ObjectivesTo systematically review the evidence base for a systems approach to healthcare design, delivery or improvement.DesignSystematic review with meta-analyses.MethodsIncluded were studies in any patients, in any healthcare setting where a systems approach was compared with usual care which reported quantitative results for any outcomes for both groups. We searched Medline, Embase, HMIC, Health Business Elite, Web of Science, Scopus, PsycINFO and CINAHL from inception to 28 May 2019 for relevant studies. These were screened, and data extracted independently and in duplicate. Study outcomes were stratified by study design and whether they reported patient and/or service outcomes. Meta-analysis was conducted with Revman software V.5.3 using ORs—heterogeneity was assessed using I2 statistics.ResultsOf 11 405 records 35 studies were included, of which 28 (80%) were before-and-after design only, five were both before-and-after and concurrent design, and two were randomised controlled trials (RCTs). There was heterogeneity of interventions and wide variation in reported outcome types. Almost all results showed health improvement where systems approaches were used. Study quality varied widely. Exploratory meta-analysis of these suggested favourable effects on both patient outcomes (n=14, OR=0.52 (95% CI 0.38 to 0.71) I2=91%), and service outcomes (n=18, OR=0.40 (95% CI 0.31 to 0.52) I2=97%).ConclusionsThis study suggests that a systems approaches to healthcare design and delivery results in a statistically significant improvement to both patient and service outcomes. However, better quality studies, particularly RCTs are needed.PROSPERO registration numberCRD42017065920.

The paper reports an evidence synthesis of how loneliness is conceptualised in qualitative studies in adults. Using PRISMA guidelines, our review evaluated exposure to or experiences of loneliness by adults (aged 16+) in any setting as outcomes, processes, or both. Our initial review included any qualitative or mixed-methods study, published or unpublished, in English, from 1945 to 2018, if it employed an identified theory or concept for understanding loneliness. The review was updated to include publications up to November 2020. We used a PEEST (Participants, Exposure, Evaluation, Study Design, Theory) inclusion criteria. Data extraction and quality assessment (CASP) were completed and cross-checked by a second reviewer. The Evidence of Reviews of Qualitative Research (CERQual) was used to evaluate confidence in the findings. We undertook a thematic synthesis using inductive methods for peer-reviewed papers. The evidence identified three types of distinct but overlapping conceptualisations of loneliness: social, emotional, and existential. We have high confidence in the evidence conceptualising social loneliness and moderate confidence in the evidence on emotional and existential loneliness. Our findings provide a more nuanced understanding of these diverse conceptualisations to inform more effective decision-making and intervention development to address the negative wellbeing impacts of loneliness.

Distinction is critical for good healthcare

Background: Social capital is often cited as shaping impacts of participatory arts, although the concept has not been systematically mapped in arts, health and wellbeing contexts. In wider health inequalities research, complex, differential, and sometimes negative impacts of social capital have been recognised. Methods: This paper maps of social capital concepts in qualitative research as part of the UK What Works for Wellbeing evidence review programme on culture, sport and wellbeing. Results: Studies often cite positive impacts of bonding and, to a lesser extent, bridging social capital. However, reported challenges suggest the need for a critical approach. Forms of linking social capital, such as reframing and political engagement to address social divisions, are less often cited but may be important in participatory arts and wellbeing. Conclusions: Future research should further specify dimensions of social capital as well as their nuanced effects in arts, and wellbeing contexts.

Objectives To describe cervical cancer screening participation among women who have sex exclusively with women (WSEW) and women who have sex with women and men (WSWM) compared with women who have sex exclusively with men (WSEM), and women who have never had sex and compare this with bowel (colorectal) and breast screening participation. To explore whether there is evidence of differential stage 3 cervical intraepithelial neoplasia (CIN3) or cervical cancer risk. Methods We describe cervical, bowel and breast cancer screening uptake in age groups eligible for the national screening programmes, prevalent CIN3 and cervical cancer at baseline, and incident CIN3 and cervical cancer at five years follow-up, among 218,674 women in UK Biobank, a cohort of healthy volunteers from the UK. Results Compared with WSEM, in adjusted analysis [odds ratio (95% confidence interval)], WSEW 0.10 (0.08–0.13), WSWM 0.73 (0.58–0.91), and women who have never had sex 0.02 (0.01–0.02) were less likely to report ever having attended cervical screening. There were no differences when considering bowel cancer screening uptake ( p = 0.61). For breast cancer screening, attendance was lower among WSWM 0.79 (0.68 to 0.91) and women who have never had sex 0.47 (0.29–0.58), compared with WSEM. There were incident and prevalent cases of both CIN3 and cervical cancer among WSEW and WSWM. Compared with WSEM with a single male partner, among WSEW there was a twofold increase in CIN3 1.91 (1.01 to 3.59); among WSWM with only one male partner, this was 2.25 (1.19 to 4.24). Conclusions These findings highlight the importance of improving uptake of cervical screening among all women who have sex with women and breast screening among WSWM and women who have never had sex.

