facilitating case study discussion

How To Facilitate A Case Study Workshop Session

A case study can be used as part of a training workshop to facilitate a learning point or as part of an assessment programme to gauge candidate’s response and analysis of situations. Case studies can be great for sharing experiences and reaffirming knowledge and understanding.

Here are some reasons to give a case study a try:

• increases awareness of a problem and helps teams formulate possible solutions.
• exchanges ideas and helps team members share past experiences.
• helps to analyse a problem and reach a decision as a team.
• facilitates and reaffirms key learning points.

Pre-printed scenario cards (optional)

Space Required:

Small. Classroom or training room

Group Size:

6 to 16 people

Total Time:

• 5 minutes to introduction and setup
• 10 minutes per case study for analysis and discussion (based on 4 case studies)
• 5 minutes for final review and case study debrief

Case Study Setup

Select the topic or theme that you were like to focus on during the training exercise. Prepare some possible scenarios or research articles related to the subject.

Case studies should be descriptions of events that really happened or fictional but based on reality. When leading the exercise, you can present the case study yourself, provide it in written form or even use videos or audio clips.

When I lead case studies sessions, I normally print the question on a piece of A4 paper and laminate them ready for workshop.

Case Study Instructions

From experience, I have found that a case studies session can be delivered two different ways.

The first way is to simply provide the group with a scenario and let them discuss it together as one big group.

The alternative is to split the group into smaller sub-groups and provide each group with the scenario. Once all groups have an opportunity to analyse and discuss the scenario, ask each group to present their findings back. This is a good way to get participants that are less likely to open up in bigger groups involved.

Look at your group and think about what will work best and give you the results you need.

When leading the case studies session, actively listen to discussion and provide necessary assistance to facilitate (guide) the analysis and discussion in the proper direction. Make sure you lead the discussion towards the learning objectives of the training workshop.

If you have people that conflicting views, then let them argue their points. If the discussion becomes too heated, stop them and summarise the discussion points and move on.

If everyone in the group agrees on something, or the discussion becomes stagnant then try playing devil’s advocate to get participants to look at the scenario from a different point of view.

When introducing the scenario, ask the group to think about the following 5 questions:

• What’s the problem?
• What’s the cause of the problem?
• How could the problem have been avoided?
• What are the solutions to the problem?
• What can you learn from this scenario?

Try to be flexible with your timings. If you need to stop a scenario early because the group become too heated or the group have explored the subject completely, stop them and summarise before moving on. If the scenario leads to valuable learning and you’re running out of time, allow an extra five minutes and skip another scenario.

Tips and Guidance

A good way to lead up to a case study is to present the scenario to the group at the end of the day and ask them to read up on the material and prepare in the evening. The first part of the following days’ workshop should then be the case study.

I like to lead a case study session by simply handed over the question cards and letting the group begin the discussion on their own. At the end of the discussion, I’ll summarise the key points – help them identify why the case study was important to the learning and move on to the next one.

If you’re discussing any sensitive subjects such as child protection etc then it is important to tell the group at the beginning of the case study. Explain that anything discussed exercise must not be mentioned again and if anyone needs to leave for a couple of minutes then they are more than welcome to.

Further Reading

10 Tips for Better Facilitation 

How To Facilitate Group Discussions: The “Gallery” Exercise

Questions? Comments?  Let us know in the comments below!

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Can you elaborate on what you mean about the case studies not being based on a problem?

A big part of the value of this type of exercise is that you can ideally take emotions out of play and analyze an undesired situation or problem neutrally helping your team to better deal with these types of scenarios in real life when emotions could potentially flare up. If the person can realize the bigger picture and be equipped with productive ways to handle the situation then hopefully the outcome with be better in real life.

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Case Study At-A-Glance

A case study is a way to let students interact with material in an open-ended manner. the goal is not to find solutions, but to explore possibilities and options of a real-life scenario..

Want examples of a Case-Study?  Check out the ABLConnect Activity Database Want to read research supporting the Case-Study method? Click here

Why should you facilitate a Case Study?

Want to facilitate a case-study in your class .

How-To Run a Case-Study

• Before class pick the case study topic/scenario. You can either generate a fictional situation or can use a real-world example.
• Clearly let students know how they should prepare. Will the information be given to them in class or do they need to do readings/research before coming to class?
• Have a list of questions prepared to help guide discussion (see below)
• Sessions work best when the group size is between 5-20 people so that everyone has an opportunity to participate. You may choose to have one large whole-class discussion or break into sub-groups and have smaller discussions. If you break into groups, make sure to leave extra time at the end to bring the whole class back together to discuss the key points from each group and to highlight any differences.
• What is the problem?
• What is the cause of the problem?
• Who are the key players in the situation? What is their position?
• What are the relevant data?
• What are possible solutions – both short-term and long-term?
• What are alternate solutions? – Play (or have the students play) Devil’s Advocate and consider alternate view points
• What are potential outcomes of each solution?
• What other information do you want to see?
• What can we learn from the scenario?
• Be flexible. While you may have a set of questions prepared, don’t be afraid to go where the discussion naturally takes you. However, be conscious of time and re-focus the group if key points are being missed
• Role-playing can be an effective strategy to showcase alternate viewpoints and resolve any conflicts
• Involve as many students as possible. Teamwork and communication are key aspects of this exercise. If needed, call on students who haven’t spoken yet or instigate another rule to encourage participation.
• Write out key facts on the board for reference. It is also helpful to write out possible solutions and list the pros/cons discussed.
• Having the information written out makes it easier for students to reference during the discussion and helps maintain everyone on the same page.
• Keep an eye on the clock and make sure students are moving through the scenario at a reasonable pace. If needed, prompt students with guided questions to help them move faster.  
• Either give or have the students give a concluding statement that highlights the goals and key points from the discussion. Make sure to compare and contrast alternate viewpoints that came up during the discussion and emphasize the take-home messages that can be applied to future situations.
• Inform students (either individually or the group) how they did during the case study. What worked? What didn’t work? Did everyone participate equally?
• Taking time to reflect on the process is just as important to emphasize and help students learn the importance of teamwork and communication.

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Harvard Business School: Teaching By the Case-Study Method

Written by Catherine Weiner

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Case Teaching

The professional real world is complex and filled with uncertainty. Rather than avoiding this complexity, case-based instruction centers around cases that tell the stories of real-life protagonists facing difficult decisions. Cases often end with a straightforward question: Which path should the protagonist take? To answer this question, students carefully read the case and its documents before class. They then spend class time discussing the context, analyzing the data, and debating potential courses of action the protagonist could take. As a facilitator of the conversation, the case instructor tracks and guides the conversation, pushing students to further clarify their ideas, teasing out disagreements, and introducing useful frameworks for analyzing the case. The end of a case discussion usually involves a "reveal," where the actual outcome is shared and students have an opportunity to reflect on their predictions. For these reasons, case-based discussion classrooms are an exciting mix: they are intensely grounded in specifics yet centered around an open-ended question. Effective case teaching instructors prepare intensely for sessions but try to always follow their students’ lead as well. 

How do you plan a case-session that will cover the key concepts but is flexible enough to follow a spontaneous conversation? How can instructors effectively follow up with students to ensure their students’ ideas have been clearly articulated and explored? How can student disagreement be harnessed for deeper understanding? How can instructors make sure that all students have an opportunity to be heard in the classroom discussion? In these videos, featured instructor Julie Battilana discusses her approach and strategies for using case teaching with graduate students across the university.

Building Structure and Flexibility into Case Lesson Plans

Engaging in Extended Dialogue with Students

Using Boards to Organize and Structure Class Thinking

Probing Student Disagreement to Achieve Deeper Understanding

Introducing Frameworks to Connect Case Specifics to Broader Concepts

Using Movement to Increase Intimacy, Energy, and Visibility

Referring Back to Student Comments as Discussion Touchstones

Tracking Student Participation to Ensure All Students Contribute

What does the research say.

• Merseth provides the historical context behind the case-based teaching method ( 1991 )

Seen from the lens of constructivism, the use of case studies requires active engagement from students. Because constructivism posits that students actively construct their understanding, instructors using case studies should consider how to build flexibility into their lessons to allow for active student engagement ( Sudzina, 1997 )

Case teaching is linked to student learning gains and positive student perceptions about their learning ( Bonney, 2015 )

• Further Print Resources
• Further Online Resources

Zakrajsek, T. D., and Nilson, L. B. (2023). Teaching at Its Best: A Research-Based Resource for College Instructors, 5th Ed. John Wiley & Sons.

Chapter 19 provides an overview of the case method and offers guidance to instructors hoping to design cases and integrate them into their teaching.

McKeachie, W., & Svinicki, M. (2014). McKeachie's teaching tips. United Kingdom: Cengage Learning.

Chapter 17 provides several tips about how to best facilitate the case method in your classroom.

•  Harvard Business School has developed a wealth of resources on case-method teaching including tips for planning an effective case session .
•  The Science Education Resource Center (SERC) at Carleton College has helpful, step-by-step instructions for how to teach a case no matter the discipline.
•  The opening question in a case is often one that generates opportunities to follow-up with students. This Harvard Business Publishing article explains the elements of a “perfect opening question” for case discussion .

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Tips for Discussion Group Leaders

Once the program begins, each discussion group is assigned a leader who serves as the facilitator for each case study

Here are some tips for leading an insightful and productive exchange.

Before you begin, make sure that all members understand the value of the discussion group process. You may find it helpful to have a brief conversation about the Discussion Group Best Practices listed above.

Think of yourself as a discussion facilitator. Your goal is to keep the group focused on moving through the case questions. Don't feel that you need to master all the content more thoroughly than the other group members do.

Guide the group through the study questions for each assignment. Keep track of time so that your group can discuss all the cases and readings, instead of being bogged down in the first case of the morning or afternoon.

The study questions are designed to keep the group focused on the key issues that will contribute to an effective discussion in the larger classroom meeting. Don’t let your peers stray too far into anecdotes or issues that aren't relevant.

If a subset of your living group appears to be dominating the discussion, encourage the less vocal members to participate. They'll be more apt to speak up if you ask them to share their unique perspectives on the topic at hand.

If you have questions about how to handle a specific situation that may arise in your group, please reach out to the faculty or staff for assistance. We’re here to help you get the most out of your group discussions.

Frequently Asked Questions

What can i expect on the first day, what happens in class if nobody talks, does everyone take part in "role-playing".

How to organize and structure academic panel discussions

Panel discussions often appear intimidating, as high-profile events featuring expert discussions at academic conferences. But what precisely are panel discussions, what different types exist, and how can you embark on organizing one yourself? Here is your ultimate guide to understanding, organizing and structuring academic panel discussions, including four example structures and a step-by-step plan to help you get started.

What constitutes a panel discussion at an academic conference?

In the context of academic conferences, panel discussions invariably revolve around research topics, amalgamating diverse viewpoints from academics immersed in the field.

The spectrum of panel discussions is remarkably broad. Some may focus on a very specific processes or phenomena, while others may cast a wider net, deliberating the future of an entire academic discipline or exploring wider trends like the use of AI in research.

How many people participate in an academic panel discussion?

How long does an academic panel discussion typically last.

Furthermore, panel discussions can exhibit considerable variation in their duration, yet more often than not, they fall within the range of 60 to 120 minutes.

Are panel discussions the same thing as roundtable discussions?

Understanding different types of academic panel discussions.

There is a multitude of panel discussion types, and academic conferences frequently specify particular requirements in their call for panel proposals. Some of the most common types include:

How to become a panel organizer at an academic conference

The application for organizing a panel closely resembles submitting an abstract to an academic conference. It typically entails providing a concise summary or description of the panel’s topic. Additionally, many conferences expect you to identify the prospective panelists, necessitating timely preparation.

It’s worth noting that deadlines for panel or roundtable discussion applications often precede the standard conference abstract submission deadlines.

Can early career researchers organize a panel at an academic conference?

How to structure an academic panel discussion.

There are numerous ways to structure an academic panel discussion, so it’s essential to carefully consider what makes the most sense for your topic and objectives. Regardless of the ultimate decision, developing a clear structure is crucial.

A well-structured panel discussion not only facilitates effective time management and moderation but also ensures a meaningful exchange of ideas.

Example structure of an academic panel discussion 1

In this scenario, a 1.5-hour panel discussion featuring three panelists is outlined. The session commences with an introduction that provides an overview of the panel’s central theme and introduces the panelists, offering a brief insight into their expertise and contributions. Following this, each of the three panelists is allocated 15 minutes to deliver their presentations. This is succeeded by a moderated discussion, where the panel moderator actively engages with the panelists, encouraging the exchange of ideas and responses to each other’s presentations. After a substantial discussion, the audience is invited to pose questions and participate in the ongoing conversation.

Example structure of an academic panel discussion 2

The panel discussion then transitions into a moderated discussion, allowing for further exploration of the topic and fostering dialogue among the panelists. A segment for audience questions and answers is integrated, enabling active engagement from those attending the discussion. Finally, the session concludes with a wrap-up, summarizing the key points and takeaways from the discussion.

Example structure of an academic panel discussion 3

The session concludes with a dedicated 5-minute wrap-up, summarizing the key takeaways and insights gleaned from the discussion, ensuring that the audience departs with a clear understanding of the discussion’s outcomes.

Example structure of an academic panel discussion 4

Furthermore, this scenario allocates time for audience participation, providing an opportunity for attendees to contribute questions and insights. The session concludes with final conclusions, summarizing the key findings and insights derived from the case studies, thus ensuring a comprehensive and informative closure to the discussion.

Step-by-step plan to organizing a panel discussion at an academic conference

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3 facilitation case studies: better and worse scenarios

Natalya Fursova and Elena Glekova from PandaDoc shared examples of real work situations that arise in companies on a daily basis. Each of them was presented with possible scenarios for how events might develop — and they discussed options, including a “not ideal” possibility and a better possibility in each instance.

In this article

We have already talked about what facilitation is in theory. Now, it's time to get down to business. How does facilitation work in practice? Below, PandaDoc HR Business Partner Natalia Fursova and PandaDoc Scrum Master Elena Glekova discuss how facilitation works using specific examples that were drawn from real situations.

Case 1. How facilitation can help clarify team expectations and secure agreements

Facts: a team has gathered in a small IT company to work on new functionality. The team consists of six people, each with a wide range of expertise in design, programming, and testing. How can facilitation help in these circumstances?

Not the best scenario

A situation arises when the expectations of individual participants regarding joint work are not met. Some team members, for example, prefer to make all architectural decisions individually, without consulting the team. This creates problems for other participants. The tension in the team is growing; there are more and more unspoken issues. The group continues to work in this mode until the next decision made without the input of the whole team leads to a serious user incident. During a discussion of the event, the conversation develops into an open conflict. The conflict is so acute that none of the team members wish to continue working on it.

Better Scenario 1

At the start of the project, the team agrees to hold regular retrospective meetings, during which they will have the opportunity to discuss joint work, how to improve the quality of the product, and collaboration. In one of the first retrospectives, facilitated by a group representative, a case study was made of an employee making a major architectural decision without discussing it with the others. The colleagues discuss why such issues require a collective decision and agree on a new rule for teamwork. After the discussion, the group feels more comfortable, since the risk of repeating an unpleasant situation has been reduced, and the participants have their first experience of creating team agreements.

Better Scenario 2

At the beginning of the work, the team agrees to hold regular retrospective meetings, and also decides to organize an introductory session of expectations alignment. Facilitation is undertaken by a colleague from another team who has experience in conducting similar meetings. In the session, each team member has the opportunity to voice their expectations about how the joint work will be organized. The group then votes to approve those expectations that all members agree with (for example, giving the team two weeks' notice of an upcoming vacation, and making decisions about the application architecture only by agreement of the entire team). The first team agreements are formed in this manner. Expectations the group is not yet ready to agree to are discussed, modified, or postponed until the next meeting. This process allows each team member to develop an understanding of exactly what expectations of teamwork they share.

Case 2. How facilitation can help organize broad discussion and gather opinions

Facts: a company that develops an online application has 30 teams, each of which releases updates for users every two weeks. It is important for each team to get feedback on the released updates from users, other teams, and company management. It is also important for teams to understand which product updates have been implemented in general. How can facilitation help to best organize everything?

Not the best scenario 1 

Each team independently decides how to get feedback and how to communicate their updates and learn about updates from other teams. The result is poorly controlled chaos.

Not the best scenario 2

We gather representatives of all teams, as well as managers and users, in one online event, where each of the thirty teams takes a turn to present the results of their work. Groups lose focus by the fifth presenter, audience engagement drops to a minimum.

Better Scenario

We use the “open space” facilitation method (in this case, in a simplified form). We draw up an agenda grid in advance: the vertical axis shows the numbers of virtual rooms where presentations will be held in parallel; the horizontal axis shows the rounds of discussion. Each team chooses a slot in which to present the results of their work, and writes down their topic in the agenda grid. When the agenda is ready, each participant can choose where they will be during the discussion rounds.

The facilitator in this method organizes an online space, explains or reviews the rules for organizing a meeting, and helps the group regulate the beginning and end of negotiations.

With the meeting organized in this way, the group has a single understandable space for discussion. With several parallel threads, the discussion is more dynamic, and each group has the most relevant audience for its presentation. Each participant independently manages their personal agenda, moving from discussion to discussion, and the inability to attend two parallel meetings is addressed by making video recording of each presentation available to participants.

This is exactly how sprint review meetings are held at PandaDoc. This discussion scheme helps successfully organize and structure a two-hour online meeting attended by 150 to 250 people.

Case 3. What facilitation tools can help an organization make important decisions

Facts: An online book-selling company hosts an annual meeting where executives and key members of the organization can identify the firm's pressing problems and work out solutions. It is assumed that 12 people will take part in the discussion. How can facilitation help optimize this process?

The discussion is not structured, the group has not agreed in advance on who can take on the role of facilitator. Three participants begin to voice their proposals regarding what problems the company should solve first. It looks like the list of problems is quite lengthy. At the same time, several people in the group are unable to voice their ideas because they feel uncomfortable interrupting colleagues. While this is happening, one employee notes that some problems do not seem significant enough for the group to devote much time and effort to them. Some participants are already starting to offer their ideas for solutions to some of the problems voiced. The group switches to discussing these solution options but, ten minutes later, someone suggests that the group decide which of the problems are the most serious. Discussion of various possibilities begins. By the end of the third hour, the general manager of the company unilaterally decides to list on the flip chart several decisions that were made during the discussion. Not everyone agrees with these decisions, but there is simply no desire to discuss further.

The sales manager, with some experience in facilitation, takes over the organization and management of the discussion. After a separate preliminary meeting with the general manager of the company and the heads of some of the departments, he defines the: goal, purpose of the meeting, list of participants, discussion scenario, and other issues. The facilitator chooses "brainstorming," "world café," and "5 fingers voting" as the main techniques that will help the group achieve the goal.

