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Providing care to marginalised communities: a qualitative study of community pharmacy teams
Background: Health inequalities in the UK are widening, particularly since the COVID- 19 pandemic. Community pharmacies are the most visited healthcare provider in England and are ideally placed to provide and facilitate access to care for those most disadvantaged. Aim: To explore the experiences and needs of community pharmacy teams in providing care for marginalised groups and how this has changed since the COVID-19 pandemic. Design and Setting: A qualitative study in community pharmacy and across primary care. Method: Semi structured interviews were undertaken with members of community pharmacy teams, PCN pharmacists, GPs and nurses in the North of England. Results: Thirty one individuals participated in an interview (26 pharmacy staff, 3 GPs and 2 nurses). Most participants acknowledged that their pharmacy had become busier since COVID-19 due to increased footfall compounded by patient difficulties in navigating remote digital systems. Few participants had received any formal training on working with marginalised communities; however, organisational barriers (lack of access to translation facilities), combined with inter-organisational barriers (lack of integrated care), made it more difficult to provide care for some marginalised groups. However, the continuity of care provided by many pharmacies was viewed as an important factor in enabling marginalised groups to access and receive care. Conclusion: There are opportunities to better utilise the skills of community pharmacy teams. Resources such as access to translation services and interventions to enable better communication between community pharmacy teams and other primary care services such as general practice are essential.
Relationship Between Clinician Language and the Success of Behavioral Weight Loss Interventions A Mixed-Methods Cohort Study
Background: International guidelines recommend that primary care clinicians recognize obesity and offer treatment opportunistically, but there is little evidence on how clinicians can discuss weight and offer treatment in ways that are well received and effective. Objective: To examine relationships between language used in the clinical visit and patient weight loss. Design: Mixed-methods cohort study. Setting: 38 primary care clinics in England participating in the Brief Intervention for Weight Loss trial. Participants: 246 patients with obesity seen by 87 general practitioners randomly sampled from the intervention group of the randomized clinical trial. Measurements: Conversation analysis of recorded discussions between 246 patients with obesity and 87 clinicians regarding referral to a 12-week behavioral weight management program offered as part of the randomized clinical trial. Clinicians’ interactional approaches were identified and their association with patient weight loss at 12 months (primary outcome) was examined. Secondary outcomes included patients’ agreement to attend weight management, attendance, loss of 5% body weight, actions taken to lose weight, and postvisit satisfaction. Results: Three interactional approaches were identified on the basis of clinicians’ linguistic and paralinguistic practices: creating a sense of referrals as “good news” related to the opportunity of the referral (n = 62); “bad news,” focusing on the harms of obesity (n = 82); or neutral (n = 102). Outcome data were missing from 57 participants, so weighted analyses were done to adjust for missingness. Relative to neutral news, good news was associated with increased agreement to attend the program (adjusted risk difference, 0.25 [95% CI, 0.15 to 0.35]), increased attendance (adjusted risk difference, 0.45 [CI, 0.34 to 0.56]), and weight change (adjusted difference, −3.60 [CI, −6.58 to −0.62]). There was no evidence of differences in mean weight change comparing bad and neutral news, and no evidence of differences in patient satisfaction across all 3 approaches. Limitations: Data were audio only, so body language and nonverbal cues could not be assessed. There is potential for selection bias and residual confounding. Conclusion: When raising the topic of excess weight in clinical visits, presenting weight loss treatment as a positive opportunity is associated with greater uptake of treatment and greater weight loss.
The financial costs of anticipatory prescribing: A retrospective observational study of prescribed, administered and wasted medications using community clinical records
Background: The prescribing of injectable end-of-life anticipatory medications ahead of possible need is recommended best practice. The financial costs of these medications have been little studied. Aim: To identify the costs of anticipatory medications prescribed, used and not used for patients approaching the end-of-life at home and in residential care. Design: Retrospective observational study using general practitioner and community nursing clinical records. Setting/participants: Data were collected from eleven general practitioner practices using the records of the 30 most recent deaths per practice. Patients were aged 18+ and died between 2017 and 2019 from any cause except trauma, sudden death or suicide. Results: Anticipatory medications were prescribed to 167/329 patients, of which 164 were included in the analysis. Costs (GBP) were analysed both at patient-level and drug-level. Median anticipatory prescription cost was £43.17 (IQR: £38.98–£60.47, range £8.76–£229.82). Median administered (used) drug cost was £2.16 (IQR: £0.00–£12.09, range £0.00–£83.14). Median unused (wasted) drug cost was £41.47 (IQR: £29.15–£54.33, range £0.00–£195.36). Prescription, administered and unused costs were significantly higher for the 59 patients prescribed an anticipatory syringe driver. There were wide variations in the unused costs of individual drugs; Haloperidol and Cyclizine contributed 49% of total unused costs. Conclusion: The costs of prescribed and unused anticipatory medications were higher than previously reported but remain modest. Usage of prescriptions was lower than previously documented. There may be scope to reduce the quantity of vials that are routinely prescribed without adversely affecting care; further research is needed to investigate this possibility.
