larger sample size before spread and scale up.Item The Kidscope Study: an analysis of a community paediatric development clinic set in a disadvantaged area of Ireland(University College Cork, 2024) Buckley, Lynn; Curtin, Margaret; Gibson, Louise; Cornally, Nicola; Harford, Katherine; Irish Research Council; Higher Education Authority; Child and Family Agency; Cork City CouncilBackground: Set in the disadvantaged community of Cork city northwest, Kidscope is the only community paediatric development clinic in Ireland to offer assessment, care, and onward referral within a highly vulnerable area. The complex healthcare intervention provides early developmental assessment and care for children aged zero to six years. Disadvantaged communities often experience a lack of empowerment and limited engagement with services, and high-quality services for children can be inconsistent and limited. Ireland’s disjointed disability system sees children from more affluent communities access health and developmental supports faster through paid private assessment. Kidscope attempts to intercept the gap within the system by providing timely and accessible health and developmental care to vulnerable children. A detailed analysis of Kidscope and its value for supporting the health and development of a vulnerable population was warranted. Methods: Analysis of Kidscope was carried out through a retrospective mixed-methods realist evaluation examining if and how engagement with Kidscope supports the health and developmental needs of vulnerable children. ‘Context (c) + mechanism (m) = outcome (o)’ configurations explained under what contexts, for whom, and how Kidscope achieves this. Underpinned by the Ecological Systems Theory and guided by the Medical Research Council Framework for Complex Interventions, realist evaluation involved three phases: 1. Develop initial programme theories (IPTs), 2. Test IPTs, and 3. Refine programme theory. From 2019 to 2023, five studies tested and refined IPTs using multiple data sources and methods of analysis. Results were collated and analysed in a convergent approach to refine programme theory and develop a set of comprehensive findings to answer the research question. Findings: Ten IPTs were tested and refined through a systematic review of international evidence and four Kidscope-specific empirical studies: a stakeholder analysis, process evaluation, experience and meaning study, and comparison study examining models of care employed in Kidscope and a hospital-based equivalent clinic. Kidscope is set in an area of social disadvantage with higher levels of adversity and complex needs. Families encounter multiple barriers to healthcare access. A long history of community collaboration provides solid foundations for implementation, and contextual elements facilitate delivery: an accessible and welcoming space cognisant of community needs; care delivered over multiple touchpoints; and, embedded practitioner training and education. Mechanisms triggering delivery of child health and developmental support include: utilising and enhancing local expertise through Infant Mental Health (IMH) approaches; relational working; timely and coordinated health and developmental assessment, care, and onward referral; care from a range of specialists; innovative and flexible implementation processes; child and family advocacy; and bridging gaps between services and sectors. Kidscope supports the health and developmental needs of vulnerable children by 1. Developing an innovative and responsive, community-driven child and family model of care, 2. Growing a coalition of IMH-informed child development professionals, 3. Building strong relationships, 4. Meaningfully engaging vulnerable families, and 5. Tackling barriers to highquality healthcare access. Conclusions: Kidscope contributes to breaking the cycle of intergenerational poverty by disrupting the impacts of exclusion to healthcare on child development. By examining interrelationships between context, mechanisms, and outcomes using a realist lens, findings explain how engagement with Kidscope supports the health and developmental needs of a vulnerable population. National healthcare policies promising efficient developmental assessment and integrated care have yet to achieve such goals. The research offers important insights into the health needs and values of a vulnerable population that can be used to thoughtfully examine models of care within contemporary child health practices in Ireland and further afield. Findings provide evidence to support implementing similar models of care across disadvantaged areas to benefit the most vulnerable in society.Item Practical new approaches to delivering biologically rational vector control in the context of conflict, displacement, extreme weather events and other natural disasters(University College Cork, 2023) Allan, Richard James; Killeen, Gerry; Cunningham, Colette; BASF Construction Chemicals