During a short introduction, the general manager reiterates the purpose of the meeting and the desired outcome, and also reminds participants that the facilitator will be taking part in the discussion.

After a quick warm-up where the participants mark their level of readiness to join the discussion from zero to ten, the group proceeds to generate a list of problems through brainstorming. The focus question for the group, which helps guide the thinking, is: “What are the problems that are preventing us from increasing sales?” The online collaboration board serves as a virtual flipchart, and all ideas are immediately visible to the whole group.

Only after all participants have independently written down their ideas does the facilitator invite the group to discuss. Everyone has the opportunity to ask questions, and to clarify the details for themselves. The facilitator monitors how the discussion is going and, if necessary, asks clarifying questions of the participants.

Once all questions have been asked, the group is ready to move on. To figure out which problems the organization will address first, the facilitator suggests:

• Group similar problems; and
• Vote on priority issues using criteria agreed in advance with the general manager (the issue is in our area of ​​influence and the issue requires immediate attention).

Each participant receives three virtual points, which will be their votes. After everyone has made their choice and allocated points to the most critical issues, the group counts the votes and determines a list of the top three issues. An excellent intermediate result of the session! The group is excited and ready to move on.

In order to look for solutions, the facilitator suggests the “world cafe" technique (simplified in this case).

For each problem, something like a “table” is organized — a separate virtual room for discussion of that problem. There will be one volunteer from the group at each “table” during the entire discussion. They will be the "host" — responsible for cataloguing all ideas raised at the "table," and sharing the collected ideas to colleagues who join the "table." Participants are divided into three groups and each group chooses their first "table" for discussion. After twenty minutes, the groups switch places and, at their new “table,” they can add their own ideas to the existing lists. After another twenty minutes, the groups change places again. This way, each participant has the opportunity to work with each of the problems. After several rounds of discussion, each host has a finite list of possible solutions.

The group comes together again and, using the now familiar three-point method, chooses the three most attractive solutions (criterion: the most impactful result with the least effort).

Since the decisions will affect the work of each employee, the facilitator offers to make sure that the group agrees with the top list of decisions that were determined as a result of the vote. The five fingers method helps to quickly find out how much each member of the group agrees with the final decisions, and is ready to put effort into their implementation.

At this point, the group will respond to each of the selected solutions by holding up their fingers as follows:

• Five fingers means full support for the solution and readiness to be the driver of implementation;
• Four — agreement with the decision, willingness to participate in implementation;
• Three — neutral attitude to the decision, but without willingness to participate in implementation;
• Two — disagreement with the decision, desire to discuss;
• One — categorical disagreement with the decision, willingness to do everything necessary to prevent this decision from being implemented; and
• A fist is a signal that such a decision cannot be made by the existing composition of participants.

The first decision collects all fives from all participants. The second decision is five fives and the balance of votes are fours. The third solution is one five, six fours and the rest threes. Based on the vote, no decision raises strong doubts, which means that the goal of the discussion is almost achieved. It is necessary to choose those responsible for the next steps and discuss the deadlines. The group does this quickly, working in three mini-groups for fifteen minutes. The goal has been reached.

From these cases it is clear that, among other things, facilitation is multifaceted and diverse. If its variety intimidates you, start with simple tools — like brainstorming — to quickly generate a list of ideas. Then, having experienced the benefits of facilitation, gradually incorporate elements of it into other discussions.

Pros of facilitation

• Facilitation enables the group to realize the potential of collaborative, collective thinking and make the best use of the time spent on group discussion of issues;
• A well-built discussion structure allows the group to successfully reach the goal without deviating from its planned scenario, and allows all participants to be heard;
• Group discussion provides a broad view of the issues under discussion, and minimizes blind spots: the group's horizons are always wider than those of individual group members;
• During the discussion, the creative potential of many people is applied to the issues in question and, as a result, the quality of the decisions within the organization increases: the wisdom of a well-coordinated group is always greater than the wisdom of any individual member of the group; and
• Members of the group will be more enthusiastically involved in the implementation of decisions in which they took an active part (and agreed with).

We invite you to discuss this topic and ask questions in our Discord channel.

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How To Do It: Use facilitated case discussions for significant event auditing

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• Peer review
• L A Robinson , general practice facilitator a ,
• R Stacy , research associate a ,
• J A Spencer , senior lecturer a ,
• R S Bhopal , professor b
• a Department of Primary Health Care, Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH
• b Department of Epidemiology and Public Health, University of Newcastle upon Tyne
• Correspondence to: Dr Robinson.
• Accepted 24 March 1995

An important type of review undertaken routinely in health care teams is analysis of individual cases. This informal process can be turned into a structured and effective form of audit by using an adaptation of the “critical incident” technique in facilitated case discussions. Participants are asked to recall personal situations that they feel represent either effective or ineffective practice. From such review of individual cases arise general standards to improve the quality of care. On the basis of a study of audit of deaths in general practice, we describe how to implement such a system, including forming and maintaining the discussion group, methodology, and guidelines for facilitators. Problems that may arise during the case discussions are outlined and their management discussed, including problems within the team and with the process of the discussions.

Medical audit has traditionally taken place within a group composed of members of the same clinical specialty. However, multidisciplinary teamwork is usual in health care, so clinical audit may be a more effective means of bringing about change within organisations. 1 2 One informal but important type of review that is routinely carried out within clinical teams is analysis of individual cases—for example, as an educational exercise (“random case analysis”) in vocational training in general practice and as a discussion between general practitioner and district nurse after the death of a terminally ill patient. This informal process can be turned into a more structured (and acceptable) method of internal audit using an adaptation of the “critical incident” technique, 3 originally developed in the 1950s. 4 Critical incidents are collected by asking participants to recall situations that they think are examples of good or bad practice in the particular setting being studied. The participants describe what first occurred, the subsequent events, and why they perceived the incident to …

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ORIGINAL RESEARCH article

Using podcasts to bridge the gap between science communication and specialized scientific fields: a case study of mass spectrometry.

• 1 WRG Europe Ltd, Exeter, United Kingdom
• 2 Jožef Stefan International Postgraduate School, Ljubljana, Slovenia
• 3 Department of Environmental Sciences, Jožef Stefan Institute, Ljubljana, Slovenia

This study aimed to evaluate the use of podcasts in disseminating specialized scientific fields, such as mass spectrometry. Four podcasts featuring interviews with researchers working with mass spectrometry were produced. A mixed methods approach, comprising questionnaires and interviews, was used to gather listener feedback. Findings indicate that audience engagement is affected by factors like familiarity with science and relatability in content; therefore, to attract a wider audience, content must be presented to balance technical aspects with real-life examples to which listeners can relate. These findings will benefit researchers and stakeholders seeking to disseminate complex scientific topics using podcasts.

1 Introduction

The digital age has revolutionized how scientific information is shared with the public ( Osterrieder, 2013 ; Collins et al., 2016 ; Jensen and Gerber, 2020 ). Among the emerging mediums in this digital landscape, the podcast has become a cultural phenomenon ( Sullivan, 2019 ). Since their introduction in 2004 ( Berry, 2016 ; MacKenzie, 2019 ), podcasts have become popular among scientists and researchers to communicate their research work to the public ( Birch and Weitkamp, 2010 ; Davies and Hara, 2017 ; Llinares et al., 2018 , p. 3; Kwok, 2019 ; MacKenzie, 2019 ; Quintana and Heathers, 2021 ).

Despite similarities to traditional broadcasting ( Bottomley, 2015 ; Berry, 2016 ; Llinares et al., 2018 , p. 2), podcasts offer increased flexibility since creators and listeners are not restricted by specific times ( Llinares et al., 2018 , p. 2). Software and tools that are freely available and easy to use can assist in the production of podcasts without requiring formal training ( Boulos et al., 2006 ). Furthermore, there is no restriction on the number of speakers or the location ( Boulos et al., 2006 ; Quintana and Heathers, 2021 ). The convenience and accessibility of podcasts through mobile apps and platforms like Apple Music, Spotify, and Google have made it easier for listeners to access them at any time ( McGarr, 2009 ; Sullivan, 2019 ; Wade Morris, 2021 ). Apart from cognitive development through gaining information and being curious, podcast listeners have also expressed an openness to new experiences, social acceptance, and efficient use of their time as reasons for listening to podcasts ( McClung and Johnson, 2010 ; Chan-Olmsted and Wang, 2020 ; Tobin and Guadagno, 2022 ).

Podcasts can cover various topics, with formats and languages tailored to specific audiences ( Berry, 2016 ). The versatility of this approach is especially valuable when it comes to communicating scientific information ( Chan-Olmsted and Wang, 2020 ). Currently, there are hundreds of science podcast series available, and this number continues to grow each year ( MacKenzie, 2019 ; Quintana and Heathers, 2021 ). Between 2004 and 2010, 952 English-language science podcasts were published worldwide, including 532 from the US and 162 from the UK ( MacKenzie, 2019 ).

While there is no set formula for gauging the success of a science podcast yet ( MacKenzie, 2019 ), several metrics can help indicate its performance. A key metric is the podcast’s overall ranking and number of followers, which indicates listener engagement ( García-Marín, 2020 ). The BBC World Service, for example, hosts two weekly science podcasts with a social media following of 60 million Facebook fans, 40 million Twitter followers, and 160,000 Instagram fans ( BBC, 2023a , b ), demonstrating their continued success. The question is—what factors have contributed to their engagement and retention?

Reviewing the literature on this topic makes it clear that humor and storytelling narratives have benefited science communication ( Picardi and Regina, 2008 ; Riesch, 2014 ; Drew, 2017 ; Barrios-O’Neill, 2018 ). Swiatek (2018) explains the importance of building a narrative akin to having a casual phone conversation. However, the question remains: could these factors also increase engagement for podcasts centered around specialized scientific content?

It is known that familiarity with science is a significant driver of public engagement with scientific research ( Kouper, 2010 ; Weingart et al., 2021 ). For example, those with a strong interest in scientific content are more likely to make logical decisions and choices in their daily tasks based on scientific reasoning ( Chantler et al., 2007 ; Shaw and McNamara, 2021 ). However, there is limited research on whether familiarity with sciences or having a scientific background influences people’s choice of podcasts.

While the popularity of podcasts has been linked to the trendiness of topics ( García-Marín, 2020 ) or the popularity of featured guests ( Handley and Chapman, 2012 , p. 246), communicating scientific subjects that can be categorized as specialized scientific subjects is equally important. However, these subjects present a unique challenge; engaging audiences with topics that may not be trendy or receive mainstream media coverage in such a way that makes them understandable to a diverse audience rather than to a specialized group ( Weingart et al., 2021 ).

For this purpose, mass spectrometry, an analytical technique used to determine molecular compositions of various substances, was chosen to assess listener perception of specialized scientific content-based podcasts. Many scientific fields that play a role in the lives of the public make use of mass spectrometry, such as environmental analysis ( Ogrinc et al., 2005 ), novel food safety ( Schönleben et al., 2024 ), food and water quality assessment ( Kaufmann, 2011 ; Kovačič et al., 2023 ), pharmaceutical research ( Swales et al., 2019 ), and in critical areas such as personalized medicine ( Heeren, 2015 ) and cancer research ( Ogrinc et al., 2021 ). However, despite its recognition as a powerful analytical tool, the public remains unaware of its capabilities ( Daughton, 2001 ).

This study has three objectives. First, it aims to assess public engagement with podcasts focused on specialized scientific fields, using mass spectrometry as a case study. Second, the study examines factors influencing how podcast listeners engage with scientific content, focusing on their prior familiarity with sciences. Third, it seeks to identify potential strategies to attract more listeners. The results of this study will enhance the effectiveness of creating science-based podcasts and bridge the gap between the public and their understanding of specialized scientific subjects.

2 Manuscript formatting

2.1 methodology.

The methodology discusses how the study podcasts were created and details the mixed methods approach used to gather feedback. Data was collected through questionnaires and interviews, followed by subsequent data analysis.

2.1.1 Podcast creation

The creation of the podcast series began with the development of four unique episodes to highlight the wide-ranging impact of mass spectrometry on various scientific fields. The episodes were designed to appeal to different listener preferences, with one being 10 min long, two being 15 min, and one lasting 30 min. This way, we could cover episodes comprising a quick update to more in-depth discussions. Each episode focused on a specific application of mass spectrometry in food and environmental analysis, proteomics and diagnostics, pharmaceuticals and forensics, and cancer research.

Experts were carefully chosen to ensure a balanced representation of gender, career stage, and geographical diversity. Each expert was invited to participate and provided a detailed briefing on the podcast’s topic and objectives. The final selection of experts included two early-career researchers (one male, one female) and two experienced researchers (one male, one female) representing the Netherlands, Slovenia, France, and Belgium. All guests were required to sign a consent form for recording and publication, with provisions allowing them to review and approve the final edited version of their episodes to ensure accuracy and comfort with the shared content. A semi-structured interview guide ( Table 1 ) was also provided to facilitate discussions. This format allowed guests to elaborate on their work experiences and discuss their motivations, challenges, and insights as researchers. Beyond addressing specific queries concerning their research fields, the interviews were designed to encourage researchers to articulate their views on the importance of mass spectrometry in society, enhancing the educational value of each episode.

Table 1 . Semi-structured interview guide for mass spectrometry podcast series.

Interviews were scheduled and conducted via Zoom to facilitate the involvement of international experts without geographical constraints. Post-recording, the audio was edited using Audacity, a popular open-source software for podcast production. Background noise and speech errors were removed to enhance clarity, and background music was added along with speed adjustments to create a more engaging listening experience.

2.1.2 Data collection

For this study, a closed-ended questionnaire was developed to gather insights into listeners’ preferences and their perceptions of mass spectrometry as presented in podcasts ( Supplementary material S1 ). Initially, we provided a brief overview of the confidentiality and data protection measures according to Articles 6–8 of the GDPR guidelines ( Intersoft Consulting, 2013 ), adhering to the Ethics for Researchers ( European Commission, 2013 ) and the Ethical Guidelines for Social Research ( Social Research Association, 2021 ). This presentation ensured that participants made decisions based on informed consent to participate in this study. The questionnaire explored general podcast listening habits, including the frequency of listening and preferred podcast length, to assess respondent engagement. Respondents then listened to four episodes from the mass spectrometry podcast series to become familiar with the content. We also included questions to assess how well the guests explained the complex topic of mass spectrometry and the overall conversation style. To understand how different scientific narratives and personal stories from the researchers influenced listener engagement, we included questions about the diversity of experiences among the researchers featured in the podcasts.

The questionnaire, designed on Typeform, was pilot tested within the research group to refine its clarity and relevance, while mass spectrometry experts ensured content validity and the topic was covered comprehensively. Reliability was assessed using Cronbach’s alpha, showing high internal consistency with a value of 0.72. To verify response authenticity, incomplete or duplicate entries were eliminated, and one response was removed. The questionnaire was distributed via LinkedIn and Twitter from August to October 2022, collecting 80 responses from participants in the European region. The inclusion criteria allowed participation from both regular and non-regular podcast listeners, including those without a scientific background.

Table 2 outlines the demographic details of the questionnaire respondents ( N  = 80), covering age groups, educational levels, and countries of residence. The largest age group was 26–35 at 42%, followed by 16–25 at 21%. Most respondents were highly educated: 34% held a Master’s degree, 28% had a Doctorate, and 31% had a Bachelor’s degree or college education. The geographical distribution shows that 30% of respondents were from the United Kingdom, making it the most represented country, followed by Germany (16%), Belgium (11%), and Poland and the Netherlands (10% each). Minor contributions from Slovenia, Italy, France, and Denmark each account for 5% of the sample, while responses from Romania and Norway are grouped under “Others” at 2% due to their lower representation.

Table 2 . Demographic characteristics of questionnaire respondents (%; N  = 80).

Following the questionnaire, personal interviews were conducted using a semi-structured format to assess the listeners’ more profound opinions on the podcasts. Participants for these interviews were selected based on a screening criterion that required them to have listened to a podcast series on a commercial platform such as Apple, Spotify, or SoundCloud within the past 6 months to ensure they had recent experience listening to podcasts.

Each interview incorporated predefined prompts ( Supplementary material S2 ) to guide the discussion. Participants elaborated on specific aspects of the scientific content they found noteworthy while providing feedback on non-scientific variables. We recruited six participants ( N  = 6) from those who completed the questionnaire, using snowball sampling to ensure demographic diversity. The group included three females and three males, evenly split between the 16–35 and 36–55 age groups. Educational backgrounds were also varied, with two participants each from natural sciences, business and accounting, and social sciences and humanities. Geographically, the participants included one from Slovenia and the Netherlands and two from Germany and the UK.

The interviews were conducted remotely from December 2022 to January 2023. Before each session, participants were given an overview of the study’s objectives, confidentiality protocols, and data processing and storage guidelines. This step was implemented to secure informed consent and ensure participants fully understood the use of the data collected from the interviews. Each interview lasted 30–45 min, during which participants were encouraged to share their experiences and perceptions freely. To ensure confidentiality and data integrity, all interview transcripts were anonymized.

2.1.3 Data analysis

The data from the questionnaire was analyzed using R software (Version 4.2.2). Descriptive statistics, including mean, median, frequency, and percentages, were used to understand the non-scientific and scientific aspects of the podcasts. We also conducted paired sample t-tests to evaluate changes in knowledge about mass spectrometry before and after listening to the podcasts. The normality of data was confirmed using the Shapiro–Wilk test to determine the validity of the t-test results. Cohen’s d was calculated to measure the effect size of the changes in knowledge. Chi-square tests were used to explore the relationship between these knowledge changes and sociodemographic variables like educational attainment and age. We verified that the chi-square tests met the necessary assumptions and only p -values below 0.05 were considered statistically significant.

For the interview data, thematic analysis was conducted using MaxQDA software for systematic coding and data organization. First, we identified initial “thematic categories” or “codes” based on the raw data. These codes were refined by identifying recurrent patterns across participants and integrating examples from the raw data to develop thematic categories. For accuracy, we did thorough checks by reviewing the transcriptions against the original audio files, with each transcript reviewed twice. For intra-coder reliability, the same researchers recoded the data three different times and compared the results for consistency ( Attride-Stirling, 2001 ; Braun and Clarke, 2006 ; Maguire and Delahunt, 2017 ).

Graphical representations were created using Power BI to interpret the data and identify patterns. All findings were categorized into scientific and non-scientific elements, followed by recommendations for improving the communication of complex scientific information through podcasts. Finally, to maintain response integrity, ellipses (…) were used to indicate the exclusion of larger text sections or interviewer prompts in quotations. All participants were represented using combinations of letters or alphanumeric identifiers to ensure anonymity.

