Anna is a Post Doctoral Research Fellow in the School of Health Sciences at the University of Surrey. Her research focuses on the development and implementation of interventions to support the provision of good ethical care throughout the life course. Anna has a particularly interest in the care experience of older people and people with learning disabilities. Anna leads the Together Project funded by Health Education England The Together Project: Supporting the delivery of good practice in maternity services for parents with learning disabilities | University of Surrey
Areas of specialism
Affiliations and memberships
Cox, A., Lucas, G., Marcu, A. Piano, M., Grosvenor, W., Mold, F., Maguire, R. & Ream, E. (2017) Cancer Survivors’ Experience With Telehealth: A Systematic Review and Thematic Synthesis. Journal of Medical Internet Research Vol 19, No 1.
Ream E, Hughes AE, Cox A, Skarparis K, Richardson A, Pedersen VH, Wiseman T, Forbes A, Bryant A. (2020) Telephone interventions for symptom management in adults with cancer. Cochrane Database of Systematic Reviews 2020, Issue 6.
Breast cancer remains a significant scientific, clinical and societal challenge. This gap analysis has reviewed and critically assessed enduring issues and new challenges emerging from recent research, and proposes strategies for translating solutions into practice.
More than 100 internationally recognised specialist breast cancer scientists, clinicians and healthcare professionals collaborated to address nine thematic areas: genetics, epigenetics and epidemiology; molecular pathology and cell biology; hormonal influences and endocrine therapy; imaging, detection and screening; current/novel therapies and biomarkers; drug resistance; metastasis, angiogenesis, circulating tumour cells, cancer ‘stem’ cells; risk and prevention; living with and managing breast cancer and its treatment. The groups developed summary papers through an iterative process which, following further appraisal from experts and patients, were melded into this summary account.
The 10 major gaps identified were: (1) understanding the functions and contextual interactions of genetic and epigenetic changes in normal breast development and during malignant transformation; (2) how to implement sustainable lifestyle changes (diet, exercise and weight) and chemopreventive strategies; (3) the need for tailored screening approaches including clinically actionable tests; (4) enhancing knowledge of molecular drivers behind breast cancer subtypes, progression and metastasis; (5) understanding the molecular mechanisms of tumour heterogeneity, dormancy, de novo or acquired resistance and how to target key nodes in these dynamic processes; (6) developing validated markers for chemosensitivity and radiosensitivity; (7) understanding the optimal duration, sequencing and rational combinations of treatment for improved personalised therapy; (8) validating multimodality imaging biomarkers for minimally invasive diagnosis and monitoring of responses in primary and metastatic disease; (9) developing interventions and support to improve the survivorship experience; (10) a continuing need for clinical material for translational research derived from normal breast, blood, primary, relapsed, metastatic and drug-resistant cancers with expert bioinformatics support to maximise its utility. The proposed infrastructural enablers include enhanced resources to support clinically relevant in vitro and in vivo tumour models; improved access to appropriate, fully annotated clinical samples; extended biomarker discovery, validation and standardisation; and facilitated cross-discipline working.
With resources to conduct further high-quality targeted research focusing on the gaps identified, increased knowledge translating into improved clinical care should be achievable within five years.
The work demands of critical care can be a major cause of stress in intensive care unit (ICU) professionals and lead to poor health outcomes. In the process of recovery from work, psychological rumination is considered to be an important mediating variable in the relationship between work demands and health outcomes. This study aimed to extend our knowledge of the process by which ICU stressors and differing rumination styles are associated with burnout, depression and risk of psychiatric morbidity among ICU professionals.
Ninety-six healthcare professionals (58 doctors and 38 nurses) who work in ICUs in the UK completed a questionnaire on ICU-related stressors, burnout, work-related rumination, depression and risk of psychiatric morbidity.
Significant associations between ICU stressors, affective rumination, burnout, depression and risk of psychiatric morbidity were found. Longer working hours were also related to increased ICU stressors. Affective rumination (but not problem-solving pondering or distraction detachment) mediated the relationship between ICU stressors, burnout, depression and risk of psychiatric morbidity, such that increased ICU stressors, and greater affective rumination, were associated with greater burnout, depression and risk of psychiatric morbidity. No moderating effects were observed.