Seasonal trends in antidepressant prescribing, depression, anxiety and self-harm in adolescents and young adults: an open cohort study using English primary care data
Abstract Background There is an increasing demand for mental health services for young people, which may vary across the year. Objective To determine whether there are seasonal patterns in primary care antidepressant prescribing and mental health issues in adolescents and young adults. Methods This cohort study used anonymised electronic health records from general practices in England contributing to QResearch. It included 5 081 263 males and females aged 14–18 (adolescents), 19–23 and 24–28 years between 2006 and 2019. The incidence rates per 1000 person-years and the incidence rate ratios (IRRs) were calculated for the first records of a selective serotonin reuptake inhibitor (SSRI) prescription, depression, anxiety and self-harm. The IRRs were adjusted for year, region, deprivation, ethnic group and number of working days. Findings There was an increase in SSRI prescribing, depression and anxiety incidence in male and female adolescents in the autumn months (September–November) that was not seen in older age groups. The IRRs for SSRI prescribing for adolescents peaked in November (females: 1.75, 95% CI 1.67 to 1.83, p<0.001; males: 1.72, 95% CI 1.61 to 1.84, p<0.001, vs in January) and for depression (females: 1.29, 95% CI 1.25 to 1.33, p<0.001; males: 1.29, 95% CI 1.23 to 1.35, p<0.001). Anxiety peaked in November for females aged 14–18 years (1.17, 95% CI 1.13 to 1.22, p<0.001) and in September for males (1.19, 95% CI 1.12 to 1.27, p<0.001). Conclusions There were higher rates of antidepressant prescribing and consultations for depression and anxiety at the start of the school year among adolescents. Clinical implications Support around mental health issues from general practitioners and others should be focused during autumn.
Improving access to general practice for and with people with severe and multiple disadvantage
Background: People with severe and multiple disadvantage (SMD- combinations of homelessness, substance misuse, violence, abuse and poor mental health) have high health needs and poor access to primary care. Aim: To explore perceptions and experiences of improving access to general practice for people with SMD in healthcare staff and people with lived experience. Design and Setting: Bridging Gaps is a collaboration between healthcare staff, researchers, women with lived experience of SMD and a charity that supports them in a UK city. We co-produced a project to improve access to general practice for people with SMD, that was further developed with 3 inner city general practices. Method: We facilitated nine service improvement meetings at three general practices and formally observed six of these. We interviewed nine practice staff and four participants with lived experience. Three participants with lived experience and one staff member who supports them participated in a focus group. Data was analysed inductively and deductively using thematic analysis. Results: Enabling motivated general practice staff with time and funding opportunities, galvanised by lived experience involvement, resulted in service changes. These included: prioritising patients on an inclusion patient list with more flexible access, continuity from a care coordinator and micro-team, and an information sharing tool. The process and outcomes improved connections within and between general practices, support organisations and people with SMD. Conclusion: These co-designed strategies could be locally adapted and evaluated in other areas. Investing in this focused way of working may improve healthcare accessibility, health equity and staff wellbeing.