2.2 Results and discussion

2.2.1 engagement with non-scientific elements.

Apart from the frequency of podcast consumption and preferred duration for podcasts, respondents were questioned about the conversation style and evaluated for their receptivity to personal statements made by the guests, such as the challenges they encountered in their journey as scientists. These components were then examined in the interview sessions with the participants.

2.2.1.1 Frequency of listening to podcasts and preferred duration

When respondents were asked to rate their frequency of listening to podcasts over the past 6 months, the results revealed a diverse range of habits: 28% listened “Seldom/Rarely”, 25% “Sometimes”, and 23% “Often”. The remaining 24% were evenly split between those who listened “Very Often” and those who chose “Never”. When considering preferred podcast durations, a clear trend emerged favoring shorter episodes. Most respondents (81%) preferred podcasts under 30 min, with the majority (56%) preferring podcasts between 15 and 30 min and a quarter favoring episodes less than 15 min. Within the smaller segment (19%) who preferred longer podcasts, most preferred episodes between 30 and 45 min (11%), and 8% opted for hour-long podcasts. Table 3 shows a distribution of these factors across different age groups and educational attainment levels.

Table 3 . Frequency of listening to podcasts and preferred duration across different age groups and educational attainment levels (%; N  = 80).

Analyzing the data across different age groups highlighted notable contrasts. The oldest age group (56+) showed a distinct pattern: 40% never listened to podcasts, while 60% listened often. In the youngest age group (16–25), 35% listened “Seldom/Rarely”, and 29% each chose “Sometimes” and “Often”. The 26–35 age group also showed varied preferences, with 38% listening “Seldom/Rarely”, 26% “Sometimes”, and 15% choosing both “Often” and “Very Often”. The 36–45 age group’s responses were more balanced, with 31% each listening “Never” and “Sometimes”, but none listening “Very Often”. In contrast, 37% of those aged 46–55 listened “Very Often”, the highest percentage in any group.

Preferences for podcast durations also varied by age. Respondents aged 56 and older preferred podcasts lasting 16–30 min (60%). In the 46–55 age group, 37% preferred episodes of 15 min or less, and 27% chose podcasts lasting 46–60 min. The 36–45 age group strongly favored 16–30 min episodes (77%). Among those aged 26–35, 65% preferred 16–30 min podcasts, with 12% opting for 46–60 min. For the 16–25 age group, 47% favored 16–30 min, with none preferring the 46–60 min duration.

Educational attainment also influenced listening habits. Respondents with a Doctoral degree had the highest frequency of listening “Often” (36%) and “Very Often” (27%). Those with a Master’s degree tended to listen “Seldom/Rarely” (44%), with only 11% listening “Often”. Respondents with a Bachelor’s or College degree preferred listening “Sometimes” (33%) and “Often” (25%). Responses were more evenly distributed for those with vocational training or high school education, with 29% listening “Never” and “Seldom/Rarely”.

Preferred podcast durations varied considerably across educational levels. Those with Doctoral degrees preferred a range of durations, with 32% each favoring episodes of 15 min or less and 16–30 min and 23% opting for 31–45 min. Master’s degree holders mainly preferred 16–30 min (70%). Respondents with a Bachelor’s or College degree also favored 16–30 min (62%). Those with Vocational training or High school education leaned towards 16–30 min (57%), with 29% preferring episodes of 15 min or less.

Interviews revealed that most participants preferred podcasts under 30 min, citing decreased attention spans and numerous distractions. Many mentioned that shorter episodes (less than 30 min) were “reasonable” and “manageable” within their daily routines ( N  = 4). Participants commonly appreciated the ability to listen while multitasking, such as during meals or while checking emails ( N  = 12). This finding aligns with Perks and Turner (2018) , who stated that frequent podcast listeners often integrate podcasts into their multitasking habits. However, one participant preferred longer episodes, enjoying the “in-depth discussions” and “detailed analyses” that hour-long podcasts provide. The data suggests that while shorter podcasts are broadly preferred, a market for longer content still appeals to those who favor extended listening sessions.

The study’s findings also align with prior research conducted by Sutton-Brady et al. (2009) , who found the short-form podcast model to be a successful learning tool for postgraduate and undergraduate students. This preference for shorter podcasts may be attributed to various factors, such as technological advancements, fast-paced modern lifestyles, and the motivation and interest of listeners ( Lodge and Harrison, 2019 ).

2.2.1.2 Podcast tone and conversation style

Respondents rated the conversation style, i.e., language, structure, formality, and patterns in discussion podcasts on mass spectrometry using a 5-point scale. The results showed that 85% of respondents found the tone “About right”, 13% “slightly too formal”, and 3% “slightly too informal”. There were no extreme opinions on the tone being too formal or informal.

All respondents aged 16–25 and 36–45 found the tone “About right”. In the 26–35 age group, 82% approved, but 18% found it slightly too formal. In the 46–55 group, 73% were satisfied, 18% thought it was slightly too formal, and 9% slightly too informal. Among those 56% and over, responses were split: 40% found the tone “About right”, 40% slightly too formal, and 20% slightly too informal. Most respondents found the tone “About right” regarding educational attainment levels. All respondents with vocational training or a high school diploma agreed with this view. Among bachelor’s or college degree holders, 96% approved of the tone, while 4% found it “Slightly too informal”. Among those with a master’s degree, 85% were satisfied, but 15% thought it “slightly too formal”. Doctoral degree holders were less uniform in their opinions: 68% approved, 27% found it “slightly too formal”, and 5% slightly too informal.

The chemistry between speakers was highlighted by some participants ( N = 4) as crucial for an engaging podcast. Their unanimous preference for the second podcast stemmed from its conversational style and the integration of personal stories and everyday examples, noting it as a key factor in its success. LL31 emphasized dynamic interaction, stating, “ The conversation was lively and engaging, and I truly believe that chemistry between the speakers is crucial for a good podcast. The second one had it perfect .”

All participants ( N  = 6) found the podcasts more engaging due to the inclusion of narratives and anecdotes. Some other participants ( N  = 3) found them entertaining and informative, especially regarding practical applications of the scientific process discussed. Another commended the second episode for its intricate and exuberant presentation, emphasizing its clarity. According to Drew (2017) , incorporating humor and storytelling enhances podcast engagement, especially those covering scientific topics. This study supports that finding, demonstrating that a conversational style that includes personal narratives and humor can make complex topics more understandable and accessible to a wider audience ( Kaplan et al., 2020 ).

2.2.1.3 Perspective on different experiences

Respondents were asked to use a 5-point Likert scale to identify any disparities in the challenges faced by podcast guests to explore listeners’ perceptions of these differences. Results indicated that 38% of respondents remained neutral, while 24% disagreed and 13% strongly disagreed that there were notable differences. Conversely, 11% agreed, and 15% strongly agreed that disparities existed. Personal interviews provided further insights, revealing that variations in experiences seemed more related to career stages—differentiating between seasoned and early-career researchers—than any other factor. Participants were particularly intrigued by discussions about work-life balance, which they felt was a common issue affecting everyone today.

When asked about the unique aspects of discussing work-life balance in this context, more than half of the participants ( N  = 4) noted that they perceived all guests, regardless of their career stage, as finding it a struggle. They also noted the stress of managing family and work commitments in research fields that require research and management. CT25 recalled, “ I remember when you asked about achieving work-life balance; it was interesting to learn how professors maintain that balance in their lives. ”

Other participants ( N  = 4) highlighted different aspects that made the podcasts engaging. Some ( N  = 2) praised the use of storytelling by some of the guests, commenting on how it seemed as if the speakers were truly fans of their work and were eager to learn more themselves. Another participant found the podcast intriguing due to its mention of a diverse team, noting the interest in how the guest worked with people from different backgrounds who contributed new ideas and commending this openness to diversity in their workplace.

2.2.2 Engagement with scientific elements

Respondents were asked about several key factors to understand how listeners perceived the scientific content in the podcasts. These included the amount of information provided, their knowledge levels before and after listening, and how well they grasped concepts related to mass spectrometry and its applications. During the interview, participants also discussed whether their familiarity with scientific subjects influenced their interest and comprehension of the podcasts.

2.2.2.1 The amount of information given in the podcasts

Respondents were asked to rate, using a 5-point Likert scale, whether they felt that “Overall, the guests gave the right amount of detail to help the audience understand their field of work”. The responses revealed that 35% strongly agreed, 40% agreed, 19% were neutral, and 6% disagreed.

Most participants ( N  = 5) described the podcast’s content as “clear”, “to the point”, and “concise”. They noted that the information on mass spectrometry and its applications was “appropriate” and “easy to follow”, providing a good understanding of the subject. One participant felt that the information was sufficient, highlighting the adequacy of the subject knowledge and its applications. In contrast, others ( N  = 4) indicated that the content was accessible even to those without a scientific background. One participant remarked that more information would have been overwhelming, leading to a loss of interest, especially for those who do not have a scientific background. The feedback suggests that the podcast effectively balanced detail and clarity, making complex topics understandable to a broad audience.

2.2.2.2 Knowledge of mass spectrometry before and after listening to the podcasts

The questionnaire utilized an ordinal scale to evaluate participants’ comprehension of mass spectrometry before and after listening to the educational podcasts. The shifts in knowledge, depicted in Figure 1 as a heatmap, show a significant transformation. Most respondents (53%) initially acknowledged they had no prior knowledge, described as “I knew nothing.” Another 14% indicated they “knew very little,” and 8% had a basic familiarity (“I knew a little”). Only a minority felt they had a substantial understanding, with 19% indicating “I knew quite a bit” and 8% opting for “I knew a great deal”. Following the podcasts, the distribution of reported knowledge improved significantly: 34% of respondents reported learning “quite a bit”. The majority (43%) said they learned “a little”, and 24% felt they learned “very little”. Importantly, there were no responses at the extremes of learning “nothing” or “a great deal”, emphasizing moderation in learning outcomes.

Figure 1 . Knowledge of mass spectrometry amongst respondents before and after listening to the podcasts.

Results from the paired sample t-test confirm these self-reported shifts. The average pre-podcast knowledge score was 2.15, with a standard deviation of 1.42, illustrating participants’ wide range of initial understanding. Post-podcast, this average increased to 3.10, and the standard deviation narrowed to 0.76, indicating a more uniform understanding across the group. This improvement was statistically significant, evidenced by a paired sample t-test (t-statistic: −5.48, p -value: 4.88 × 10 −7 ).

A Chi-squared test revealed significant initial associations between knowledge levels and demographic factors such as educational attainment (χ 2  = 36.27, p  < 0.00) and age (χ 2  = 30.13, p  = 0.017). These findings suggest that educational background and age significantly influenced participants’ initial understanding. However, no significant associations were detected between these demographic factors and knowledge gains post-podcast, indicating that the educational content effectively bridged initial knowledge disparities. These podcasts enhanced listeners’ understanding of mass spectrometry regardless of age and educational background, demonstrating that carefully designed podcasts effectively elevate scientific literacy on specialized subjects among diverse audiences.

2.2.2.3 Understanding of mass spectrometry and its applications

Using a 5-point Likert scale, participants were asked to indicate their level of understanding of both the explanation of mass spectrometry and its applications. For the explanation of mass spectrometry, 44% of respondents strongly agreed they understood it, 48% agreed, 2% were neutral, and 16% disagreed. None of the participants strongly disagreed. Regarding the applications of mass spectrometry, 23% strongly agreed that they understood, 28% agreed, 33% were neutral, and 18% disagreed, with no one strongly disagreeing.

A heat map ( Figure 2 ) illustrates these findings, showing that 43% of respondents agreed or strongly agreed that they understood the explanation and applications of mass spectrometry. Interestingly, among those who strongly agreed they understood mass spectrometry, none disagreed about understanding its applications, but 13% of those who agreed they understood mass spectrometry did not understand its applications. Approximately 21% of participants were neutral about their understanding of both. Among these neutral respondents, 27% disagreed with the applications, and 8% agreed. Half of those who disagreed with understanding mass spectrometry also disagreed about the applications, while the other half were neutral or agreed.

Figure 2 . Perception of mass spectrometry and its applications amongst respondents.

A paired sample t-test compared the responses for understanding mass spectrometry and its applications, revealing a statistically significant difference ( p  = 0.017). The mean understanding score for mass spectrometry was 3.75, compared to 3.55 for its applications. However, the effect size, measured by Cohen’s d, was 0.20, indicating a slight difference. Further analysis of confidence intervals adds context to these findings. The 95% confidence interval for understanding mass spectrometry ranged from 3.53 to 3.97; its applications ranged from 3.32 to 3.78. The confidence interval between these means ranged from −0.12 to 0.52, including zero, which suggests the actual difference might be negligible and the respondents’ understanding of mass spectrometry and its applications are similar.

2.2.2.4 Role of familiarity in understanding scientific content

The study revealed that participants particularly valued podcast content that resonated with them on a personal level. Some participants ( N  = 4) highlighted how discussions around why guests opted for science in their careers and how their work shaped their life’s trajectory were surprisingly relatable, aligning with Murray’s (2019) findings that podcasts can serve as a means for listeners to hear experts in a more personal and relatable manner, which is more effective than merely reading their profiles and academic work.

Most participants ( N  = 5) appreciated the practical applications of mass spectrometry, especially in everyday contexts such as food quality assessment. For instance, the technology’s role in verifying the freshness of produce resonated with those interested in a healthy lifestyle, while discussions on personalized medicine were particularly relevant for participants with personal or family experiences of rare diseases. However, the feedback was not uniformly positive. Many participants ( N  = 4) critiqued the first episode for its lack of depth and practical examples, noting that this diminished its relatability and engagement. This criticism underscores findings by Stocklmayer and Bryant (2012) that scientific content is more engaging when presented in a context relevant to the audience’s daily lives.

The diversity of perspectives, especially the enthusiasm of researchers featured in the podcasts, was another aspect that all participants ( N  = 6) found enriching. This aspect enhanced their understanding of mass spectrometry and maintained their interest in what might otherwise have been a daunting topic. This approach reflects Bandura’s (2001) social cognitive theory, which suggests that motivational dialogue can significantly enhance comprehension and encourage the practical application of learned concepts. These findings also suggest that a listener’s pre-existing familiarity with scientific topics plays a crucial role in their engagement with content. As Wade and Kidd (2019) conclude, curiosity can drive interest towards scientific topics, expanding the listener’s knowledge and increasing engagement with unfamiliar or specialized content areas. Despite the inherently technical nature of the podcasts, the content appealed to those with a specific interest in the field. This niche appeal highlights the importance of aligning scientific content with the audience’s existing interests and backgrounds to foster engagement.

2.2.3 Suggested improvements for the podcasts

The participants provided several suggestions for improvements to make the podcasts more appealing to a broader audience. A common theme in the feedback was the use of technical terms, particularly “mass spectrometry”. Many participants ( N  = 4) suggested changing the name to make it more accessible, with MK28 participant recommending, “ If you use more layperson’s terms, more people will listen to these podcasts. ” Another participant proposed renaming it to “A Day in the Life of a Scientist” to make it more relatable.

Participants ( N  = 3) suggested focusing more on practical applications of mass spectrometry to make the podcast more engaging. They emphasized the importance of understanding how mass spectrometry is used across various fields, with CF31 stating, “ As I understand, it is used for so many other things as well, and I would like to know more. ” Additionally, they recommended creating a series format that avoids repetitive details and instead introduces guests while discussing their fields and interesting cases they have encountered.

Another suggestion was to include elements that would allow listeners to learn more about the personal lives of the guests and their interest in the field, aiming to make the podcast series more enjoyable and relatable. Participants ( N  = 3) expressed a keen interest in understanding how the guests chose their careers. They proposed that including questions such as, “ How did you become involved in this field ?” would provide valuable insights. One participant explained that if the guests had pursued their careers in greater detail, it would offer a deeper understanding of the various paths available in the field of research, making the content more relatable and inspiring for the audience.

To improve the format, some participants ( N  = 2) suggested altering the podcast format to include group discussions, which they found more interesting than one-on-one conversations. Additionally, the absence of video was noted as a drawback. Participants believed that a video podcast could capture the body language and excitement of guests, adding an emotional connection that is often missing in audio-only formats.

Participants ( N  = 2) also suggested discussing stress management in highly scientific fields, noting that this information would be valuable to listeners in similar work environments. Participant MV26 mentioned, “ I would love to hear about how to cope with stress and the feelings of imposter syndrome. ” Participants emphasized that hearing multiple people discuss stress and coping mechanisms can be reassuring and helpful, particularly in mental health. They noted that such discussions are not limited to scientific fields and have broader implications for well-being in other non-scientific fields.

The results show that most listeners are more interested in personal stories than in the science itself. Engaging storytelling is an important element of successful science podcasts. Personal stories can make scientific content more relatable and compelling, keeping listeners entertained while they learn ( Bray et al., 2012 ). Keeping this in mind ensures that the audience remains interested and invested in the content. Also, the observation that listeners are more interested in personal stories than science suggests significant value in integrating human narratives with scientific content. By doing so, science podcasts can achieve a balanced approach that educates, engages, and inspires their audience providing a platform for experts to discuss their work from their perspectives ( Besley and Nisbet, 2011 ; Middleton, 2016 ; DeMarco, 2022 ).

2.2.4 Study limitations and future research

A limitation of this study is the low number of participants for the questionnaire, with the majority belonging to younger age groups and having higher educational attainment. This distribution could be explained by the requirement to listen to podcasts before attempting the questionnaire, which takes up a considerable amount of time for a topic that may or may not interest the listeners. Research findings may also be biased due to the distribution of questionnaires via personal networks and social media channels. Since the questionnaire and podcast were circulated through links shared by the researchers, the sampled population may not be representative and may include individuals who already had some knowledge about mass spectrometry, further introducing potential bias. Another limitation is the measurement of knowledge. While we included questions in the survey to gauge participants’ understanding of mass spectrometry, we relied solely on their responses as the metric without a further formal investigation in the form of an examination to evaluate knowledge acquisition. Lastly, the study’s focus on mass spectrometry podcasts may limit the applicability of the findings to other scientific disciplines. Different fields have unique challenges and opportunities for podcast-based science communication, and further research is needed to explore these variations.

Future researchers can build upon these findings by addressing these limitations. Expanding the participant pool to include a more diverse demographic range and reducing reliance on personal networks and social media channels for recruitment will help provide a more representative sample. Further research should also consider the impact of different podcast formats, such as video podcasts versus audio-only formats, on listener engagement and comprehension. Investigating the effectiveness of incorporating multimedia elements, like visual aids or interactive components, could also provide insights into optimizing podcast delivery for complex scientific content. Additionally, longitudinal studies tracking changes in listeners’ knowledge and perceptions over time would help understand the long-term educational impact of scientific podcasts. Such studies should assess whether repeated exposure to scientific podcasts leads to increased scientific literacy and interest in scientific careers.