The impact of losing a limb in military service extends well beyond initial recovery and rehabilitation, with long-term consequences and challenges requiring health-care commitments across the lifecourse. This paper presents a systematic review of the current state of knowledge regarding the long-term impact of ageing and limb-loss in military veterans. Key databases were systematically searched including: ASSIA, CINAHL, Cochrane Library, Medline, Web of Science, PsycArticles/PsychInfo, ProQuest Psychology and ProQuest Sociology Journals, and SPORTSDiscus. Empirical studies which focused on the long-term impact of limb-loss and/or healthcare requirements in veterans were included. The search process revealed  papers relevant for inclusion. These papers focused broadly on four themes: (a) long-term health outcomes, prosthetics use and quality of life; (b) long-term psychosocial adaptation and coping with limb-loss; (c) disability and identity; and (d) estimating the long-term costs of care and prosthetic provision. Findings present a compelling case for ensuring the long-term care needs and costs of rehabilitation for older limbless veterans are met. A dearth of information on the lived experience of limb-loss and the needs of veterans' families calls for further research to address these important issues.

Invisibility is an issue that affects a number of minority groups. There can be an assumption that there is no difference between the minority group and the majority and no effort is made to check whether this assumption holds true. Even where there might be evidence to the contrary, this can be discounted, leading to minority group concerns being not reported or underreported. This marginalization forms part of the institutional discrimination that minority groups can face.

BackgroundEpidemiological evidence for specific long-term conditions is required to inform best practices regarding the substantial health inequalities experienced by sexual minority individuals compared with heterosexual peers.AimTo describe inequalities in long-term conditions among sexual minority (lesbian, gay, and bisexual [LGB]) adults.Design & settingCross-sectional analysis of 1 341 339 nationally representative survey responses from the English GP Patient Survey (GPPS).MethodStratifying by sex, the weighted prevalence and covariate-adjusted association of 15 long-term conditions were calculated, comparing sexual minority and heterosexual adults, considering variation by sexual orientation and variation in sexual orientation inequalities by deprivation, ethnic group, region, and age.ResultsAfter adjusting for deprivation, ethnic group, region, and age, 13 long-term conditions (all except cancer and hypertension) were more prevalent among sexual minority women than their heterosexual peers, with the largest inequalities for mental health problems (odds ratio [OR] 2.8, 95% confidence interval [CI] = 2.7 to 3.0), neurological conditions (OR 1.7, 95% CI = 1.5 to 1.8), dementia (OR 1.6, 95% CI = 1.3 to 1.9), and back problems (OR 1.4, 95% CI = 1.3 to 1.5). It was found that nine long-term conditions were also more prevalent among sexual minority men including mental health problems (OR 2.3, 95% CI = 2.2 to 2.4), 'all other conditions' (OR 1.8, 95% CI = 1.7 to 1.8), neurological conditions (OR 1.5, 95% CI = 1.4 to 1.6), and kidney or liver disease (OR 1.4, 95% CI = 1.3 to 1.5); inequalities were often largest for bisexual adults. Inequalities did not vary significantly by deprivation, ethnic group, or region except for mental health problems. Inequalities in multimorbidity were highest at younger ages; for example, LGB women aged 18–24 years had multimorbidity at the same level (approximately 20%) as heterosexual women aged 45–54 years.ConclusionSexual minority adults, especially bisexual adults, are at elevated risk for many long-term conditions and multimorbidity; this risk spans socioeconomic status and ethnic group, representing a significant healthcare challenge.