The Longitudinal Impact of Social Media Use on UK Adolescents' Mental Health: Longitudinal Observational Study
Background: Cross-sectional studies have found a relationship between social media use and depression and anxiety in young people. However, few longitudinal studies using representative data and mediation analysis have been conducted to understand the causal pathways of this relationship. Objective: This study aims to examine the longitudinal relationship between social media use and young people’s mental health and the role of self-esteem and social connectedness as potential mediators. Methods: The sample included 3228 participants who were 10- to 15-year-olds from Understanding Society (2009-2019), a UK longitudinal household survey. The number of hours spent on social media was measured on a 5-point scale from “none” to “7 or more hours” at the ages of 12-13 years. Self-esteem and social connectedness (number of friends and happiness with friendships) were measured at the ages of 13-14 years. Mental health problems measured by the Strengths and Difficulties Questionnaire were assessed at the ages of 14-15 years. Covariates included demographic and household variables. Unadjusted and adjusted multilevel linear regression models were used to estimate the association between social media use and mental health. We used path analysis with structural equation modeling to investigate the mediation pathways. Results: In adjusted analysis, there was a nonsignificant linear trend showing that more time spent on social media was related to poorer mental health 2 years later (n=2603, β=.21, 95% CI −0.43 to 0.84; P=.52). In an unadjusted path analysis, 68% of the effect of social media use on mental health was mediated by self-esteem (indirect effect, n=2569, β=.70, 95% CI 0.15-1.30; P=.02). This effect was attenuated in the adjusted analysis, and it was found that self-esteem was no longer a significant mediator (indirect effect, n=2316, β=.24, 95% CI −0.12 to 0.66; P=.22). We did not find evidence that the association between social media and mental health was mediated by social connectedness. Similar results were found in imputed data. Conclusions: There was little evidence to suggest that more time spent on social media was associated with later mental health problems in UK adolescents. This study shows the importance of longitudinal studies to examine this relationship and suggests that prevention strategies and interventions to improve mental health associated with social media use could consider the role of factors like self-esteem.
Physical rehabilitation for people with advanced dementia who fracture their hip – expert consensus process
Purpose: Hip fracture is common in older people – with prevalence even higher for people with dementia. Research often excludes people with dementia – especially those in the more advanced stages. Therefore, the most appropriate interventions remain unknown. The main aim of this study was to gain consensus about the core considerations needed to deliver a physical intervention for people with advanced dementia who fracture their hip. Materials and Methods: An expert consensus process was undertaken, using Nominal Group Technique, to explore the key considerations when delivering rehabilitation. Data collection was undertaken in January 2023 and involved an online group discussion followed by voting and off-line rating. Qualitative content analysis and quantitative analysis of consensus scoring was undertaken. An international group of seven highly specialised physiotherapists took part. Results: 59 statements were agreed following the process. Content analysis was used to categorise these statements according to the International Classification of Functioning, Disability and Health. Although consensus levels were high, there was disagreement in several areas. Conclusion: The statements provide an overarching understanding of the multidisciplinary expertise that is needed to effectively deliver rehabilitation interventions to this population. People with dementia require highly skilled and trained professionals, providing holistic and person-centred approaches to deliver rehabilitation interventions.
Family carers' administration of injectable medications at the end of life: a service evaluation of a novel intervention
Abstract Timely and safe administration of injectable medications for patients at home is vital in optimally managing distressing symptoms in the final days of life. This article discusses a service evaluation of family carers' (including close friends) administrating subcutaneous end-of-life medications. The procedure was not intended to become normal care, rather the exception when appropriate and needed, with 24/7 skilled support from community nursing and palliative care services. A service evaluation of the procedure was undertaken in rural and urban areas in the South East of England. The procedure ran over 6 months and used detailed processes with recruitment criteria to mitigate risk of harm. In total, 11 patients participated with their family carers, including five carers with experience in healthcare roles. Of the 11 family carers, 10 were able to administer injections safely with structured training and support in place. Patients received timely symptom relief and their family carers were able to support loved ones by administering injectable medications rapidly without waiting for a nurse to arrive. This was particularly welcomed in more rural areas where waiting times were greater due to the large geographical area covered and limited staff availability during out-of-hours periods. The findings informed a carefully monitored wider rollout and ongoing evaluation in adult community nursing services in the NHS Trust.