3 Conclusion

Based on the results of this study, podcasts were found to be effective tools for educating and informing listeners about specialized scientific topics. All respondents indicated learning at least some level of detail about mass spectrometry from these podcasts. For the discussion of technical research, incorporating humor and storytelling elements was appreciated by the listeners, enhancing engagement and comprehension. The study also found that most participants showed a positive acceptance of the conversational style and the duration of the mass spectrometry podcasts. These preferences varied depending on the listeners’ age group and educational attainment level, highlighting the importance of tailoring podcasts to the target audience. Younger listeners and those with higher educational attainment tended to prefer shorter, conversational episodes that included relatable narratives and practical applications.

Overall, the findings suggest that well-designed scientific podcasts have the potential to bridge knowledge gaps and make complex topics more relatable and engaging. To maximize their impact, science communicators should consider incorporating the elements discussed in this study.

Data availability statement

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author.

Author contributions

NR: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Resources, Validation, Visualization, Writing – original draft. VE: Conceptualization, Methodology, Supervision, Validation, Writing – review & editing. NO: Conceptualization, Funding acquisition, Methodology, Supervision, Validation, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. The study was performed with the financial assistance of the FoodTraNet Project funded by the European Union’s Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement no. 956265.

Acknowledgments

The authors would like to thank the podcast guests (Prof. Dr. Ron Heeren from the Maastricht MultiModal Molecular Imaging Institute/ University of Maastricht, Prof. Dr. Alexander van Nuijs from the Toxicological Centre, University of Antwerp, and Dr. Nina Ogrinc from the Leiden University Medical Center) for their time and participation in the podcast series.

Conflict of interest

NR and VE were employed by WRG Europe Ltd.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fcomm.2024.1384389/full#supplementary-material

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Keywords: science podcasts, podcasting, mass spectrometry, public engagement, science communication

Citation: Rehman N, Edkins V and Ogrinc N (2024) Using podcasts to bridge the gap between science communication and specialized scientific fields: a case study of mass spectrometry. Front. Commun . 9:1384389. doi: 10.3389/fcomm.2024.1384389

Received: 09 February 2024; Accepted: 06 August 2024; Published: 15 August 2024.

Reviewed by:

Copyright © 2024 Rehman, Edkins and Ogrinc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Nives Ogrinc, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Open access
• Published: 10 August 2024

How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK

• Charlotte Parbery-Clark 1 ,
• Lorraine McSweeney 2 ,
• Joanne Lally 3 &
• Sarah Sowden 4  

BMC Public Health volume  24 , Article number:  2168 ( 2024 ) Cite this article

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Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system’s level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions.

In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach.

Interviews ( n  = 14) with wide representation from local authority ( n  = 8), NHS ( n  = 5) and voluntary, community and social enterprise (VCSE) sector ( n  = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system’s approach to reducing health inequalities was evident as was collective action and involving people, with links to a “strong third sector”. Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system.

We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system’s working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Highlights:

• Reducing health inequalities in avoidable hospital admissions is yet to be explicitly linked in practice and is an important area to address.

• Understanding the local context helps to identify existing assets and threats including the leverage points for action.

• Requiring action includes building the resilience of our complex systems by addressing structural barriers and threats as well as supporting the workforce (training and wellbeing with improved retention and recruitment) in addition to the analysis and accessibility of data across the system.

Peer Review reports

Introduction

The health of our population is determined by the complex interaction of several factors which are either non-modifiable (such as age, genetics) or modifiable (such as the environment, social, economic conditions in which we live, our behaviours as well as our access to healthcare and its quality) [ 1 ]. Health inequalities are the avoidable and unfair systematic differences in health and healthcare across different population groups explained by the differences in distribution of power, wealth and resources which drive the conditions of daily life [ 2 , 3 ]. Essentially, health inequalities arise due to the systematic differences of the factors that influence our health. To effectively deal with most public health challenges, including reducing health inequalities and improving population health, broader integrated approaches [ 4 ] and an emphasis on systems is required [ 5 , 6 ] . A system is defined as ‘the set of actors, activities, and settings that are directly or indirectly perceived to have influence in or be affected by a given problem situation’ (p.198) [ 7 ]. In this case, the ‘given problem situation' is reducing health inequalities with a focus on avoidable admissions. Therefore, we must consider health systems, which are the organisations, resources and people aiming to improve or maintain health [ 8 , 9 ] of which health services provision is an aspect. In this study, the system considers NHS bodies, Integrated Care Systems, Local Authority departments, and the voluntary and community sector in a UK region.

A plethora of theories [ 10 ], recommended policies [ 3 , 11 , 12 , 13 ], frameworks [ 1 , 14 , 15 ], and tools [ 16 ] exist to help understand the existence of health inequalities as well as provide suggestions for improvement. However, it is reported that healthcare leaders feel under-skilled to reduce health inequalities [ 17 ]. A lack of clarity exists on how to achieve a system’s multi-agency coherence to reduce health inequalities systematically [ 17 , 18 ]. This is despite some countries having legal obligations to have a regard to the need to attend to health and healthcare inequalities. For example, the Health and Social Care Act 2012 [ 19 ], in England, mandated Clinical Commissioning Groups (CCGs), now transferred to Integrated Care Boards (ICBs) [ 20 ], to ‘have a regard to the need to reduce inequalities between patients with respect to their ability to access health services, and reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services’. The wider determinants of health must also be considered. For example, local areas have a mandatory requirement to have a joint strategic needs assessment (JSNA) and joint health and wellbeing strategy (JHWS) whose purpose is to ‘improve the health and wellbeing of the local community and reduce inequalities for all ages' [ 21 ] This includes addressing the wider determinants of health [ 21 ]. Furthermore, the hospital care costs to the NHS associated with socioeconomic inequalities has been previously reported at £4.8 billion a year due to excess hospitalisations [ 22 ]. Avoidable emergency admissions are admissions into hospital that are considered to be preventable with high-quality ambulatory care [ 23 ]. Both ambulatory care sensitive conditions (where effective personalised care based in the community can aid the prevention of needing an admission) and urgent care sensitive conditions (where a system on the whole should be able to treat and manage without an admission) are considered within this definition [ 24 ] (encompassing more than 100 International Classification of Diseases (ICD) codes). The disease burden sits disproportionately with our most disadvantaged communities, therefore highlighting the importance of addressing inequalities in hospital pressures in a concerted manner [ 25 , 26 ].

Research examining one component of an intervention, or even one part of the system, [ 27 ] or which uses specific research techniques to control for the system’s context [ 28 ] are considered as having limited use for identifying the key ingredients to achieve better population health and wellbeing [ 5 , 28 ]. Instead, systems thinking considers how the system’s components and sub-components interconnect and interrelate within and between each other (and indeed other systems) to gain an understanding of the mechanisms by which things work [ 29 , 30 ]. Complex interventions or work programmes may perform differently in varying contexts and through different mechanisms, and therefore cannot simply be replicated from one context to another to automatically achieve the same outcomes. Ensuring that research into systems and systems thinking considers real-world context, such as where individuals live, where policies are created and interventions are delivered, is vital [ 5 ]. How the context and implementation of complex or even simple interventions interact is viewed as becoming increasingly important [ 31 , 32 ]. Case study research methodology is founded on the ‘in-depth exploration of complex phenomena in their natural, or ‘real-life’, settings’ (p.2) [ 33 ]. Case study approaches can deepen the understanding of complexity addressing the ‘how’, ‘what’ and ‘why’ questions in a real-life context [ 34 ]. Researchers have highlighted the importance of engaging more deeply with case-based study methodology [ 31 , 33 ]. Previous case study research has shown promise [ 35 ] which we build on by exploring a systems lens to consider the local area’s context [ 16 ] within which the work is implemented. By using case-study methodology, our study aimed to explore and develop an in-depth understanding of how a local area addresses health inequalities, with a focus on avoidable hospital admissions. As part of this, systems processes were included.

Study design

This in-depth case study is part of an ongoing larger multiple (collective [ 36 ]) case study approach. An instrumental approach [ 34 ] was taken allowing an in-depth investigation of an issue, event or phenomenon, in its natural real-life context; referred to as a ‘naturalistic’ design [ 34 ]. Ethics approval was obtained by Newcastle University’s Ethics Committee (ref 13633/2020).

Study selection

This case study, alongside the other three cases, was purposively [ 36 ] chosen considering overall deprivation level of the area (Indices of Multiple Deprivation (IMD) [ 37 ]), their urban/rural location, differing geographical spread across the UK (highlighted in patient and public feedback and important for considering the North/South health divide [ 38 ]), and a pragmatic judgement of likely ability to achieve the depth of insight required [ 39 ]. In this paper, we report the findings from one of the case studies, an urban local authority in the Northern region of the UK with high levels of socioeconomic disadvantage. This area was chosen for this in-depth case analysis due to high-level of need, and prior to the COVID-19 pandemic (2009-2018) had experienced a trend towards reducing socioeconomic inequalities in avoidable hospital admission rates between neighbourhoods within the local area [ 40 ]. Thereby this case study represents an ‘unusual’ case [ 41 ] to facilitate learning regarding what is reported and considered to be the key elements required to reduce health inequalities, including inequalities in avoidable admissions, in a local area.

Semi-structured interviews

The key informants were identified iteratively through the documentary analysis and in consultation with the research advisory group. Initially board level committee members (including lay, managerial, and clinical members) within relevant local organisations were purposively identified. These individuals were systems leaders charged with the remit of tackling health inequalities and therefore well placed to identify both key personnel and documents. Snowball sampling [ 42 ] was undertaken thereafter whereby interviewees helped to identify additional key informants within the local system who were working on health inequalities, including avoidable emergency admissions, at a systems level. Interview questions were based on an iteratively developed topic guide (supplementary data 1), informed from previous work’s findings [ 43 ] and the research advisory network’s input. A study information sheet was emailed to perspective interviewees, and participants were asked to complete an e-consent form using Microsoft Forms [ 42 ]. Each interviewee was interviewed by either L.M. or C.P.-C. using the online platforms Zoom or Teams, and lasted up to one hour. Participants were informed of interviewers’ role, workplace as well as purpose of the study. Interviewees were asked a range of questions including any work relating to reducing health inequalities, particularly avoidable emergency admissions, within the last 5 years. Brief notes were taken, and the interviews were recorded, transcribed verbatim and anonymised.

Documentary analysis

The documentary analysis followed the READ approach [ 44 ]. Any documents from the relevant local/regional area with sections addressing health inequalities and/or avoidable emergency admissions, either explicitly stated or implicitly inferred, were included. A list of core documents was chosen, including the local Health and Wellbeing Strategy (Table 1 ). Subsequently, other documents were identified by snowballing from these core documents and identification by the interviewees. All document types were within scope if produced/covered a period within 5 years (2017-2022), including documents in the public domain or not as well as documents pertaining to either a regional, local and neighbourhood level. This 5-year period was a pragmatic decision in line with the interviews and considered to be a balance of legacy and relevance. Attempts were made to include the final version of each document, where possible/applicable, otherwise the most up-to-date version or version available was used.

An Excel spreadsheet data extraction tool was adapted with a priori criteria [ 44 ] to extract the data. This tool included contextual information (such as authors, target area and document’s purpose). Also, information based on previous research on addressing socioeconomic inequalities in avoidable emergency admissions, such as who stands to benefit, was extracted [ 43 ]. Additionally, all documents were summarised according to a template designed according to the research’s aims. Data extraction and summaries were undertaken by L.M. and C.P.-C. A selection was doubled coded to enhance validity and any discrepancies were resolved by discussion.

Interviews and documents were coded and analysed independently based on a thematic analysis approach [ 45 ], managed by NVivo software. A combination of ‘interpretive’ and ‘positivist’ stance [ 34 , 46 ] was taken which involved understanding meanings/contexts and processes as perceived from different perspectives (interviewees and documents). This allowed for an understanding of individual and shared social meanings/reasonings [ 34 , 36 ]. For the documentary analysis, a combination of both content and thematic analysis as described by Bowen [ 47 ] informed by Braun and Clarke’s approach to thematic analysis [ 45 ] was used. This type of content analysis does not include the typical quantification but rather a review of the document for pertinent and meaningful passages of text/other data [ 47 ]. Both an inductive and deductive approach for the documentary analysis’ coding [ 46 , 47 ] was chosen. The inductive approach was developed a posteriori; the deductive codes being informed by the interviews and previous findings from research addressing socioeconomic inequalities in avoidable emergency admissions [ 43 ]. In line with qualitative epistemological approach to enquiry, the interview and documentary findings were viewed as ‘truths’ in themselves with the acceptance that multiple realities can co-exist [ 48 ]. The analysis of each set of themes (with subthemes) from the documentary analysis and interviews were cross-referenced and integrated with each other to provide a cohesive in-depth analysis [ 49 ] by generating thematic maps to explore the relationships between the themes. The codes, themes and thematic maps were peer-reviewed continually with regular meetings between L.M., C.P.-C., J.L. and S.S. Direct quotes are provided from the interviews and documentary analysis. Some quotes from the documents are paraphrased to protect anonymity of the case study after following a set process considering a range of options. This involved searching each quote from the documentary analysis in Google and if the quote was found in the first page of the result, we shortened extracts and repeated the process. Where the shortened extracts were still identifiable, we were required to paraphrase that quote. Each paraphrased quote and original was shared and agreed with all the authors reducing the likelihood of inadvertently misinterpreting or misquoting. Where multiple components over large bodies of text were present in the documents, models were used to evidence the broadness, for example, using Dahlgren’s and Whitehead’s model of health determinants [ 1 ]. Due to the nature of the study, transcripts and findings were not shared with participants for checking but will be shared in a dissemination workshop in 2024.

Patient and public involvement and engagement

Four public contributors from the National Institute for Health and Care Research (NIHR) Research Design Service (RDS) North East and North Cumbria (NENC) Public and Patient Involvement (PPI) panel have been actively engaged in this research from its inception. They have been part of the research advisory group along with professional stakeholders and were involved in the identification of the sampling frame’s key criteria. Furthermore, a diverse group of public contributors has been actively involved in other parts of the project including developing the moral argument around action by producing a public facing resource exploring what health inequalities mean to people and public views of possible solutions [ 50 ].

Semi-structured interviews: description

Sixteen participants working in health or social care, identified through the documentary analysis or snowballing, were contacted for interview; fourteen consented to participate. No further interviews were sought as data sufficiency was reached whereby no new information or themes were being identified. Participant roles were broken down by NHS ( n  = 5), local authority/council ( n  = 8), and voluntary, community and social enterprise (VSCE) ( n  = 1). To protect the participants’ anonymity, their employment titles/status are not disclosed. However, a broad spectrum of interviewees with varying roles from senior health system leadership (including strategic and commissioner roles) to roles within provider organisations and the VSCE sector were included.

Documentary analysis: description

75 documents were reviewed with documents considering regional ( n  = 20), local ( n  = 64) or neighbourhood ( n  = 2) area with some documents covering two or more areas. Table 2 summarises the respective number of each document type which included statutory documents to websites from across the system (NHS, local government and VSCE). 45 documents were named by interviewees and 42 documents were identified as either a core document or through snowballing from other documents. Of these, 12 documents were identified from both. The timescales of the documents varied and where possible to identify, was from 2014 to 2031.

Integrative analysis of the documentary analysis and interviews

The overarching themes encompass:

Understanding the local context

Facilitators to tacking health inequalities: the assets

Emerging risks and concerns

Figure 1 demonstrates the relationships between the main themes identified from the analysis for tackling health inequalities and improving health in this case study.

Diagram of the relationship between the key themes identified regarding tackling health inequalities and improving health in a local area informed by 2 previous work [ 14 , 51 ]. NCDs = non-communicable diseases; HI = health inequalities

Understanding the local context was discussed extensively in both the documents and the interviews. This was informed by local intelligence and data that was routinely collected, monitored, and analysed to help understand the local context and where inequalities lie. More bespoke, in-depth collection and analysis were also described to get a better understanding of the situation. This not only took the form of quantitative but also considered qualitative data with lived experience:

‛So, our data comes from going out to talk to people. I mean, yes, especially the voice of inequalities, those traditional mechanisms, like surveys, don't really work. And it's about going out to communities, linking in with third sector organisations, going out to communities, and just going out to listen…I think the more we can bring out those real stories. I mean, we find quotes really, really powerful in terms of helping people understand what it is that matters.’ (LP16).

However, there were limitations to the available data including the quality as well as having enough time to do the analysis justice. This resulted in difficulties in being able to fully understand the context to help identify and act on the required improvements.

‘A lack of available data means we cannot quantify the total number of vulnerable migrants in [region]’ (Document V).

‛So there’s lots of data. The issue is joining that data up and analysing it, and making sense of it. That’s where we don’t have the capacity.’ (LP15).

Despite the caveats, understanding the context and its data limitations were important to inform local priorities and approaches on tackling health inequalities. This understanding was underpinned by three subthemes which were understanding:

the population’s needs including identification of people at higher risk of worse health and health inequalities

the driving forces of those needs with acknowledgement of the impact of the wider determinants of health

the threats and barriers to physical and mental health, as well as wellbeing

Firstly, the population’s needs, including identification of people at higher risk of worse health and health inequalities, was important. This included considering risk factors, such as smoking, specific groups of people and who was presenting with which conditions. Between the interviews and documents, variation was seen between groups deemed at-risk or high-risk with the documents identifying a wider range. The groups identified across both included marginalised communities, such as ethnic minority groups, gypsy and travellers, refugees and asylum seekers as well as people/children living in disadvantaged area.

‘There are significant health inequalities in children with asthma between deprived and more affluent areas, and this is reflected in A&E admissions.' (Document J).

Secondly, the driving forces of those needs with acknowledgement of the impact of the wider determinants of health were described. These forces mapped onto Dahlgren’s and Whitehead’s model of health determinants [ 1 ] consisting of individual lifestyle factors, social and community networks, living and working conditions (which include access to health care services) as well as general socio-economic, cultural and environmental conditions across the life course.

…. at the centre of our approach considering the requirements to improve the health and wellbeing of our area are the wider determinants of health and wellbeing, acknowledging how factors, such as housing, education, the environment and economy, impact on health outcomes and wellbeing over people’s lifetime and are therefore pivotal to our ambition to ameliorate the health of the poorest the quickest. (Paraphrased Document P).