ItaliaConflicts and extreme weather events have multiplied since the 1960s, disproportionately affecting some regions and displacing escalating numbers of people annually. By 2022, 114 ongoing armed conflicts, mainly in countries with endemic vector borne diseases (VBD), left 274 million people dependent on humanitarian assistance, including 103 million forcibly displaced facing dreadful journeys, often without shelter, followed by years living in camps. The UN predict numbers needing humanitarian assistance will rise to 339 million during 2023. Extreme events often generate hazardous environmental conditions in which arthropod vectors thrive and human vulnerability to VBD increases. Related morbidity and mortality rates escalate in the early weeks of new humanitarian crises, remaining high until implementation of effective vector control (VC) measures. In the most challenging contexts, disease transmission may continue uncontrolled due to lack of suitable VC tools. Roll Back Malaria halved annual malaria deaths by 2015, and averted 2 billion malaria cases (2000 to 2021). Distribution of >2.5 billion insecticide treated nets (ITNs) and targeted indoor residual spraying were credited for 69% and 10% of cases averted, respectively. These tools exploit the specialized behaviours of just a few largely nocturnal mosquito species, together with humans’ night-time behaviour in houses, making these very efficient malaria vectors highly vulnerable to control. Mosquito species without this sterotypical behaviour may avoid control and continue to transmit malaria. For homeless displaced people sleeping outside or in flimsy temporary shelters in high malaria burden countries in Africa, standard VC house tools can be poorly adapted. Between 2015 and 2021, annual global malaria deaths rose by 41%; just eleven countries accounted for 80% of these, with eight affected by humanitarian crises. This thesis covers research investigating the feasibility, acceptability, durability, and effectiveness of existing and new VC measures for suppressing disease transmission throughout the hellish journeys of the forced displaced. The first study compared 12-month performance of Interceptor® LLIN and conventional ITNs amongst returnees to rural villages in Liberia. User-perceived effectiveness drove high (94%) retention and utilization, with 11 >50% reduction of malaria prevalence. Laboratory analysis revealed just 22% total insecticide loss in Interceptor® over 12 months. The durability of the LLINs most commonly distributed in 2000-2011 (Interceptor®, Olyset® and Permanet®) was investigated amongst displaced and host families living in grass and stick shelters and mud huts, during conflict in Chad. Fourteen months post-distribution, standard hole index (STI) categorisation classed 69.5% of LLIN in “poor” or “very poor” condition, with “poor” condition 4.2 times more likely in polyester compared to polyethylene LLINs. Performance of PermaNet® Dumuria, an innovative non-mesh polyester LLIN, with UV protectant, was assessed amongst nomadic people sleeping outdoors in north-east Kenya. Data analysis revealed 95.3% of respondents liked this LLIN at 12 months, with 98.0% retention at 22 months and 97.1% nets in “good” condition (STI); acceptable insecticide levels (WHO definition) were found in 100% and 66.7% of nets after 18 and 22 months outdoor usage, respectively. Studies exploring an alternative VC option for displaced populations confirmed that temporary shelters constructed fully with novel insecticide-treated plastic sheeting were safe and reduced malaria incidence among young refugee children by 61% in camps in Sierra Leone. Finally, a randomised cluster trial of durable wall lining (DWL) was carried out amongst Liberian returnees. The DWLs contained Abamectin and Fenpyroximate, never previously used for controlling malaria mosquitoes. DWL installed on internal walls and ceilings of houses in 20 villages resulted in a reduction of malaria 12 months later (p=0.022), although this effect was limited to upland villages. Rapid reduction of bioefficacy after 12 months indicates the need for further research and development. In conclusion, this thesis helps inform practical and biologically-rational VC planning in different humanitarian crises’ contexts. It provides insights into the overall effectiveness of conventional and practical technical variations on the deployment of insecticide-treated materials to physically shelter crisis victims and target the anthropophagic vectors responsible for most of their night-time malaria exposure. The thesis reviews published work on the need to integrate VC strategies and develop new tools, to control the wider range of 12 insects that then thrive among living conditions associated with newly settled human communities as populations emerge from crisis and either resettle back into their rural homes or move permanently into poor, overcrowded, informal urban settlements.