Feasibility of a placebo-controlled trial of antibiotics for possible urinary tract infection in care homes: a qualitative interview study
Abstract Background Diagnosis of suspected urinary tract infection (UTI) in care and nursing home residents is commonly based on vague non-localising symptoms (for example, confusion), potentially leading to inappropriate antibiotic prescription. The safety of withholding antibiotics in such cases could be addressed by a randomised controlled trial (RCT); however, this would require close monitoring of residents, and support from care home staff, clinicians, residents, and families. Aim To explore the views of residential care and nursing home staff (herein referred to as care home staff) and primary care clinicians on the feasibility and design of a potential RCT of antibiotics for suspected UTI in care home residents, with no localising urinary symptoms. Design & setting A qualitative interview study with primary care clinicians and care home staff in the UK. Method Semi-structured interviews with 16 care home staff and 11 primary care clinicians were thematically analysed. Results Participants were broadly supportive of the proposed RCT. The safety of residents was a priority and there was strong support for using the RESTORE2 (Recognise Early Soft Signs, Take Observations, Respond, Escalate) assessment tool to monitor residents; however, there were concerns about associated training requirements, especially for night and temporary staff. Effective communication (with residents, families, and staff) was deemed essential, and carers were confident that residents and families would be supportive of the RCT if the rationale was clearly explained and safety systems were robust. There were mixed views on a placebo-controlled design. The perceived additional burden was seen as a potential barrier, and the use of temporary staff and the out-of-hours period were highlighted as potential risk areas. Conclusion The support for this potential trial was encouraging. Future development will need to prioritise resident safety (especially in the out-of-hours period), effective communication, and minimising additional burden on staff to optimise recruitment.
Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis
Summary Background Many international clinical guidelines recommend therapeutic exercise as a core treatment for knee and hip osteoarthritis. We aimed to identify individual patient-level moderators of the effect of therapeutic exercise for reducing pain and improving physical function in people with knee osteoarthritis, hip osteoarthritis, or both. Methods We did a systematic review and individual participant data (IPD) meta-analysis of randomised controlled trials comparing therapeutic exercise with non-exercise controls in people with knee osteoathritis, hip osteoarthritis, or both. We searched ten databases from March 1, 2012, to Feb 25, 2019, for randomised controlled trials comparing the effects of exercise with non-exercise or other exercise controls on pain and physical function outcomes among people with knee osteoarthritis, hip osteoarthritis, or both. IPD were requested from leads of all eligible randomised controlled trials. 12 potential moderators of interest were explored to ascertain whether they were associated with short-term (12 weeks), medium-term (6 months), and long-term (12 months) effects of exercise on self-reported pain and physical function, in comparison with non-exercise controls. Overall intervention effects were also summarised. This study is prospectively registered on PROSPERO (CRD42017054049). Findings Of 91 eligible randomised controlled trials that compared exercise with non-exercise controls, IPD from 31 randomised controlled trials (n=4241 participants) were included in the meta-analysis. Randomised controlled trials included participants with knee osteoarthritis (18 [58%] of 31 trials), hip osteoarthritis (six [19%]), or both (seven [23%]) and tested heterogeneous exercise interventions versus heterogeneous non-exercise controls, with variable risk of bias. Summary meta-analysis results showed that, on average, compared with non-exercise controls, therapeutic exercise reduced pain on a standardised 0–100 scale (with 100 corresponding to worst pain), with a difference of –6·36 points (95% CI –8·45 to –4·27, borrowing of strength [BoS] 10·3%, between-study variance [τ2] 21·6) in the short term, –3·77 points (–5·97 to –1·57, BoS 30·0%, τ2 14·4) in the medium term, and –3·43 points (–5·18 to –1·69, BoS 31·7%, τ2 4·5) in the long term. Therapeutic exercise also improved physical function on a standardised 0–100 scale (with 100 corresponding to worst physical function), with a difference of –4·46 points in the short term (95% CI –5·95 to –2·98, BoS 10·5%, τ2 10·1), –2·71 points in the medium term (–4·63 to –0·78, BoS 33·6%, τ2 11·9), and –3·39 points in the long term (–4·97 to –1·81, BoS 34·1%, τ2 6·4). Baseline pain and physical function moderated the effect of exercise on pain and physical function outcomes. Those with higher self-reported pain and physical function scores at baseline (ie, poorer physical function) generally benefited more than those with lower self-reported pain and physical function scores at baseline, with the evidence most certain in the short term (12 weeks). Interpretation There was evidence of a small, positive overall effect of therapeutic exercise on pain and physical function compared with non-exercise controls. However, this effect is of questionable clinical importance, particularly in the medium and long term. As individuals with higher pain severity and poorer physical function at baseline benefited more than those with lower pain severity and better physical function at baseline, targeting individuals with higher levels of osteoarthritis-related pain and disability for therapeutic exercise might be of merit.