Thirdly, the threats and barriers to health included environmental risks, communicable diseases and associated challenges, non-communicable conditions and diseases, mental health as well as structural barriers. In terms of communicable diseases, COVID-19 predominated. The environmental risks included climate change and air pollution. Non-communicable diseases were considered as a substantial and increasing threat and encompassed a wide range of chronic conditions such as diabetes, and obesity.

‛Long term conditions are the leading causes of death and disability in [case study] and account for most of our health and care spending. Cases of cancer, diabetes, respiratory disease, dementia and cardiovascular disease will increase as the population of [case study] grows and ages.’ (Document A).

Structural barriers to accessing and using support and/or services for health and wellbeing were identified. These barriers included how the services are set up, such as some GP practices asking for proof of a fixed address or form of identification to register. For example:

Complicated systems (such as having to make multiple calls, the need to speak to many people/gatekeepers or to call at specific time) can be a massive barrier to accessing healthcare and appointments. This is the case particularly for people who have complex mental health needs or chaotic/destabilized circumstances. People who do not have stable housing face difficulties in registering for GP and other services that require an address or rely on post to communicate appointments. (Paraphrased Document R).

A structural threat regarding support and/or services for health and wellbeing was the sustainability of current funding with future uncertainty posing potential threats to the delivery of current services. This also affected the ability to adapt and develop the services, or indeed build new ones.

‛I would say the other thing is I have a beef [sic] [disagreement] with pilot studies or new innovations. Often soft funded, temporary funded, charity funded, partnership work run by enthusiasts. Me, I've done them, or supported people doing many of these. And they're great. They can make a huge impact on the individuals involved on that local area. You can see fantastic work. You get inspired and you want to stand up in a crowd and go, “Wahey, isn't this fantastic?” But actually the sad part of it is on these things, I've seen so many where we then see some good, positive work being done, but we can't make it permanent or we can't spread it because there's no funding behind it.’ (LP8).

Facilitators to tackling health inequalities: the assets

The facilitators for improving health and wellbeing and tackling health inequalities are considered as assets which were underpinned by values and principles.

Values driven supported by four key principles

Being values driven was an important concept and considered as the underpinning attitudes or beliefs that guide decision making [ 52 ]. Particularly, the system’s approach was underpinned by a culture and a system's commitment to tackle health inequalities across the documents and interviews. This was also demonstrated by how passionately and emotively some interviewees spoke about their work.

‛There's a really strong desire and ethos around understanding that we will only ever solve these problems as a system, not by individual organisations or even just part of the system working together. And that feels great.’ (LP3).

Other values driving the approach included accountability, justice, and equity. Reducing health inequalities and improving health were considered to be the right things to do. For example:

We feel strongly about social justice and being inclusive, wishing to reflect the diversity of [case study]. We campaign on subjects that are important to people who are older with respect and kindness. (Paraphrased Document O).

Four key principles were identified that crosscut the assets which were:

Shared vision

Strong partnership

Asset-based approaches

Willingness and ability to act on learning

The mandated strategy, identifying priorities for health and wellbeing for the local population with the required actions, provided the shared vision across each part of the system, and provided the foundations for the work. This shared vision was repeated consistently in the documents and interviews from across the system.

[Case study] will be a place where individuals who have the lowest socioeconomic status will ameliorate their health the quickest. [Case study] will be a place for good health and compassion for all people, regardless of their age. (Paraphrased Document A).

‛One thing that is obviously becoming stronger and stronger is the focus on health inequalities within all of that, and making sure that we are helping people and provide support to people with the poorest health as fast as possible, so that agenda hasn’t shifted.’ (LP7).

This drive to embed the reduction of health inequalities was supported by clear new national guidance encapsulated by the NHS Core20PLUS5 priorities. Core20PLUS5 is the UK's approach to support a system to improve their healthcare inequalities [ 53 ]. Additionally, the system's restructuring from Clinical Commissioning Groups (CCGs) to Integrated Care Boards (ICBs) and formalisation of the now statutory Integrated Care Systems (ICS) in England was also reported to facilitate the driving of further improvement in health inequalities. These changes at a regional and local level helped bring key partners across the system (NHS and local government among others) to build upon their collective responsibility for improving health and reducing health inequalities for their area [ 54 ].

‛I don’t remember the last time we’ve had that so clear, or the last time that health inequalities has had such a prominent place, both in the NHS planning guidance or in the NHS contract. ’ (LP15). ‛The Health and Care Act has now got a, kind of, pillar around health inequalities, the new establishment of ICPs and ICBs, and also the planning guidance this year had a very clear element on health inequalities.’ (LP12)

A strong partnership and collaborative team approach across the system underpinned the work from the documents and included the reoccurrence of the concept that this case study acted as one team: ‘Team [case study]'.

Supporting one another to ensure [case study] is the best it can be: Team [case study]. It involves learning, sharing ideas as well as organisations sharing assets and resources, authentic partnerships, and striving for collective impact (environmental and social) to work towards shared goals . (Paraphrased Document B).

This was corroborated in the interviews as working in partnership to tackle health inequalities was considered by the interviewees as moving in the right direction. There were reports that the relationship between local government, health care and the third sector had improved in recent years which was still an ongoing priority:

‘I think the only improvement I would cite, which is not an improvement in terms of health outcomes, but in terms of how we work across [case study] together has moved on quite a lot, in terms of teams leads and talking across us, and how we join up on things, rather than see ourselves all as separate bodies' (LP15).

‘I think the relationship between local authorities and health and the third sector, actually, has much more parity and esteem than it had before.' (LP11)

The approaches described above were supported by all health and care partners signing up to principles around partnership; it is likely this has helped foster the case study's approach. This also builds on the asset-based approaches that were another key principle building on co-production and co-creation which is described below.

We begin with people : instead of doing things to people or for them, we work with them, augmenting the skills, assets and strength of [case study]’s people, workforce and carers. We achieve : actions are focused on over words and by using intelligence, every action hones in on the actual difference that we will make to ameliorate outcomes, quality and spend [case study]’s money wisely; We are Team [case study ]: having kindness, working as one organisation, taking responsibility collectively and delivering on what we agreed. Problems are discussed with a high challenge and high support attitude. (Paraphrased Document D).

At times, the degree to which the asset-based approaches were embedded differed from the documents compared to the interviews, even when from the same part of the system. For example, the documents often referred to the asset-based approach as having occurred whilst interviewees viewed it more as a work in progress.

‘We have re-designed many of our services to focus on needs-led, asset-based early intervention and prevention, and have given citizens more control over decisions that directly affect them .’ (Document M).

‘But we’re trying to take an asset-based approach, which is looking at the good stuff in communities as well. So the buildings, the green space, the services, but then also the social capital stuff that happens under the radar.’ (LP11).

A willingness to learn and put in action plans to address the learning were present. This enables future proofing by building on what is already in place to build the capacity, capability and flexibility of the system. This was particularly important for developing the workforce as described below.

‘So we’ve got a task and finish group set up, […] So this group shows good practice and is a space for people to discuss some of the challenges or to share what interventions they are doing around the table, and also look at what other opportunities that they have within a region or that we could build upon and share and scale.’ (LP12).

These assets that are considered as facilitators are divided into four key levels which are the system, services and support, communities and individuals, and workforce which are discussed in turn below.

Firstly, the system within this case study was made up of many organisations and partnerships within the NHS, local government, VSCE sector and communities. The interviewees reported the presence of a strong VCSE sector which had been facilitated by the local council's commitment to funding this sector:

‘Within [case study], we have a brilliant third sector, the council has been longstanding funders of infrastructure in [case study], third sector infrastructure, to enable those links [of community engagement] to be made' (LP16).

In both the documents and interviews, a strong coherent strategic integrated population health management plan with a system’s approach to embed the reduction of health inequalities was evident. For example, on a system level regionally:

‘To contribute towards a reduction in health inequalities we will: take a system wide approach for improving outcomes for specific groups known to be affected by health inequalities, starting with those living in our most deprived communities….’ (Document H).

This case study’s approach within the system included using creative solutions and harnessing technology. This included making bold and inventive changes to improve how the city and the system linked up and worked together to improve health. For example, regeneration work within the city to ameliorate and transform healthcare facilities as well as certain neighbourhoods by having new green spaces, better transport links in order to improve city-wide innovation and collaboration (paraphrased Document F) were described. The changes were not only related to physical aspects of the city but also aimed at how the city digitally linked up. Being a leader in digital innovation to optimise the health benefits from technology and information was identified in several documents.

‘ Having the best connected city using digital technology to improve health and wellbeing in innovative ways.’ (Document G).

The digital approaches included ongoing development of a digitalised personalised care record facilitating access to the most up-to-date information to developing as well as having the ‘ latest, cutting edge technologies’ ( Document F) in hospital care. However, the importance of not leaving people behind by embedding digital alternatives was recognised in both the documents and interviews.

‘ We are trying to just embed the culture of doing an equity health impact assessment whenever you are bringing in a digital solution or a digital pathway, and that there is always an alternative there for people who don’t have the capability or capacity to use it. ’ (LP1).

The successful one hundred percent [redacted] programme is targeting some of our most digitally excluded citizens in [case study]. For our city to continue to thrive, we all need the appropriate skills, technology and support to get the most out of being online. (Paraphrased Document Q)

This all links in with the system that functions in a ‘place' which includes the importance of where people are born, grow, work and live. Working towards this place being welcoming and appealing was described both regionally and locally. This included aiming to make the case study the place of choice for people.

‘Making [case study] a centre for good growth becoming the place of choice in the UK to live, to study, for businesses to invest in, for people to come and work.’ (Document G).

Services and support

Secondly, a variety of available services and support were described from the local authority, NHS, and voluntary community sectors. Specific areas of work, such as local initiatives (including targeted work or campaigns for specific groups or specific health conditions) as well as parts of the system working together with communities collaboratively, were identified. This included a wide range of work being done such as avoiding delayed discharges or re-admissions, providing high quality affordable housing as well as services offering peer support.

‘We have a community health development programme called [redacted], that works with particular groups in deprived communities and ethnically diverse communities to work in a very trusted and culturally appropriate way on the things that they want to get involved with to support their health.’ (LP3 ).

It is worth noting that reducing health inequalities in avoidable admissions was not often explicitly specified in the documents or interviews. However, either specified or otherwise inferred, preventing ill health and improving access, experience, and outcomes were vital components to addressing inequalities. This was approached by working with communities to deliver services in communities that worked for all people. Having co-designed, accessible, equitable integrated services and support appeared to be key.

‘Reducing inequalities in unplanned admissions for conditions that could be cared for in the community and access to planned hospital care is key.’ (Document H)

Creating plans with people: understanding the needs of local population and designing joined-up services around these needs. (Paraphrased Document A).

‘ So I think a core element is engagement with your population, so that ownership and that co-production, if you're going to make an intervention, don't do it without because you might miss the mark. ’ (LP8).

Clear, consistent and appropriate communication that was trusted was considered important to improve health and wellbeing as well as to tackle health inequalities. For example, trusted community members being engaged to speak on the behalf of the service providers:

‘The messenger is more important than the message, sometimes.’ (LP11).

This included making sure the processes are in place so that the information is accessible for all, including people who have additional communication needs. This was considered as a work in progress in this case study.

‘I think for me, things do come down to those core things, of health, literacy, that digital exclusion and understanding the wider complexities of people.’ (LP12)

‘ But even more confusing if you've got an additional communication need. And we've done quite a lot of work around the accessible information standard which sounds quite dry, and doesn't sound very- but actually, it's fundamental in accessing health and care. And that is, that all health and care organisations should record your communication preferences. So, if I've got a learning disability, people should know. If I've got a hearing impairment, people should know. But the systems don’t record it, so blind people are getting sent letters for appointments, or if I've got hearing loss, the right provisions are not made for appointments. So, actually, we're putting up barriers before people even come in, or can even get access to services.’ (LP16).

Flexible, empowering, holistic care and support that was person-centric was more apparent in the documents than the interviews.

At the centre of our vision is having more people benefiting from the life chances currently enjoyed by the few to make [case study] a more equal place. Therefore, we accentuate the importance of good health, the requirement to boost resilience, and focus on prevention as a way of enabling higher quality service provision that is person-centred. [Paraphrased Document N).

Through this [work], we will give all children and young people in [case study], particularly if they are vulnerable and/or disadvantaged, a start in life that is empowering and enable them to flourish in a compassionate and lively city. [Paraphrased Document M].

Communities and individuals

Thirdly, having communities and individuals at the heart of the work appeared essential and viewed as crucial to nurture in this case study. The interconnectedness of the place, communities and individuals were considered a key part of the foundations for good health and wellbeing.

In [case study], our belief is that our people are our greatest strength and our most important asset. Wellbeing starts with people: our connections with our friends, family, and colleagues, our behaviour, understanding, and support for one another, as well as the environment we build to live in together . (Paraphrased Document A).

A recognition of the power of communities and individuals with the requirement to support that key principle of a strength-based approach was found. This involved close working with communities to help identify what was important, what was needed and what interventions would work. This could then lead to improved resilience and cohesion.

‛You can't make effective health and care decisions without having the voice of people at the centre of that. It just won't work. You won't make the right decisions.’ (LP16).

‘Build on the strengths in ourselves, our families, carers and our community; working with people, actively listening to what matters most to people, with a focus on what’s strong rather than what’s wrong’ (Document G).

Meaningful engagement with communities as well as strengths and asset-based approaches to ensure self-sufficiency and sustainability of communities can help communities flourish. This includes promoting friendships, building community resilience and capacity, and inspiring residents to find solutions to change the things they feel needs altering in their community . (Paraphrased Document B).

This close community engagement had been reported to foster trust and to lead to improvements in health.

‘But where a system or an area has done a lot of community engagement, worked really closely with the community, gained their trust and built a programme around them rather than just said, “Here it is. You need to come and use it now,” you can tell that has had the impact. ' (LP1).

Finally, workforce was another key asset; the documents raised the concept of one workforce across health and care. The key principles of having a shared vision, asset-based approaches and strong partnership were also present in this example:

By working together, the Health and Care sector makes [case study] the best area to not only work but also train for people of all ages. Opportunities for skills and jobs are provided with recruitment and engagement from our most disadvantaged communities, galvanizing the future’s health and care workforce. By doing this, we have a very skilled and diverse workforce we need to work with our people now as well as in the future. (Paraphrased Document E).

An action identified for the health and care system to address health inequalities in case study 1 was ‘ the importance of having an inclusive workforce trained in person-centred working practices ’ (Document R). Several ways were found to improve and support workforce skills development and embed awareness of health inequalities in practice and training. Various initiatives were available such as an interactive health inequalities toolkit, theme-related fellowships, platforms and networks to share learning and develop skills.

‛We've recently launched a [redacted] Fellowship across [case study’s region], and we've got a number of clinicians and managers on that………. We've got training modules that we've put on across [case study’s region], as well for health inequalities…we've got learning and web resources where we share good practice from across the system, so that is our [redacted] Academy.’ (LP2).

This case study also recognised the importance of considering the welfare of the workforce; being skilled was not enough. This had been recognised pre-pandemic but was seen as even more important post COVID-19 due to the impact that COVID-19 had on staff, particularly in health and social care.

‛The impacts of the pandemic cannot be underestimated; our colleagues and services are fatigued and still dealing with the pressures. This context makes it even more essential that we share the responsibility, learn from each other at least and collaborate with each other at best, and hold each other up to be the best we can.’ (Document U).

Concerns were raised such as the widening of health inequalities since the pandemic and cost of living crisis. Post-pandemic and Brexit, recruiting health, social care and third sector staff was compounding the capacity throughout this already heavily pressurised system.

In [case study], we have seen the stalling of life expectancy and worsening of the health inequality gap, which is expected to be compounded by the effects of the pandemic. (Paraphrased Document T)

‘I think key barriers, just the immense pressure on the system still really […] under a significant workload, catching up on activity, catching up on NHS Health Checks, catching up on long-term condition reviews. There is a significant strain on the system still in terms of catching up. It has been really difficult because of the impact of COVID.’ (LP7).

‘Workforce is a challenge, because the pipelines that we’ve got, we’ve got fewer people coming through many of them. And that’s not just particular to, I don't know, nursing, which is often talking talked [sic] about as a challenged area, isn't it? And of course, it is. But we’ve got similar challenges in social care, in third sector.’ (LP5).

The pandemic was reported to have increased pressures on the NHS and services not only in relation to staff capacity but also regarding increases in referrals to services, such as mental health. Access to healthcare changed during the pandemic increasing barriers for some:

‘I think people are just confused about where they're supposed to go, in terms of accessing health and care at the moment. It's really complex to understand where you're supposed to go, especially, at the moment, coming out of COVID, and the fact that GPs are not the accessible front door. You can't just walk into your GP anymore.’ (LP16).

‘Meeting this increased demand [for work related to reducing ethnic inequalities in mental health] is starting to prove a challenge and necessitates some discussion about future resourcing.’ (Document S)

Several ways were identified to aid effective adaptation and/or mitigation. This included building resilience such as developing the existing capacity, capability and flexibility of the system by learning from previous work, adapting structures and strengthening workforce development. Considerations, such as a commitment to Marmot Principles and how funding could/would contribute, were also discussed.

The funding’s [linked to Core20PLUS5] purpose is to help systems to ensure that health inequalities are not made worse when cost-savings or efficiencies are sought…The available data and insight are clear and [health inequalities are] likely to worsen in the short term, the delays generated by pandemic, the disproportionate effect of that on the most deprived and the worsening food and fuel poverty in all our places. (Paraphrased Document L).

Learning from the pandemic was thought to be useful as some working practices had altered during COVID-19 for the better, such as needing to continue to embed how the system had collaborated and resist old patterns of working:

‘So I think that emphasis between collaboration – extreme collaboration – which is what we did during COVID is great. I suppose the problem is, as we go back into trying to save money, we go back into our old ways of working, about working in silos. And I think we’ve got to be very mindful of that, and continue to work in a different way.’ (LP11).

Another area identified as requiring action, was the collection, analysis, sharing and use of data accessible by the whole system.

‘So I think there is a lot of data out there. It’s just how do we present that in such a way that it’s accessible to everyone as well, because I think sometimes, what happens is that we have one group looking at data in one format, but then how do we cascade that out?’ (LP12)

We aimed to explore a system’s level understanding of how a local area addresses health inequalities with a focus on avoidable emergency admissions using a case study approach. Therefore, the focus of our research was strategic and systematic approaches to inequalities reduction. Gaining an overview of what was occurring within a system is pertinent because local areas are required to have a regard to address health inequalities in their local areas [ 20 , 21 ]. Through this exploration, we also developed an understanding of the system's processes reported to be required. For example, an area requiring action was viewed as the accessibility and analysis of data. The case study described having health inequalities ‘at the heart of its health and wellbeing strategy ’ which was echoed across the documents from multiple sectors across the system. Evidence of a values driven partnership with whole systems working was centred on the importance of place and involving people, with links to a ‘strong third sector ’ . Working together to support and strengthen local assets (the system, services/support, communities/individuals, and the workforce) were vital components. This suggested a system’s committed and integrated approach to improve population health and reduce health inequalities as well as concerted effort to increase system resilience. However, there was juxtaposition at times with what the documents contained versus what interviewees spoke about, for example, the degree to which asset-based approaches were embedded.