Longer working hours were associated with increased ICU stressors, and increased ICU stressors conferred greater burnout, depression and risk of psychiatric morbidity via increased affective rumination. The importance of screening healthcare practitioners within intensive care for depression, burnout and psychiatric morbidity has been highlighted. Future research should evaluate psychological interventions which target rumination style and could be made available to those at highest risk. The efficacy and cost effectiveness of delivering these interventions should also be considered.
People with cancer experience a variety of symptoms as a result of their disease and the therapies involved in its management. Inadequate symptom management has implications for patient outcomes including functioning, psychological well-being and quality of life (QoL). Attempts to reduce the incidence and severity of cancer symptoms have involved the development and testing of psycho-educational interventions to enhance patients' symptom self-management. With the trend for care to be provided nearer patients' homes, telephone-delivered psycho-educational interventions have evolved to provide support for the management of a range of cancer symptoms. Early indications suggest that these can reduce symptom severity and distress through enhanced symptom self-management.
To assess the effectiveness of telephone-delivered interventions for reducing symptoms associated with cancer and its treatment. To determine which symptoms are most responsive to telephone interventions. To determine whether certain configurations (active ingredients, dosage) of telephone interventions mediate observed cancer symptom outcome effects.
We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library; MEDLINE via OVID (1946 to January 2019); Embase via OVID (1980 to January 2019); CINAHL via Athens (1982 to January 2019); British Nursing Index (1984 to January 2019); and PsychINFO (1989 to January 2019). Additionally, we searched conference proceedings to identify published abstracts, and SIGLE and trial registers for unpublished studies. We also searched the reference lists of all included articles for additional relevant studies. Finally, we hand searched the following journals: Cancer, Journal of Clinical Oncology, Psycho-oncology, Cancer Practice, Cancer Nursing, Oncology Nursing Forum, Journal of Pain and Symptom Management, Palliative Medicine. Search was restricted to publications published in English.
We included randomised control trials (RCTs) and quasi-RCTs which compared one or more telephone interventions with each other, or with other types of interventions (e.g. a face-to-face intervention) and/or usual care, with the stated aim of addressing any physical or psychological symptoms of cancer and its treatment, which recruited adult (over 18 years) men and women with a clinical diagnosis of cancer, regardless of tumour type, stage of cancer, type of treatment and time of recruitment (e.g. pre, during or post treatment).
Data collection and analysis
Two review authors independently selected articles, extracted data, and appraised methodological quality and risk of bias. Disagreements were resolved through discussion, involving the entire review team where necessary. Risk of bias was assessed using the Cochrane's risk of bias tool. We had planned to conduct meta-analyses using random effects models for symptoms where there were sufficient data to enable this. Heterogeneity between study outcomes was planned to be determined through visual inspection of forest plots and calculation of the I2 statistic. Where possible, outcomes are reported as standardised mean differences (SMDs) with 95% confidence intervals (CIs) and a descriptive synthesis of study findings is presented. Findings are reported on according to symptom addressed and intervention type (e.g. telephone only or telephone combined with other elements). As many studies had small samples, and baseline scores for study outcomes often varied for intervention and control groups, change scores and associated standard deviations were used.
Thirty-two studies were eligible for the review; most had moderate risk of bias, mostly related to blinding. Collectively they recruited 6250 people. Interventions were studied in people with a variety of cancer types and across the disease trajectory although many participants had breast cancer, early stage cancers and/or were starting treatment. Symptoms measured were anxiety, depression, emotional distress, uncertainty, fatigue, pain, sexuality-related symptoms and general symptom intensity and/or distress.
Interventions were primarily (n = 24) delivered by nurses, most (n=16) had a background in oncology, research or psychiatry. Ten were delivered solely by telephone; the rest combined telephone with additional elements (face-to-face consultation, and digital/online/printed resources). Number of calls delivered ranged from 1 to 18; most provided 3 to 4 calls.
Twenty‐one studies provided evidence on effectiveness of telephone‐delivered interventions and the majority appeared to reduce symptoms of depression compared to control. Nine studies contributed quantitative change scores (CSs) and associated standard deviation results (or these could be calculated). Likewise, many telephone interventions appeared effective when compared to control in reducing anxiety (16 studies; 5 contributed quantitative CS results); fatigue (9 studies; 6 contributed to quantitative CS results); and emotional distress (7 studies; 5 contributed quantitative CS results). Due to significant clinical heterogeneity with regards to interventions introduced, study participants recruited, and outcomes measured, meta‐analysis was not conducted.