Non-pharmaceutical interventions and risk of COVID-19 infection: survey of U.K. public from November 2020 – May 2021
Abstract Introduction Non-pharmaceutical interventions (NPIs), such as handwashing, social distancing and face mask wearing, have been widely promoted to reduce the spread of COVID-19. This study aimed to explore the relationship between self-reported use of NPIs and COVID-19 infection. Methods We conducted an online questionnaire study recruiting members of the UK public from November 2020 to May 2021. The association between self-reported COVID-19 illness and reported use of NPIs was explored using logistic regression and controlling for participant characteristics, month of questionnaire completion, and vaccine status. Participants who had been exposed to COVID-19 in their household in the previous 2 weeks were excluded. Results Twenty-seven thousand seven hundred fifty-eight participants were included and 2,814 (10.1%) reported having a COVID-19 infection. The odds of COVID-19 infection were reduced with use of a face covering in unadjusted (OR 0.17 (95% CI: 0.15 to 0.20) and adjusted (aOR 0.19, 95% CI 0.16 to 0.23) analyses. Social distancing (OR 0.27, 95% CI: 0.22 to 0.31; aOR 0.35, 95% CI 0.28 to 0.43) and handwashing when arriving home (OR 0.57, 95% CI 0.46 to 0.73; aOR 0.63, 95% CI: 0.48 to 0.83) also reduced the odds of COVID-19. Being in crowded places of 10–100 people (OR 1.89, 95% CI: 1.70 to 2.11; aOR 1.62, 95% CI: 1.42 to 1.85) and > 100 people (OR 2.33, 95% CI: 2.11 to 2.58; aOR 1.73, 95% CI: 1.53 to 1.97) were both associated with increased odds of COVID-19 infection. Handwashing before eating, avoiding touching the face, and cleaning things with virus on were all associated with increased odds of COVID-19 infections. Conclusions This large observational study found evidence for strong protective effects for individuals from use of face coverings, social distancing (including avoiding crowded places) and handwashing on arriving home on developing COVID-19 infection. We also found evidence for an increased risk associated with other behaviours, possibly from recall bias.
The relationship between reported daily nicotine dose from NRT and daily cigarette consumption in pregnant women who smoke in an observational cohort study
Abstract Introduction For nonpregnant people unable to quit smoking, the NHS recommends nicotine replacement therapy (NRT) for smoking reduction. This is not recommended during pregnancy due to concerns about higher nicotine intake than smoking alone. We investigated the relationship between daily nicotine dose from NRT and cigarette consumption reported by pregnant women receiving smoking cessation support. Methods We conducted secondary analysis of data from currently smoking pregnant women, recruited from antenatal clinics (Nottingham University Hospitals, UK) or online between June 2019–September 2020. Participants set a quit date, received a prototype NRT adherence intervention, and reported cigarettes per day (CPD) and daily NRT dose (mg) via smartphone app for 28 days. Results 388 women were screened, 32 (8%) were eligible and joined the study. 24 (75%) submitted 510 app reports in total. 17 (71%) reported smoking and using NRT concurrently on at least one day, with concurrent use reported on 109 (21%) of app reports. The relationship between daily NRT dose and CPD followed an exponential decay curve of approximately 7%. In multilevel repeated measures modelling using 4 linear splines (knots 17, 40, and 85 mg/NRT), significant fixed effects of daily NRT dose on CPD were observed for splines 1, 3, and 4. The strongest association was spline 1 (0–17 mg/NRT), where each 10 mg NRT increase was associated with a 0.6 CPD reduction (24% on average). Conclusions Among women in a cessation study, many smoked and used NRT concurrently; within these women, daily nicotine dose and heaviness of smoking were inversely related. Implications Findings have implications for the design of future interventions intended to reduce harm associated with smoking in pregnancy. They suggest using NRT alongside smoking in pregnancy could help some women reduce the number of cigarettes they smoke per day.