Furthermore, despite having a priori codes for the documentary analysis and including specific questions around work being undertaken to reduce health inequalities in avoidable admissions in the interviews with key systems leaders, this explicit link was still very much under-developed for this case study. For example, how to reduce health inequalities in avoidable emergency admissions was not often specified in the documents but could be inferred from existing work. This included work around improving COVID-19 vaccine uptake in groups who were identified as being at high-risk (such as older people and socially excluded populations) by using local intelligence to inform where to offer local outreach targeted pop-up clinics. This limited explicit action linking reduction of health inequalities in avoidable emergency admissions was echoed in the interviews and it became clear as we progressed through the research that a focus on reduction of health inequalities in avoidable hospital admissions at a systems level was not a dominant aspect of people’s work. Health inequalities were viewed as a key part of the work but not necessarily examined together with avoidable admissions. A strengthened will to take action is reported, particularly around reducing health inequalities, but there were limited examples of action to explicitly reduce health inequalities in avoidable admissions. This gap in the systems thinking is important to highlight. When it was explicitly linked, upstream strategies and thinking were acknowledged as requirements to reduce health inequalities in avoidable emergency admissions.

Similar to our findings, other research have also found networks to be considered as the system’s backbone [ 30 ] as well as the recognition that communities need to be central to public health approaches [ 51 , 55 , 56 ]. Furthermore, this study highlighted the importance of understanding the local context by using local routine and bespoke intelligence. It demonstrated that population-based approaches to reduce health inequalities are complex, multi-dimensional and interconnected. It is not about one part of the system but how the whole system interlinks. The interconnectedness and interdependence of the system (and the relevant players/stakeholders) have been reported by other research [ 30 , 57 ], for example without effective exchange of knowledge and information, social networks and systems do not function optimally [ 30 ]. Previous research found that for systems to work effectively, management and transfer of knowledge needs to be collaborative [ 30 ], which was recognised in this case study as requiring action. By understanding the context, including the strengths and challenges, the support or action needed to overcome the barriers can be identified.

There are very limited number of case studies that explore health inequalities with a focus on hospital admissions. Of the existing research, only one part of the health system was considered with interviews looking at data trends [ 35 ]. To our knowledge, this research is the first to build on this evidence by encompassing the wider health system using wider-ranging interviews and documentary analysis. Ford et al. [ 35 ] found that geographical areas typically had plans to reduce total avoidable emergency admissions but not comprehensive plans to reduce health inequalities in avoidable emergency admissions. This approach may indeed widen health inequalities. Health inequalities have considerable health and costs impacts. Pertinently, the hospital care costs associated with socioeconomic inequalities being reported as £4.8 billion a year, mainly due to excess hospitalisations such as avoidable admissions [ 58 ] and the burden of disease lies disproportionately with our most disadvantaged communities, addressing inequalities in hospital pressures is required [ 25 , 26 ].

Implications for research and policy

Improvements to life expectancy have stalled in the UK with a widening of health inequalities [ 12 ]. Health inequalities are not inevitable; it is imperative that the health gap between the deprived and affluent areas is narrowed [ 12 ]. This research demonstrates the complexity and intertwining factors that are perceived to address health inequalities in an area. Despite the evidence of the cost (societal and individual) of avoidable admissions, explicit tackling of inequality in avoidable emergency admissions is not yet embedded into the system, therefore highlights an area for policy and action. This in-depth account and exploration of the characteristics of ‘whole systems’ working to address health inequalities, including where challenges remain, generated in this research will be instrumental for decision makers tasked with addressing health and care inequalities.

This research informs the next step of exploring each identified theme in more detail and moving beyond description to develop tools, using a suite of multidimensional and multidisciplinary methods, to investigate the effects of interventions on systems as previously highlighted by Rutter et al. [ 5 ].

Strengths and limitations

Documentary analysis is often used in health policy research but poorly described [ 44 ]. Furthermore, Yin reports that case study research is often criticised for not adhering to ‘systematic procedures’ p. 18 [ 41 ]. A clear strength of this study was the clearly defined boundary (in time and space) case as well as following a defined systematic approach, with critical thought and rationale provided at each stage [ 34 , 41 ]. A wide range and large number of documents were included as well as interviewees from across the system thereby resulting in a comprehensive case study. Integrating the analysis from two separate methodologies (interviews and documentary analysis), analysed separately before being combined, is also a strength to provide a coherent rich account [ 49 ]. We did not limit the reasons for hospital admission to enable a broad as possible perspective; this is likely to be a strength in this case study as this connection between health inequalities and avoidable hospital admissions was still infrequently made. However, for example, if a specific care pathway for a health condition had been highlighted by key informants this would have been explored.

Due to concerns about identifiability, we took several steps. These included providing a summary of the sectors that the interviewees and document were from but we were not able to specify which sectors each quote pertained. Additionally, some of the document quotes required paraphrasing. However, we followed a set process to ensure this was as rigorous as possible as described in the methods section. For example, where we were required to paraphrase, each paraphrased quote and original was shared and agreed with all the authors to reduce the likelihood to inadvertently misinterpreting or misquoting.

The themes are unlikely to represent an exhaustive list of the key elements requiring attention, but they represent the key themes that were identified using a robust methodological process. The results are from a single urban local authority with high levels of socioeconomic disadvantage in the North of England which may limit generalisability to different contexts. However, the findings are still generalisable to theoretical considerations [ 41 ]. Attempts to integrate a case study with a known framework can result in ‘force-fit’ [ 34 ] which we avoided by developing our own framework (Fig. 1 ) considering other existing models [ 14 , 59 ]. The results are unable to establish causation, strength of association, or direction of influence [ 60 ] and disentangling conclusively what works versus what is thought to work is difficult. The documents’ contents may not represent exactly what occurs in reality, the degree to which plans are implemented or why variation may occur or how variation may affect what is found [ 43 , 61 ]. Further research, such as participatory or non-participatory observation, could address this gap.

Conclusions

This case study provides an in-depth exploration of how local areas are working to address health and care inequalities, with a focus on avoidable hospital admissions. Key elements of this system’s reported approach included fostering strategic coherence, cross-agency working, and community-asset based working. An area requiring action was viewed as the accessibility and analysis of data. Therefore, local areas could consider the challenges of data sharing across organisations as well as the organisational capacity and capability required to generate useful analysis in order to create meaningful insights to assist work to reduce health and care inequalities. This would lead to improved understanding of the context including where the key barriers lie for a local area. Addressing structural barriers and threats as well as supporting the training and wellbeing of the workforce are viewed as key to building resilience within a system to reduce health inequalities. Furthermore, more action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

Availability of data and materials

Individual participants’ data that underlie the results reported in this article and a data dictionary defining each field in the set are available to investigators whose proposed use of the data has been approved by an independent review committee for work. Proposals should be directed to [email protected] to gain access, data requestors will need to sign a data access agreement. Such requests are decided on a case by case basis.

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Acknowledgements

Thanks to our Understanding Factors that explain Avoidable hospital admission Inequalities - Research study (UNFAIR) PPI contributors, for their involvement in the project particularly in the identification of the key criteria for the sampling frame. Thanks to the research advisory team as well.

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This research was funded by the National Institute for Health and Care Research (NIHR), grant number (ref CA-CL-2018-04-ST2-010). The funding body was not involved in the study design, collection of data, inter-pretation, write-up, or submission for publication. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care or Newcastle University.

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Charlotte Parbery-Clark

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Lorraine McSweeney

Senior Research Methodologist & Public Involvement Lead, Faculty of Medical Sciences, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK

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Conceptualization - J.L. and S.S.; methodology - C.P.-C., J.L. & S.S.; formal analysis - C. P.-C. & L.M.; investigation- C. P.-C. & L.M., resources, writing of draft manuscript - C.P.-C.; review and editing manuscript L.M., J.L., & S.S.; visualization including figures and tables - C.P.-C.; supervision - J.L. & S.S.; project administration - L.M. & S.S.; funding acquisition - S.S. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Charlotte Parbery-Clark or Sarah Sowden .

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Parbery-Clark, C., McSweeney, L., Lally, J. et al. How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK. BMC Public Health 24 , 2168 (2024). https://doi.org/10.1186/s12889-024-19531-5

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A pragmatic, stepped-wedge, hybrid type II trial of interoperable clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury

• Christopher J. Tignanelli   ORCID: orcid.org/0000-0002-8079-5565 1 , 2 , 3 , 4 ,
• Surbhi Shah 5 ,
• David Vock 6 ,
• Lianne Siegel 6 ,
• Carlos Serrano 6 ,
• Elliott Haut 7 ,
• Sean Switzer 8 ,
• Christie L. Martin 9 ,
• Rubina Rizvi 2 , 3 ,
• Vincent Peta 1 ,
• Peter C. Jenkins 10 ,
• Nicholas Lemke 1 ,
• Thankam Thyvalikakath 11 , 12 ,
• Jerome A. Osheroff 13 ,
• Denise Torres 14 ,
• David Vawdrey 15 ,
• Rachael A. Callcut 16 ,
• Mary Butler 3 , 17 &
• Genevieve B. Melton 1 , 2 , 3  

Implementation Science volume  19 , Article number:  57 ( 2024 ) Cite this article

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Venous thromboembolism (VTE) is a preventable medical condition which has substantial impact on patient morbidity, mortality, and disability. Unfortunately, adherence to the published best practices for VTE prevention, based on patient centered outcomes research (PCOR), is highly variable across U.S. hospitals, which represents a gap between current evidence and clinical practice leading to adverse patient outcomes.

This gap is especially large in the case of traumatic brain injury (TBI), where reluctance to initiate VTE prevention due to concerns for potentially increasing the rates of intracranial bleeding drives poor rates of VTE prophylaxis. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death. Clinical decision support (CDS) is an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption and successful scaling across health systems. Clinical practice guidelines (CPGs) informed by PCOR evidence can be deployed using CDS systems to improve the evidence to practice gap. In the Scaling AcceptabLE cDs (SCALED) study, we will implement a VTE prevention CPG within an interoperable CDS system and evaluate both CPG effectiveness (improved clinical outcomes) and CDS implementation.

The SCALED trial is a hybrid type 2 randomized stepped wedge effectiveness-implementation trial to scale the CDS across 4 heterogeneous healthcare systems. Trial outcomes will be assessed using the RE 2 -AIM planning and evaluation framework. Efforts will be made to ensure implementation consistency. Nonetheless, it is expected that CDS adoption will vary across each site. To assess these differences, we will evaluate implementation processes across trial sites using the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (a determinant framework) using mixed-methods. Finally, it is critical that PCOR CPGs are maintained as evidence evolves. To date, an accepted process for evidence maintenance does not exist. We will pilot a “Living Guideline” process model for the VTE prevention CDS system.

The stepped wedge hybrid type 2 trial will provide evidence regarding the effectiveness of CDS based on the Berne-Norwood criteria for VTE prevention in patients with TBI. Additionally, it will provide evidence regarding a successful strategy to scale interoperable CDS systems across U.S. healthcare systems, advancing both the fields of implementation science and health informatics.

Trial registration

Clinicaltrials.gov – NCT05628207. Prospectively registered 11/28/2022, https://classic.clinicaltrials.gov/ct2/show/NCT05628207 .

Contributions to the Literature

This paper provides a study protocol for a new and novel stepped wedge study variation which includes external control sites to take into account external influences on the uptake of traumatic brain injury guidelines nationally

This paper provides a study design for one of the largest trauma pragmatic trials in the U.S. of 9 heterogenous hospitals

This study is also unique and first-in-kind feature as the guideline may change over time during the study due to the “living” nature of the guideline being implemented.

Introduction

Venous thromboembolism (VTE) is a preventable complication of traumatic brain injury (TBI), which has a substantial impact on patient morbidity, mortality, disability. It is also associated with significant economic burden > $1.5 billion per year [ 1 , 2 ]. VTE is considered a preventable medical condition in the majority of cases [ 2 , 3 ]. Unfortunately, adherence with patient centered outcomes research (PCOR)-informed VTE prevention best practices is highly variable and often poor across U.S. hospitals. Compliance with best practice is especially relevant in the case of TBI as 54% of TBI patients will develop a VTE if they do not receive appropriate anticoagulation [ 4 ]. The delivery of appropriate VTE prophylaxis to TBI patients is such an important quality measure that adherence is tracked nationally and benchmarked by the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) [ 5 ]. We have previously shown that instituting a hospital-wide VTE prevention initiative modeled after the Berne-Norwood criteria for VTE prophylaxis in TBI was associated with significantly increased compliance with VTE-related process and improved outcome metrics [ 6 ]. Specifically, we observed improved adherence with the Berne-Norwood criteria [ 7 , 8 ], reduced time to initiation of VTE prophylaxis, and reduced VTE events [ 9 ]. Multiple studies have shown that VTE prophylaxis in trauma patients not only reduces VTE events, but also significantly reduces mortality [ 10 ]. We noted the same reduction in mortality for TBI patients following the initiation of a VTE prophylaxis guideline for patients with TBI [ 11 ]. Unfortunately, despite widely published PCOR-informed best practice, nationally there is reluctance to initiate VTE prevention due to concerns for progression of intracranial hemorrhage. This is despite research which has shown early initiation of VTE prophylaxis to be safe in TBI without increased risk of delayed neurosurgical intervention or death [ 12 , 13 , 14 , 15 , 16 ].

Since approximately 40% of TBI patients do not receive DVT prophylaxis in a timely manner, there is a critical and timely need to close the gap between current PCOR evidence and clinical practice. [ 17 , 18 , 19 , 20 , 21 , 22 , 23 ]. Clinical decision support (CDS) systems are an indispensable solution to close this practice gap; however, design and implementation barriers hinder CDS adoption [ 24 , 25 ]. Another significant challenge to the implementation of CDS is that health information technology (IT) needs a common language for PCOR evidence to translate it into practice across multiple organizations [ 26 ]. Because of these challenges, we will deploy CDS using fast healthcare interoperability resources (FHIR) standards to rapidly implement PCOR evidence into practice [ 27 , 28 ]. We hypothesize that, FHIR standards will reduce CDS development and maintenance costs, increase PCOR uptake in rural and other underserved sites, and speed the development timeline to build a comprehensive suite of CDS for PCOR evidence [ 29 ].

Few studies have investigated specific barriers to and facilitating factors for adoption of interoperable FHIR-based CDS [ 30 ]. For example, many current studies investigating barriers and facilitators for interoperable CDS are limited to expert opinion [ 30 , 31 ] or lack a formal implementation science framework-guided investigation [ 32 , 33 ]. Barriers to and facilitating factors for adoption of interoperable CDS following real-life implementation and multicenter scaling guided by validated implementation science frameworks should be rigorously investigated. This study will facilitate comprehensive exploration of clinician and environmental (internal and external) contextual elements that influence interoperable CDS implementation success. In this study, we will scale and assess the effectiveness of a CDS system for a VTE prophylaxis guideline in patients with TBI and evaluate implementation across 9 sites within 4 U.S. trauma systems.

Study aims and implementation framework

This trial consists of a stepped wedge hybrid effectiveness-implementation trial to scale the CDS system across 4 trauma systems and in parallel evaluate implementation strategy guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework (Fig.  1 a) [ 34 ]. We anticipate variability in CDS adoption across sites during the implementation trial. This variation represents a unique opportunity to study implementation at each site and understand what strategies, system factors, and engagement of specific stakeholders are associated with improved CDS adoption. We will rigorously evaluate each implementation phase, guided by The EPIS Implementation Framework [ 34 ], our determinant framework (Fig.  1 b). We will apply the EPIS framework to guide assessment of implementation phases, barriers, and facilitators (Fig.  2 ) [ 34 ]. EPIS comprises 16 constructs over 4 domains (outer context, inner context, bridging factors, and innovation factors). We selected EPIS as our determinant framework as it includes clearly delineated implementation stages and allows for examination of change at multiple levels, across time, and through phases that build toward implementation. While EPIS was initially developed for implementation in public service, it has since been translated to healthcare, especially for complex multi-institutional healthcare interventions [ 34 , 35 , 36 ].

a Randomized Stepped Wedge design of the SCALED clinical trial. b Parallel, implementation evaluation guided by Explore, Preparation, Implementation and Sustain (EPIS) framework

Implementation evaluation across study sites

Trial overview, setting, and inclusion/exclusion criteria

This trial will be conducted at 4 healthcare systems with 1–3 hospitals per system and is projected to occur over a 3 to 4-year period. The trial uses a randomized stepped-wedge design to scale an interoperable CDS system for the Berne-Norwood TBI CPG. Figure  1 a provides a schematic for the trial design. The order of health systems and sites will be randomly determined. This study will include a heterogeneous number of hospitals by trauma verification status, electronic health record (EHR) platform, bed size, and setting (Table  1 ). Our target population is adult patients admitted with an acute TBI defined as International Classification of Disease 10 Clinical Modification (ICD-10-CM): S06.1 – S06.9 or S06.A. Patients who die within 24 h of hospital admission and patients documented as “comfort cares” during the first 72 h of hospitalization will be excluded, as they would have a limited opportunity to receive adherence with the Berne-Norwood criteria. Additionally, patients with a pre-existing VTE or inferior vena cava (IVC) filter at the time of admission, and patients with a mechanical heart valve or ventricular assist device will be excluded from final analysis.

This study will also include up to 3 control sites (Fig.  1 a), a feature not typically included with historic stepped-wedge trial designs, which will strengthen our ability to understand external influences on the study findings. These control sites, which do not receive the CDS intervention and do not have any planned initiatives around guideline implementation, will allow the study to assess baseline adherence and variation in clinical practice over the study period.

CDS Intervention

TBI diagnosis upon admission will activate an interoperable CDS system leveraging the Stanson Health (Charlotte, NC) CDS platform [ 37 ], which is being expanded to include interoperable offerings for TBI VTE prophylaxis. This system provides a knowledge representation framework to faithfully express the intent of the Berne-Norwood prevention criteria computationally (Table  2 ). The interoperable FHIR data standard will be used for bi-directional data transfer between each site’s EHR and the CDS platform. Workflow integration includes a combination of both passive and interruptive provider and trauma system leader information and “nudges”. Table 2 represents the Standards-based, Machine-readable, Adaptive, Requirements-based, and Testable (SMART) L2 layer [ 38 ] of the Berne-Norwood criteria.