For other symptoms (uncertainty, pain, sexuality-related symptoms, dyspnoea and general symptom experience) there was limited evidence; meta-analysis was similarly not possible and the results from individual studies were largely conflicting making conclusions about their management through telephone-delivered intervention hard to draw. There was considerable heterogeneity across all trials for all outcomes.
Overall, the certainty of the evidence was low for all outcomes in the review due to uncertainty over estimates. Outcomes were all downgraded due to concerns about overall risk of bias profiles being frequently unclear and due to inconsistencies in results and general heterogeneity.
Unsubstantiated evidence suggests that telephone interventions in some capacity may have a place in symptom management for adults with cancer. However, in the absence of reliable and homogeneous evidence, caution is needed in interpreting the narrative synthesis. Further, there were no clear patterns across studies regarding which forms of interventions (telephone alone versus augmented with other elements) are most effective. It is impossible to conclude with any certainty which forms of telephone intervention are most effective in managing the range of cancer‐related symptoms that people with cancer experience.
Telephone interventions provide a convenient way of supporting self-management of cancer-related symptoms in adults with cancer. They are becoming more important with the shift of care closer to patients' homes, need for resource/cost containment and potential for voluntary-sector providers to deliver healthcare interventions. There is some evidence supporting use of telephone-delivered interventions for symptom management in adults with cancer; most evidence relates to four commonly experienced symptoms - depression, anxiety, emotional distress and fatigue. Some telephone-delivered interventions were augmented by combining them with face-to-face meetings and provision of printed or digital materials. The review was unable to determine whether telephone alone or in combination with other elements provides optimal reduction in symptoms; it appears most likely that this will vary by symptom. It is noteworthy that, despite the potential for telephone interventions to deliver cost savings, none of the studies reviewed included any form of health economic evaluation.
Further robust and adequately reported trials are needed across all cancer-related symptoms as the certainty of evidence generated in studies within this review was largely low to moderate, and reporting was of variable quality. Efforts are needed by researchers to reduce variability between studies in future. Studies in the review were characterised by both clinical and methodological diversity; the level of diversity hindered comparison across studies. At the very least, efforts should be made to standardise outcome measures. Finally, studies were compromised by having small samples, inadequate concealment of group allocation, lack of observer blinding and short length of follow up. Consequently, conclusions relating to symptoms most amenable to management by telephone-delivered intervention are tentative.
Background: Despite compelling evidence from the US of ethnic inequalities in physical functioning and ethnic differences in risk factors for poor physical functioning, very little is known about ethnic differences in the UK. Furthermore, the life stage at which these ethnic differentials are first observed has not been examined.
Methods: Using cross-sectional data from Wave 1 of the UK Household Longitudinal Study (UKHLS), we compared self-reported physical functioning among 35,816 White British, 4450 South Asian and 2512 African Caribbean men and women across different stages of adulthood (young adulthood, early middle age, late middle age, older age). Regression analyses examined ethnic differences in functional limitations, with adjustment for socioeconomic and clinical covariates. Ethnicity by sex and ethnicity by age-group interactions were examined, and subgroup heterogeneity was explored.
Results: Compared with White British adults over the age of 60, older South Asian men and women reported higher odds of functional limitations (OR 2.77 (95% CI: 2.00-3.89) and OR 3.99 (2.61-6.10) respectively); these ethnic differentials were observed as early as young adulthood. Young African Caribbean men had lower odds of functional limitations than White British men (OR 0.56 (0.34-0.94)), yet African Caribbean women reported higher odds of functional limitations in older age (OR 1.84 (1.21-2.79)).
Conclusions: There is an elevated risk of functional limitations relating to ethnicity, even in young adulthood where the impact on future health and socioeconomic position is considerable. When planning and delivering health care services to reduce ethnic inequalities in functional health, the intersectionality with age and sex should be considered.
Net survival rates for cancer are increasing worldwide, placing a strain on health service provision. There is a drive to transfer care of cancer survivors - individuals living with and beyond cancer - to the community and encourage them to play an active role in their own care. Telehealth, the use of technology in remote exchange of data and communication between patients and healthcare professionals, is an important contributor to this evolving model of care and may offer additional benefits to cancer survivors. Telehealth is a complex intervention and understanding patient experiences of it is important in evaluating its impact. However, a wider view of patient experience is lacking as qualitative studies detailing cancer survivor engagement with telehealth have yet to be synthesised.
