BackgroundStepped wedge randomised trial designs involve sequential roll-out of an intervention to participants (individuals or clusters) over a number of time periods. By the end of the study, all participants will have received the intervention, although the order in which participants receive the intervention is determined at random. The design is particularly relevant where it is predicted that the intervention will do more good than harm (making a parallel design, in which certain participants do not receive the intervention unethical) and/or where, for logistical, practical or financial reasons, it is impossible to deliver the intervention simultaneously to all participants. Stepped wedge designs offer a number of opportunities for data analysis, particularly for modelling the effect of time on the effectiveness of an intervention. This paper presents a review of 12 studies (or protocols) that use (or plan to use) a stepped wedge design. One aim of the review is to highlight the potential for the stepped wedge design, given its infrequent use to date.MethodsComprehensive literature review of studies or protocols using a stepped wedge design. Data were extracted from the studies in three categories for subsequent consideration: study information (epidemiology, intervention, number of participants), reasons for using a stepped wedge design and methods of data analysis.ResultsThe 12 studies included in this review describe evaluations of a wide range of interventions, across different diseases in different settings. However the stepped wedge design appears to have found a niche for evaluating interventions in developing countries, specifically those concerned with HIV. There were few consistent motivations for employing a stepped wedge design or methods of data analysis across studies. The methodological descriptions of stepped wedge studies, including methods of randomisation, sample size calculations and methods of analysis, are not always complete.ConclusionWhile the stepped wedge design offers a number of opportunities for use in future evaluations, a more consistent approach to reporting and data analysis is required.

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This paper highlights the major challenges and considerations for addressing COVID-19 in informal settlements. It discusses what is known about vulnerabilities and how to support local protective action. There is heightened concern about informal urban settlements because of the combination of population density and inadequate access to water and sanitation, which makes standard advice about social distancing and washing hands implausible. There are further challenges to do with the lack of reliable data and the social, political and economic contexts in each setting that will influence vulnerability and possibilities for action. The potential health impacts of COVID-19 are immense in informal settlements, but if control measures are poorly executed these could also have severe negative impacts. Public health interventions must be balanced with social and economic interventions, especially in relation to the informal economy upon which many poor urban residents depend. Local residents, leaders and community-based groups must be engaged and resourced to develop locally appropriate control strategies, in partnership with local governments and authorities. Historically, informal settlements and their residents have been stigmatized, blamed, and subjected to rules and regulations that are unaffordable or unfeasible to adhere to. Responses to COVID-19 should not repeat these mistakes. Priorities for enabling effective control measures include: collaborating with local residents who have unsurpassed knowledge of relevant spatial and social infrastructures, strengthening coordination with local governments, and investing in improved data for monitoring the response in informal settlements.

BackgroundEmpathy is frequently cited as an important attribute in physicians and some groups have expressed a desire to measure empathy either at selection for medical school or during medical (or postgraduate) training. In order to do this, a reliable and valid test of empathy is required. The purpose of this systematic review is to determine the reliability and validity of existing tests for the assessment of medical empathy.MethodsA systematic review of research papers relating to the reliability and validity of tests of empathy in medical students and doctors. Journal databases (Medline, EMBASE, and PsycINFO) were searched for English-language articles relating to the assessment of empathy and related constructs in applicants to medical school, medical students, and doctors.ResultsFrom 1147 citations, we identified 50 relevant papers describing 36 different instruments of empathy measurement. As some papers assessed more than one instrument, there were 59 instrument assessments. 20 of these involved only medical students, 30 involved only practising clinicians, and three involved only medical school applicants. Four assessments involved both medical students and practising clinicians, and two studies involved both medical school applicants and students.Eight instruments demonstrated evidence of reliability, internal consistency, and validity. Of these, six were self-rated measures, one was a patient-rated measure, and one was an observer-rated measure.ConclusionA number of empathy measures available have been psychometrically assessed for research use among medical students and practising medical doctors. No empathy measures were found with sufficient evidence of predictive validity for use as selection measures for medical school. However, measures with a sufficient evidential base to support their use as tools for investigating the role of empathy in medical training and clinical care are available.

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Standardised mortality rates are a poor measure of the quality of hospital care and should not be a trigger for public inquiries such as the investigation at the Mid Staffordshire hospital, say Richard Lilford and Peter Pronovost