CDS user-centered design

We will complete a rapid cycle CDS evaluation to optimize CDS workflow integration by conducting a user-driven simulation and expert-driven heuristic usability optimization as we have previously done [ 39 ]. For rapid cycle CDS evaluation, multidisciplinary trauma end-user “teams” will complete up to 3 scenarios designed to represent various extremes in TBI VTE prevention decision making. Simulation usability testing will be overseen by usability experts, who will catalogue usability issues that arise during simulation. Via consensus ranking, the development and planning teams will rank usability issues from 0 (cosmetic) to 5 (usability catastrophe). Using 10 predefined heuristics for usability design [ 40 ], we will conduct a heuristic evaluation of the CDS, then catalogue and rank usability issues. These results will inform CDS application design, optimized for TBI workflow integration.

Implementation strategy

Following CDS development, our healthcare system relies on a time-tested approach for the implementation and scaling of user-centered CDS: this approach is called the Scaling AcceptabLE cDs (SCALED) Strategy [ 41 ]. This framework integrates multiple evidence-based implementation strategies (Table  3 ).

Study outcomes

The primary implementation outcome is patient-level adherence with the CPG: Specifically, did the patient received guideline-concordant care? Adherence will be measured as an all-or-none measure (binary endpoint at the encounter/patient-level). Thus, if a patient is low-risk for TBI progression, by 24 h they should have risk-specific VTE prevention ordered; if they receive this after 24 h, or if they receive the intermediate risk VTE prevention regimen, this would be deemed non-adherent. The primary effectiveness outcome is VTE (binary endpoint at the patient-encounter level). Safety outcomes evaluated include: TBI progression, in-hospital mortality, and bleeding events. A secondary hypothesis is that as the trial scales to additional sites, iterative implementations will be more efficient (reduced implementation time) and more effective (improved adoption). Secondary hypotheses will be evaluated using the RE 2 -AIM framework [ 42 , 43 ] and are displayed in Table  4 .

Clinical trial data collection methods

Data sources used in this trial include the Stanson Health CDS eCaseReport and site trauma registry. The eCaseReport is a living registry of all patients, and their associated clinical trial data elements, that were eligible for the CDS. All sites also maintain a trauma registry adhering to the National Trauma Data Standards [ 44 ], a requirement for ACS trauma center verification. This dataset is manually annotated by trained clinical abstractors. Data will be sent to the biostatistical team at 6-month intervals. Control and pre-implementation sites will provide their trauma registry in addition to supplemental standards-based EHR extraction of clinical trial data elements or manual abstraction. A data dictionary has been created for the study and will be made available on the trial webpage.

Multiple methods evaluation of implementation success at each EPIS phase

Survey instruments will be prepared using Likert-type scales. Outcomes will be calculated based on scoring guides for the following validated scales: Program Sustainability Assessment Tool (PSAT) [ 45 ], Clinical Sustainability Assessment Tool (CSAT) [ 46 ], Implementation Leadership Scale (ILS) [ 47 ], and Evidenced-based Practice Attitude Scale-36 (EBPAS-36) [ 48 ]. Two scales do not have scoring rubrics: the Organizational Readiness for Change Questionnaire [ 49 , 50 ] and the Normalization Measure Development (NoMAD) Questionnaire [ 51 , 52 , 53 ]. Since both of these scales group questions into constructs, they will be analyzed by generating mean Likert scores and standard deviations per construct, and a mean across constructs, at each of the four implementation phases [ 54 ].

To deeply investigate barriers and facilitators of successful implementation, semi-structured qualitative interviews of key personnel (clinical leadership and end-users, IT leadership and staff) will be conducted at each of the 4 implementation phases. Studies suggest saturation of new ideas occurs after approximately 12 interviews [ 55 ]. Additional samples will be added as needed if thematic saturation is not achieved. Following informed consent, interviews will be performed by a trained qualitative research assistant, audio recorded, and transcribed verbatim. An interview guide, informed by the EPIS framework, was developed to collect key informant experiences with CDS implementation with a focus on inner and outer context factors [ 56 ]. A hybrid approach, primarily deductive and secondarily inductive, approach will be applied. All interviews will be independently double-coded and coding discrepancies will be resolved through discussion. A descriptive thematic analysis approach [ 57 ] will be used to characterize the codes into themes and sub-themes representing the barriers and facilitators to implementation success.

Results for all instruments will be primarily stratified according to site implementation success at each study phase. Additional stratifications may include respondent role, discipline, and hospital system. Bar charts displaying mean survey domains with integrative quotations from the qualitative analysis will be used to facilitate data visualization and understanding of key themes representing barriers and facilitators to successful CDSS implementation.

Statistical analysis

Mixed-effects logistic regression models will be fit to test whether or not CDS implementation changes the likelihood of a VTE event during TBI admission (effectiveness outcome) and the likelihood that the clinical guideline was followed (implementation outcome). The models for these outcomes include fixed-effects for month (when available, to account for secular trends) and an indicator variable for whether the center had the CDS integrated in the EHR. The primary test statistic will be a Wald test of the coefficient for this treatment indicator. We will include random center-specific intercepts to account for correlation within center. Assuming there are 9 sites enrolled with an average of 400 TBI admissions per year and the typical site has between 20%-40% adherence to the clinical guidelines, we will have > 80.0% and > 99.9% power to detect a 5 and 10 percentage point increase in the adherence. Similarly, assuming the typical site has between a VTE event rate of 5–6%, we will have > 80.0% power to detect a 40%-50% reduction in VTE consistent with our published data [ 11 ].

Study oversight

This study is overseen by the University of Minnesota Surgical Clinical Trials Office and by an independent Data Safety Monitoring Board (DSMB). Even though this intervention is deploying a TBI clinical guideline that is currently considered best practice, we believe the addition of a DSMB will improve trial safety, data quality, and trial integrity [ 58 ]. DSMB membership will be independent from the study investigators and will consist of 3 members including: 1 trauma surgeon, 1 informaticist, and 1 statistician. Annual reports including data from all sites, including control sites, will be shared with the DSMB to assure timely monitoring of safety and data quality. The trial will not be stopped early in the event of CDS efficacy because a critical secondary outcome focuses on studying implementation and effectiveness over time.

VTE guideline monitoring and maintenance

Given the potential for a changing evidence-base, it is possible that best practice VTE prevention guidance may change during the study period or afterwards. A critical element in improving adherence with PCOR evidence is updating guidance based on this evidence – in this study, this requires ensuring that the CDS system remains current.

We will pilot a model for producing and maintaining TBI VTE prophylaxis 'Living Guidance and CDS' to ensure that the CDS remains current (Fig.  3 ). The University of Minnesota Evidence-based Practice Center (EPC) Evidence Generation team will conduct and maintain a “living” systematic review. Systematic review data will be uploaded to the AHRQ’s Systematic Review Data Repository (SRDR). “Living” implies that every 6 months the EPC team will evaluate and synthesize new evidence related to TBI VTE prophylaxis, update the existing systematic review and deliver it to a multi-stakeholder Guideline Committee. The Guideline Committee will then use the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) evidence-to-decision (EtD) framework to develop VTE prophylaxis guidelines for patients with TBI [ 59 , 60 , 61 ]. A computational representation of these guidelines will be updated and maintained within the CDS platform by Stanson Health, the CDS Vendor.

Pilot process for “Living Guideline”

Spreading successful results beyond study sites

The ultimate goal of this study is to spread successful CDS tools and strategies to broadly improve TBI VTE-related care processes and outcomes. The research outlined above will surface sharable insights about what information needs to be presented to which people in what formats through what channels at what times to reliably deliver guideline-based care – i.e., specific instantiations of the “CDS 5 Rights Framework” applied to this target [ 62 ]. We will use Health Service Blueprint tools to describe our recommended implementation approaches; these tools are being applied in an increasing number of public and private care delivery organizations as a structured approach to ‘get the CDS 5 Right right’ for various improvement targets. We will further adapt and apply Health Service Blueprint foundations supported by VA and AHRQ [ 63 ] to capture VTE care transformation guidance in Health Service Blueprint tooling [ 64 ]. Presenting recommended CDS-enabled workflow, information flow – as well as and related implementation considerations and broader healthcare ecosystem implications – in this structured format will help organizations beyond the initial study participants put study results into action efficiently and effectively.

In this paper, we present the protocol for the SCALED trial, a stepped-wedge cluster randomized trial of a CDS intervention to improve adherence with VTE prevention best practices for patients with TBI. As a hybrid type 2 trial, this study will evaluate both implementation and effectiveness outcomes. In addition to investigating effectiveness, we will also be able to provide insight into the implementation challenges for deploying interoperable CDS across heterogenous health systems. In our pilot study [ 9 ], while patients who received guideline-concordant care had significantly improved outcomes, we noted that not all patients receive guideline concordant care following implementation. Additionally, best strategies for scaling interoperable CDS systems are poorly studied. Thus, this study represents one of the earliest implementation evaluations of scaling interoperable CDS systems across heterogeneous health systems.

This study has several strengths. First, it will rigorously test implementation of a CPG for VTE prevention across 9 U.S. trauma centers using a multi-faceted CDS platform supporting both passive and interruptive decision support. Second, it will rigorously investigate scalable and interoperable CDS strategies to deploy CPGs. Third, this study leverages a centralized eCaseReport generated by the CDS system, a solution which can drive data collection for future pragmatic trials. Importantly, this study takes place at trauma centers which are geographically distinct, utilize different EHR vendors, include both ACS-verified level 1 through level 3 trauma centers, and include rural, community, and university-based trauma centers. In addition to helping spread recommended care transformation strategies beyond additional study sites, documenting these approaches in Health Service Blueprint tools will also support creation of learning communities for sharing, implementing, and enhancing these strategies.

This study also has limitations. First, we are only investigating 4 trauma systems which already have fairly advanced informatics divisions and experience implementing interoperable CDS systems. Thus, these findings may not be broadly applicable to health systems with less informatics experience and expertise. Second, we are only investigating implementation across two EHR vendors: Epic and Cerner, thus these findings may not be applicable to health systems with different EHR vendors such as Meditech or Allscripts. However, the Health Service Blueprint implementation strategy representations should still enable users of other systems to glean valuable insights about components of the transformation approach less dependent on specific EHRs used.

In summary, this study will implement and scale a CDS-enabled care transformation approach across a diverse collaborative CDS community, serving as an important demonstration of this critical healthcare challenge. We will integrate lessons learned for a planned national scaling in collaboration with U.S. trauma societies. Finally, we will pilot an approach for the “Living Guideline” and use that to maintain evidenced-based decision logic within CDS platforms.

Availability of data and materials

Following trial completion data will be made available upon request through the University of Minnesota Data Repository.

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This research was supported by the Agency for Healthcare Research and Quality (AHRQ), grant R18HS028583, the University of Minnesota Center for Learning Health System Sciences – a partnership between the University of Minnesota Medical School and the School of Public Health. The authors have no other conflicts of interest.

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CT conceived and jointly designed the study protocol and helped write and critically revise this protocol paper, SS conceived and jointly designed the study protocol and helped write and critically revise this protocol paper, DV jointly designed the study protocol and helped write and critically revise this protocol paper, LS jointly designed the study protocol and helped write and critically revise this protocol paper, CS jointly designed the study protocol and helped write and critically revise this protocol paper, EH jointly designed the study protocol and helped write and critically revise this protocol paper, SS jointly designed the study protocol and helped write and critically revise this protocol paper, CM jointly designed the study protocol and helped write and critically revise this protocol paper, RR jointly designed the study protocol and helped write and critically revise this protocol paper, VP jointly designed the study protocol and helped write and critically revise this protocol paper, PJ jointly designed the study protocol and helped write and critically revise this protocol paper, NL jointly designed the study protocol and helped write and critically revise this protocol paper, TT jointly designed the study protocol and helped write and critically revise this protocol paper, JO jointly designed the study protocol and helped write and critically revise this protocol paper, DT jointly designed the study protocol and helped write and critically revise this protocol paper, DV jointly designed the study protocol and helped write and critically revise this protocol paper, RC jointly designed the study protocol and helped write and critically revise this protocol paper, MB jointly designed the study protocol and helped write and critically revise this protocol paper, GM conceived and jointly designed the study protocol and helped write and critically revise this protocol paper.

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Tignanelli, C.J., Shah, S., Vock, D. et al. A pragmatic, stepped-wedge, hybrid type II trial of interoperable clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury. Implementation Sci 19 , 57 (2024). https://doi.org/10.1186/s13012-024-01386-4

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InfoQ Homepage News Netflix Adopts Virtual Threads: a Case Study on Performance and Pitfalls

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Adding to Netflix's findings, a recent case study on InfoQ also delves into the practical challenges and benefits of virtual threads, particularly in scenarios involving heavy concurrent workloads. This study underscores the need for careful consideration and testing when integrating virtual threads into production systems, as even small architectural details can lead to significant performance impacts.

In addition to virtual threads, Netflix’s adoption of generational ZGC has also played a crucial role in optimizing its systems, as mentioned in one of the recent articles . ZGC, with its ability to maintain low pause times even as heap sizes grow, has significantly improved Netflix's application performance by reducing garbage collection overhead and enhancing responsiveness. More on generational ZGC can be found in this InfoQ news item .

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• Open access
• Published: 10 August 2024

Performance of calf circumference in identifying sarcopenia in older patients with chronic low back pain: a retrospective cross-sectional study

• Hee Jung Kim 1 ,
• Ji Young Kim 1 &
• Shin Hyung Kim   ORCID: orcid.org/0000-0003-4058-7697 1  

BMC Geriatrics volume  24 , Article number:  674 ( 2024 ) Cite this article

200 Accesses

Metrics details

Calf circumference is currently recommended as a case-finding marker for sarcopenia, but its usefulness has not been determined in chronic pain conditions. Therefore, the present study aimed to evaluate the predictive performance of calf circumference in diagnosing sarcopenia in older patients with chronic low back pain.

Ambulatory adult patients aged ≥ 65 years with chronic low back pain were enrolled. A diagnosis of sarcopenia was established based on the criteria outlined by the Asian Working Group for Sarcopenia in 2019. Patient demographics, pain-related factors, clinical factors, and sarcopenia-related measurements were compared between non-sarcopenic and sarcopenic patients. Linear regression analysis was used to evaluate the correlation of calf circumference with muscle mass, strength, and physical performance. Also, a receiver operating characteristic curve analysis for calf circumference in predicting sarcopenia was conducted; and area under the curve (AUC) values, along with their corresponding 95% confidence intervals (CI), were calculated.

Data from 592 patients were included in the analysis. Eighty-five patients were diagnosed with sarcopenia (14.3%), 71 of whom had severe sarcopenia (11.9%). A higher prevalence of sarcopenia was observed in female patients (9.0% vs. 16.7%, p  = 0.016). After adjusting for age, BMI, and comorbidities, calf circumference correlated positively with muscle mass but not with muscle strength and physical performance. The AUC values for sarcopenia were 0.754 (95% CI = 0.636–0.871, p  = 0.001) in males and 0.721 (95% CI = 0.657–0.786, p  < 0.001) in females. The cut-offs for calf circumference in predicting sarcopenia were 34 cm (sensitivity 67.1%, specificity 70.6%) in males, and 31 cm (sensitivity 82.5%, specificity 51.5%) in females.

Conclusions

Even though sex differences in its predictive value for sarcopenia should be considered, our findings suggest that calf circumference can be used as an indicator for predicting muscle mass and may serve as a potential marker for identifying sarcopenia in older patients with chronic low back pain.

Peer Review reports

Sarcopenia is currently defined as the decline in skeletal muscle mass and strength that occurs with advancing age and is often accompanied by diminished physical performance in its severe form [ 1 , 2 ]. Sarcopenia is associated with adverse health outcomes, including increased risk of falls and fractures, higher rates of hospitalization, and elevated mortality risk [ 1 , 3 ]. This condition is an increasing problem in our aging society; thus, sarcopenia prevention, treatment, and rehabilitation have become significant public health concerns when considering the economic and societal burden of sarcopenia. [ 3 , 4 ].

Chronic low back pain (CLBP) is one of the most common and major disabling health conditions among older adult populations [ 5 ]. The prevalence of sarcopenia among older patients with CLBP seems to be somewhat higher than in patients without pain [ 6 ]. Also, sarcopenia is associated with poor CLBP treatment outcomes [ 6 , 7 ]. Therefore, early identification of older patients at risk of sarcopenia is important for those with CLBP.

In the Asian Working Group for Sarcopenia 2019 (AWGS 2019) guidelines, calf circumference is recommended as an anthropometric measurement for identifying sarcopenia, facilitating early detection in older adults [ 1 ]. The role of calf circumference in the diagnosis algorithm for sarcopenia is supported by validation reports [ 8 , 9 , 10 , 11 , 12 , 13 ]. Calf circumference demonstrated a positive correlation with skeletal muscle mass assessed through dual-energy X-ray absorptiometry [ 8 , 9 , 10 , 11 , 12 ] and was also significantly associated with both muscle strength and physical performance [ 12 ]. However, these results were obtained from samples of the community-dwelling older population [ 12 ]. In recent reports, calf circumference showed promise for the screening for sarcopenia in subgroups with several comorbidities such as stroke, Parkinson’s disease, and diabetes [ 14 , 15 , 16 ]. However, the usefulness of calf circumference as a screening marker for sarcopenia has not been investigated in older patients with symptomatic degenerative lumbar spinal disease.

Accordingly, the aims of this study were to determine calf circumference cut-off values for sarcopenia prediction in older patients with CLBP and to evaluate its diagnostic performance using AWGS 2019 criteria. Also, the relationship between calf circumference and skeletal muscle mass, muscle strength, and physical performance was investigated in this population.

Study population

This study received approval from the Institutional Review Board of Yonsei University Health System, Seoul, Republic of Korea (IRB No. 4-2024-0094). In our previous studies, we have observed that low handgrip strength and high fat infiltration of paraspinal muscles resulted in poor treatment outcomes in older patients with CLBP [ 17 , 18 ]. Therefore, in 2022, we began sarcopenia screening and diagnosis for older patients with chronic pain at their initial visit to our pain clinic. The present study employs a retrospective cross-sectional observational design. Specifically, it is a retrospective audit of CLBP patients who completed sarcopenia assessment based on the AWGS 2019 diagnostic protocol. Patients who visited our clinic seeking treatment for low back pain from January to December 2022 were enrolled in the study. Based on the patho-anatomical approach of CLBP used for confirmation [ 19 ], adult patients aged 65 years and above diagnosed with degenerative lumbar spinal disease, such as spondylolisthesis, herniated disc, spinal/foraminal stenosis, and facet joint arthropathy, confirmed by radiological evaluation within one year from the date of initial visit were included. Pain duration of three months or longer was used to define chronicity. Non-ambulatory patients or patients with severe cognitive impairment that precluded completion of the sarcopenia assessment protocol were excluded. Patients with abnormal calf asymmetry with a difference in circumference greater than 2.0 cm between calves [ 20 ] or pitting edema of the lower limbs were excluded. To assess lower limb pitting edema, visual inspection for swelling or skin changes, gentle palpation to assess skin indentation, and observation for persistence of indentation after pressure release were conducted. In addition, patients with incomplete medical records for this study were excluded.