Systematically identify, appraise and synthesise qualitative research evidence on the experiences of adult cancer survivors participating in telehealth intervention(s), to characterise the patient experience of telehealth interventions for this group.
Medline (PubMed), PsychINFO, CINAHL (Cumulative Index for Nursing and Allied Health Professionals), Embase and Cochrane Central Register of Controlled Trial were searched on 14th August 2015 and 8th March 2016 for English-language papers published between 2006 and 2016. Inclusion criteria were: adult cancer survivors aged 18 and over; cancer diagnosis; experience of participating in a telehealth intervention (defined as remote communication and/or remote monitoring with a healthcare professional(s) delivered by telephone, internet, or hand-held/mobile technology); reporting qualitative data including verbatim quotes. An adapted Critical Appraisal Skill Programme (CASP) Checklist for Qualitative Research was used to assess paper quality. The results section of each included article was coded line by line and all papers underwent inductive analysis, involving comparison, re-examination and grouping of codes to develop descriptive themes. Analytical themes were developed through an iterative process of reflection on, and interpretation of, the descriptive themes within and across studies.
22 papers were included. Three analytical themes emerged, each with three descriptive subthemes: 1. Influence of telehealth on the disrupted lives of cancer survivors a. Convenience b. Independence c. Burden 2. Personalised care in a virtual world a. Time b. Space c. The human factor 3. Remote reassurance – a safety net of healthcare professional connection a. Active connection b. Passive connection c. Slipping through the net Telehealth interventions represent a convenient approach which can potentially minimise treatment burden and disruption to cancer survivors’ lives. Telehealth interventions can facilitate an experience of personalised care and reassurance for those living with and beyond cancer, but it is important to consider individual factors when tailoring interventions to ensure engagement promotes benefit rather than burden.
Telehealth interventions can provide cancer survivors with both independence and reassurance; both important for everyday life or wellbeing. Future telehealth interventions need to be developed iteratively and in collaboration with a broad range of cancer survivors to maximise engagement and benefit.
This paper discusses findings from an immersive simulation pilot project whereby six domiciliary care-givers took on the profile of people receiving domiciliary care. Five domiciliary care-givers received care in their own homes and one received care in the training area of their domiciliary care company. Care was delivered by 2nd and 3rd year student nurses with support from a registered nurse. The following themes from post-intervention interviews and a focus group with the care-givers who assumed the profile of a care-recipient (simulants) are discussed: Recognising the need for stimulation; Reflecting on the importance of person-centred communication; The value of companionship and confidence in care-givers; Understanding boundaries and vulnerabilities; and Empathy and practice changes.
After the experience most participants reported viewing care differently and being more attuned to the wishes of care-recipients.
In order to avoid unnecessary hospital admission and associated complications, there is an urgent need to improve the early detection of infection in nursing home residents. Monitoring signs and symptoms with checklists or aids called decision support tools may help nursing home staff to detect infection in residents, particularly during the current COVID-19 pandemic. We plan to conduct a survey exploring views and experiences of how infections are detected and managed in practice by nurses, care workers and managers in nursing homes in England and Sweden.
Methods and analysis
An international cross-sectional descriptive survey, using a pretested questionnaire, will be used to explore nurses, care workers and managers views and experiences of how infections are detected and managed in practice in nursing homes. Data will be analysed descriptively and univariate associations between personal and organisational factors explored. This will help identify important factors related to awareness, knowledge, attitudes, belief and skills likely to affect future implementation of a decision support tool for the early detection of infection in nursing home residents.
Ethics and dissemination
This study was approved using the self-certification process at the University of Surrey and Linköping University ethics committee (Approval 2018/514-32) in 2018. Study findings will be disseminated through community/stakeholder/service user engagement events in each country, publication in academic peer-reviewed journals and conference presentations. A LAY summary will be provided to participants who indicate they would like to receive this information. This is the first stage of a plan of work to revise and evaluate the Early Detection of Infection Scale (EDIS) tool and its effect on managing infections and reducing unplanned hospital admissions in nursing home residents. Implementation of the EDIS tool may have important implications for the healthcare economy; this will be explored in cost–benefit analyses as the work progresses.