Sarcopenia assessment

All measurements followed standard protocols for each measurement based on AWGS 2019 recommendations [ 1 ]. An independent nurse practitioner experienced in comprehensive geriatric assessment conducted all measurements throughout the study period. Calf circumference was measured at the widest part of both calves using a non-elastic tape to capture the maximum value. Patients were instructed to stand with their feet shoulder-width apart to ensure equal distribution of body weight. The tape was applied snugly but without compressing the calf and was positioned flat on the skin and parallel to the floor. After measuring each calf twice, an average circumference was recorded. Handgrip strength (HGS) was assessed by conducting three measurements on each hand using a Smedley-type dynamometer (EH101; CAMRY, Guangdong, China). Patients were instructed to stand with their elbows fully extended and to exert a maximum-effort isometric contraction while squeezing the dynamometer. The highest reading obtained from three measurements on each hand was recorded, and the maximum value from either hand was utilized for analysis. Appendicular skeletal muscle mass (ASM) was measured using a bioelectrical impedance analysis (BIA) device (Inbody H20N, InBody Co., Ltd., Seoul, Korea). Participants were instructed to undergo BIA measurements in the morning on an empty stomach to standardize body water distribution, ensuring they emptied their bladder and bowels and refrained from physical activities, showering, sauna use, or any activities affecting body moisture beforehand. Skeletal muscle mass index (SMI) was calculated by dividing ASM by the square of the patient’s height. A short physical performance battery (SPPB) was conducted, and its subtest scores and timings were determined. The SPPB consists of three subsets including static balance, gait speed, and chair sit-to-stand test [ 21 ]. To evaluate static balance, patients were instructed to maintain three standing postures of increasing difficulty, feet-together, semi-tandem, and full-tandem stance, for up to 10 s each. Patients were timed until movement or until 10 s had elapsed. For the gait speed test, patients walked at their comfortable pace across a 4-meter distance, and the average time for two trials was recorded. To assess chair sit-to-stand time, patients crossed their arms over their chests and, as quickly as possible, performed five stands from a standard chair. The time taken to complete the five sit-to-stand tasks was recorded. Each of the three subtests was scored on a scale from 0 to 4; the total score, ranging from 0 to 12, was the sum of these subtest scores.

Definition of Sarcopenia

In this study, cut-off values recommended by AWGS 2019 were utilized for identifying low calf circumference (males: < 34 cm and females: < 33 cm), low SMI (males: < 7.0 kg/m 2 and females: < 5.7 kg/m 2 ), low HGS (males: < 28 kg and females: < 18 kg), and low SPPB score (total score ≤ 9 for both sexes) [ 1 ]. Calf circumference cut-off values were used for screening or case-finding of sarcopenia. Sarcopenia was defined as cases with both low muscle mass and strength (low SMI + low HGS), irrespective of the SPPB score, and cases with poor physical performance were classified into severe sarcopenia (low SMI + low HGS + low SPPB score) [ 1 ].

Patient demographics and clinical data

Demographic information, pain-related data, and clinical data were extracted from the institutional electronic medical record database system. Patient characteristics encompassed age, sex, and body mass index (BMI). Patient history of diagnosed comorbid conditions and current medications was obtained. Conditions assessed included fall history, cerebro-cardiovascular diseases, diabetes mellitus, osteoporosis, and urinary incontinence. The presence of leg pain (a sciatica symptom), pain duration, and average pain intensity score using a 0 to 10 numeric rating scale (NRS) for the preceding week were identified as pain-related variables.

Statistical analysis

Descriptive statistics were utilized to summarize continuous variables and are presented as mean values along with standard deviations (SD) and ranges. Categorical variables are expressed as counts and percentages. For data not conforming to normal distribution, median values and interquartile ranges (IQR) are reported with the Shapiro-Wilk test normality assessment results. To compare patient characteristics between the non-sarcopenia and sarcopenia groups, various statistical tests were employed. Independent Student’s t-tests compared means for continuous variables with normal distributions, while the Mann–Whitney U test compared medians for continuous variables with non-normal distributions. Chi-squared tests or Fisher’s exact tests were used for categorical variables. To explore the relationship between calf circumference and SMI, HGS, and SPPB score, linear regression analysis was performed with adjustments for age, BMI and comorbidities that showed significant differences between sarcopenia and non-sarcopenia groups. Specifically, calf circumference was adjusted based on BMI categories (< 25 kg/m² [normal], 25–29 kg/m² [overweight], and ≥ 30 kg/m² [obese]), as recommended by Gonzalez et al. [ 22 ], to address potential underestimation in individuals with excess weight who could otherwise show falsely normal calf circumference values. Receiver operating characteristic (ROC) curve analysis was utilized to assess the predictive ability of calf circumference, and corresponding area under the curve (AUC) values and confidence intervals were calculated. Sex-specific calf circumference cut-off values for predicting low SMI, sarcopenia, and severe sarcopenia were determined using ROC analysis and the Youden index. Statistical analyses were conducted using IBM SPSS Statistics, version 25.0 (IBM Corp, Armonk, NY), and statistical significance was set at a p -value less than 0.05.

Within the study period, 988 patients presented with low back pain as their chief complaint at our clinic. After excluding 396 patients based on the study’s exclusion criteria, 592 patients aged 65–90 years (mean age 71.77 ± 6.24 years) were included in the analysis. The sample consisted of 187 males and 405 females. All participants underwent sarcopenia assessment according to the AWGS 2019 criteria, with 507 patients classified as non-sarcopenic and 85 patients (14.3%) classified as sarcopenic (Fig.  1 ). There was a notable difference in the prevalence of sarcopenia between male and female patients; prevalence was 9.0% among males and 16.7% among females ( p  = 0.016). The number of patients diagnosed as having severe sarcopenia was 71 out of 592 patients (11.9%).

Study flowchart. MRI, magnetic resonance imaging; AWGS, Asian Working Group for Sarcopenia

A comparison of patient demographics, comorbid medical conditions, sarcopenia-related measurements, and pain-related data between patients with and without sarcopenia is presented in Table  1 . For both sexes, older patients and patients with lower BMIs were more frequently diagnosed with sarcopenia. In the sarcopenia group, more patients of both sexes had a history of falling. The prevalence of osteoporosis was higher in women with sarcopenia than in those without sarcopenia. Smaller calf circumference, lower muscle mass, lower HGS, and lower SPBB scores were observed in the sarcopenia group. Between the two groups in both sexes, there were no significant differences in pain-related variables. Also, after adjusting for age, BMI, and comorbidities, calf circumference showed a positive correlation with SMI but not with HGS and SPPB score in both male and female patients (Table  2 ).

The results of ROC analysis for predicting low muscle mass and sarcopenia using calf circumference values are illustrated in Fig.  2 . The AUC values for low SMI and sarcopenia were 0.776 (95% CI = 0.698–0.854, p  < 0.001) and 0.754 (95% CI = 0.636–0.871, p  = 0.001), respectively, in males, and 0.717 (95% CI = 0.663–0.771, p  < 0.001) and 0.721 (95% CI = 0.657–0.786, p  < 0.001), respectively, in females. The cut-off values of calf circumference for predicting low SMI and sarcopenia were 34 cm (sensitivity 71.8%, specificity 68.4%) and 34 cm (sensitivity 67.1%, specificity 70.6%), respectively, in males, and 32 cm (sensitivity 74.9%, specificity 57.1%) and 31 cm (sensitivity 82.5%, specificity 51.5%) respectively, in females. When applying the AWGS 2019 cut-off of calf circumference, < 33 cm, for predicting sarcopenia in female patients, sensitivity and specificity were 57.3% and 75.0%, respectively.

Receiver operating characteristic curves for calf circumference in predicting low muscle mass and sarcopenia. Receiver operating characteristic curves for calf circumference in the prediction of low muscle mass (solid line) and sarcopenia (dotted line) in males (A) and females (B) The area under the curve values with 95% confidence intervals for low muscle mass and sarcopenia were 0.776 (0.698–0.854) and 0.754 (0.636–0.871), respectively in males, and 0.717 (0.663–0.771) and 0.721 (0.657–0.786), respectively, in females

In this study, we observed that calf circumference cut-off values for predicting low muscle mass and sarcopenia were determined to be 34 cm in males, while in females, these values were 32 cm and 31 cm, respectively, which diverged from the AWGS 2019 recommendations. Furthermore, our findings indicated a significant positive correlation between calf circumference and muscle mass, though no such association was observed with muscle strength and physical performance measures.

Previously reported cut-offs for calf circumference were 32 to 34 cm in men and 32 to 33 cm in women among the older Asian population [ 8 , 9 , 10 , 11 , 12 ]. These values were developed in consideration of the increase in sensitivity and were consistent with AWGS 2019 recommendations of < 34 cm for men and < 33 cm for women during sarcopenia screening or case-finding [ 1 ]. The AUC value of calf circumference cut-offs suggested by AWGS 2019 for predicting sarcopenia (defined by low SMI and low HGS) was 0.647 in 2123 adults aged 70 to 84 years [ 11 ]. In 657 adults with mean age of 76.2 years, the AUC values of calf circumference for predicting sarcopenia met AWGS 2019 criteria, 0.82 for men and 0.72 for women [ 12 ]. Thus, the predictive performance of calf circumference for sarcopenia in the study population, AUC = 0.754 in males and AUC = 0.721 in females, was similar to previous results from the older population data according to AWGS 2019 criteria. These data are clinically acceptable; however, the predictive power of calf circumference for muscle mass and sarcopenia was lower in women than in men in this study. This observation was consistent with previous results [ 7 , 12 ]. As higher fat mass in the legs is generally observed in women compared to men [ 23 ], this factor could potentially affect the predictive power of calf circumference regarding muscle mass and sarcopenia in female patients in this study.

The pattern of changes in calf circumference in patients with symptomatic degenerative lumbar spinal disease has not been widely studied. Peripheral nerves originating from the lumbar spinal nerves are distributed to the muscles of the lower limbs. In this anatomical context, muscle denervation as the result of neural compression following degenerative change of lumbar spine structures causes a reduction in muscle size in the affected area of the lower limbs [ 24 ]. In older patients with CLBP, leg pain and neurogenic claudication can precipitate a detrimental cycle in which reduced physical activity contributes to muscle atrophy and exacerbates deconditioning and disability [ 25 ]. Furthermore, electromyographical evidence suggests that reinnervation of muscle fibers in the older population with sarcopenia to compensate for the loss of innervating motor neurons and denervation of muscle fibers was observed significantly less frequently than in healthy controls [ 26 ]. These potential changes of calf circumference in our study population might affect relatively lower sensitivity values of calf circumference for identifying low muscle mass and sarcopenia when compared with those from general older papulation data [ 12 ].

Also, the clinical features discussed occur more among women with CLBP than among men; in addition, among patients with degenerative lumbar spinal disease, female patients have higher pain scores and more frequent functional impairment and lower quality of life than male patients [ 27 ]. In this study, the prevalence of sarcopenia was almost twice as high in female patients compared to male patients. The difference in the prevalence of sarcopenia between sexes varies depending on which guidelines are applied. In recent European and Asian guideline reports, sarcopenia was more prevalent in men than in women [ 11 , 28 ]. Although the causal relationship between sarcopenia and pain cannot be determined from this study, female patients seem to be more vulnerable to the risk of sarcopenia in chronic pain conditions.

Our results showed that the proposed AWGS 2019 calf circumference cut-off values were valid for predicting sarcopenia in male patients with CLBP. However, in female CLBP patients, the sensitivity of calf circumference for predicting sarcopenia was 82.5% when applying a cut-off of < 31 cm; however, when applying the AWGS 2019 recommended value of < 33 cm, a 30% reduction in sensitivity resulted. Therefore, when using calf circumference as a case-finding marker for sarcopenia among patients with CLBP, sex difference in predictive value for sarcopenia should be considered.

Notably, severe sarcopenia was more prevalent in the study population than in the general older population. In a previous study using AWGS 2019 criteria, the prevalence of severe sarcopenia was 3.3% [ 11 ], but our prevalence was 11.9%, almost four times higher. In this study, physical performance was measured using SPPB, a tool designed to evaluate lower limb function encompassing balance, strength, and mobility [ 21 ]. We found that the presence or absence of sarcopenia did not correlate with differences in reported pain levels or pain-related characteristics among our study participants. However, it is important to note that patients with CLBP often experience leg or foot pain and may exhibit difficulties in walking, which could adversely impact their SPPB scores. This suggests that while sarcopenia may not directly correlate with reported pain levels, the functional implications of CLBP are significant considerations in this patient population.

Anthropometric measurements do not reflect body composition including intramuscular and subcutaneous fat. Therefore, calf circumference does not fully reflect muscle quality which is closely related to muscle strength and physical function [ 29 ]. Indeed, calf circumference did not significantly correlate with muscle strength and physical performance in this study, which contrasts with the results from the general older population [ 12 ]. Recent research has indicated that age-related declines in skeletal muscle strength, muscle mass, and muscle quality vary between the upper limbs and lower limbs, leading to potential differences in clinical interpretations for diagnosing sarcopenia [ 30 , 31 ]. Therefore, when diagnosing sarcopenia and evaluating the severity of sarcopenia for this population, it is crucial to employ a multidimensional assessment approach that considers not only anthropometric measurements and functional assessments but also integrates the clinical characteristics of the chronic pain condition and specific muscle group impairments.

This study has some limitations. The study was conducted at a single tertiary care hospital and included patients of a homogeneous racial and ethnic background, potentially limiting the generalizability of our results to other clinical settings and populations. Our study specifically included patients with confirmed degenerative lumbar spinal diseases identified through radiological evaluation, excluding those with idiopathic low back pain, which is the most prevalent type. This selection criterion may restrict the external validity of our findings. The sample size, particularly for male participants, was small. This not only increases the possibility of sample bias but also limits the statistical power to detect differences and associations accurately within the study cohort. This retrospective analysis only included patients with complete clinical data; the presence of selection biases in the findings cannot be entirely ruled out. The ROC curve can be influenced by class imbalance, where the number of non-sarcopenic cases outweighs the number of sarcopenic cases. This imbalance can lead to misleading optimism about the diagnostic performance of calf circumference as a predictor for sarcopenia. As this study adopts a cross-sectional design, a causal relationship between calf circumference and sarcopenia could not be established. Consequently, longitudinal studies are necessary to validate our findings and elucidate any potential causal associations. BIA is not considered the gold standard for body composition measurement. Also, we did not exclude patients taking diuretic and corticosteroid medications from the analyses, which could affect body water distribution and potentially influence BIA results. However, BIA measurements with multifrequency devices have shown closer correlation with ASM measured by dual-energy X-ray absorptiometry and its adequate performance across multiple domains [ 32 ]. Additionally, while there is no worldwide consensus on the exact list of geriatric syndromes, we collected data on several important factors leading to geriatric syndromes, including falls, urinary incontinence, functional decline, and sarcopenia. Although polypharmacy was not explicitly investigated, the comorbidities we examined are based on current medication diagnoses and thus reflect drug administration to some extent. Specific malnutrition and cognitive impairment statuses were not measured with dedicated tools for each individual; however, we excluded patients who were non-ambulatory or unable to complete the sarcopenia assessment due to severe cognitive impairment. Future studies should include a broader range of factors to provide a more comprehensive assessment and to better inform clinical interventions.

In conclusion, calf circumference appears to be a proxy marker for muscle mass estimated by BIA measurements and may serve as a potential case-finding marker for sarcopenia in older patients with CLBP. Also, although the predictive characteristics differed between the sexes, the predictive performance of calf circumference for sarcopenia in the study population was similar to the results from the older, community-dwelling population data. Therefore, our results suggest that calf circumference is a clinical indicator for predicting muscle mass and may serve as a case-finding marker for sarcopenia in older patients with CLBP.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors thank C.H. Hwang, BS, for helping with the data analysis for this study.

This work was supported by the National Research Foundation Korea grant funded by the Korea government (No.RS-2023-00245723).

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Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea

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HJK: literature review, data collection, data analysis, manuscript writing, and manuscript editing, JYK: literature review and data collection, SHK: conceptualization, study design, data analysis, manuscript writing, and manuscript editing. All authors approved the final manuscript.

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Correspondence to Shin Hyung Kim .

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Kim, H., Kim, J. & Kim, S. Performance of calf circumference in identifying sarcopenia in older patients with chronic low back pain: a retrospective cross-sectional study. BMC Geriatr 24 , 674 (2024). https://doi.org/10.1186/s12877-024-05263-z

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Hydraulic risk assessment on historic masonry bridges using hydraulic open-source software and geomatics techniques: a case study of the “hannibal bridge”, italy.

1. Introduction

3. case study, 3.1. identification of study area, 3.2. geomatics data, 5. discussion, 5.1. climate change impacts, 5.2. impact of dem in hydraulic modeling, 6. conclusions, author contributions, data availability statement, acknowledgments, conflicts of interest.

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Share and Cite

Dewedar, A.K.H.; Palumbo, D.; Pepe, M. Hydraulic Risk Assessment on Historic Masonry Bridges Using Hydraulic Open-Source Software and Geomatics Techniques: A Case Study of the “Hannibal Bridge”, Italy. Remote Sens. 2024 , 16 , 2994. https://doi.org/10.3390/rs16162994

Dewedar AKH, Palumbo D, Pepe M. Hydraulic Risk Assessment on Historic Masonry Bridges Using Hydraulic Open-Source Software and Geomatics Techniques: A Case Study of the “Hannibal Bridge”, Italy. Remote Sensing . 2024; 16(16):2994. https://doi.org/10.3390/rs16162994

Dewedar, Ahmed Kamal Hamed, Donato Palumbo, and Massimiliano Pepe. 2024. "Hydraulic Risk Assessment on Historic Masonry Bridges Using Hydraulic Open-Source Software and Geomatics Techniques: A Case Study of the “Hannibal Bridge”, Italy" Remote Sensing 16, no. 16: 2994. https://doi.org/10.3390/rs16162994

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