Ideas, concerns, expectations, and effects on life (ICEE) in GP consultations: an observational study using video-recorded UK consultations
Abstract Background Eliciting patients’ ideas, concerns, expectations, and whether a problem has an 'effect' on their life (ICEE), is a widely recommended communication technique. However, it is not known how frequently ICEE components are raised in UK GP consultations. Aim To assess the frequency of ICEE in routine GP consultations with adult patients and explore variables associated with ICEE. Design & setting An observational study was undertaken. It involved secondary analysis of a pre-existing archive of video-recorded, face-to-face GP consultations in the UK. Method Observational coding of 92 consultations took place. Associations were assessed using binomial and ordered logistic regression. Results Most consultations included at least one ICEE component (90.2%). The most common ICEE component per consultation was patient ideas (79.3%), followed by concerns (55.4%), expectations (51.1%), and then effects on life (42.4%). For all ICEE components patients more commonly initiated the ICEE dialogue, and in only three consultations (3.3%) did GPs directly ask patients about their expectations. Problems that were acute (odds ratio [OR] 2.98, 95% confidence interval [CI] = 1.36 to 6.53, P = 0.007) or assessed by GPs aged ≥50 years (OR 2.10, 95% CI = 1.07 to 4.13, P = 0.030) were associated with more ICEE components. Problems assessed later in the consultation (OR 0.60 per problem order increase, 95% CI = 0.41 to 0.87, P = 0.007) by patients aged ≥75 years (OR 0.40, 95% CI = 0.16 to 0.98, P = 0.046) and from the most deprived cohort (OR 0.39, 95% CI = 0.17 to 0.92, P = 0.032) were associated with fewer ICEE components. Patient ideas were associated with more patients being ‘very satisfied’ post-consultation (OR 10.74, 95% CI = 1.60 to 72.0, P = 0.014) and the opposite was true of concerns (OR 0.14, 95% CI = 0.02 to 0.86, P = 0.034). Conclusion ICEE components were associated with patient satisfaction and demographic variables. Further research is required to assess if the way ICEE are communicated affects these associations and other potential confounders.
Effectiveness of self-management interventions for long-term conditions in people experiencing socio-economic deprivation in high-income countries: a systematic review and meta-analysis
Abstract Background Long-term conditions (LTCs) are prevalent in socio-economically deprived populations. Self-management interventions can improve health outcomes, but socio-economically deprived groups have lower participation in them, with potentially lower effectiveness. This review explored whether self-management interventions delivered to people experiencing socio-economic deprivation improve outcomes. Methods We searched databases up to November 2022 for randomized trials. We screened, extracted data and assessed the quality of these studies using Cochrane Risk of Bias 2 (RoB2). We narratively synthesized all studies and performed a meta-analysis on eligible articles. We assessed the certainty of evidence using GRADE for articles included in the meta-analysis. Results The 51 studies included in this review had mixed findings. For the diabetes meta-analysis, there was a statistically significant pooled reduction in haemoglobin A1c (−0.29%). We had moderate certainty in the evidence. Thirty-eight of the study interventions had specific tailoring for socio-economically deprived populations, including adaptions for low literacy and financial incentives. Each intervention had an average of four self-management components. Conclusions Self-management interventions for socio-economically deprived populations show promise, though more evidence is needed. Our review suggests that the number of self-management components may not be important. With the increasing emphasis on self-management, to avoid exacerbating health inequalities, interventions should include tailoring for socio-economically deprived individuals.
Trauma-informed co-production: Collaborating and combining expertise to improve access to primary care with women with complex needs
Abstract Introduction Health, social care, charitable and justice sectors are increasingly recognising the need for trauma-informed services that seek to recognise signs of trauma, provide appropriate paths to recovery and ensure that services enable people rather than retraumatise. Foundational to the development of trauma-informed services is collaboration with people with lived experience of trauma. Co-production principles may provide a useful framework for this collaboration, due to their emphasis on lived experience, and intent to address power imbalances and promote equity. This article aims to examine trauma-informed and co-production principles to consider the extent to which they overlap and explore how to tailor co-production approaches to support people who have experienced trauma. Methods Bridging Gaps is a collaboration between women who have experienced complex trauma, a charity that supports them, primary care clinicians and health researchers to improve access to trauma-informed primary care. Using co-production principles, we aimed to ensure that women who have experienced trauma were key decision-makers throughout the project. Through reflective notes (n = 19), observations of meetings (n = 3), interviews with people involved in the project (n = 9) and reflective group discussions on our experiences, we share learning, successes and failures. Data analysis followed a framework approach, using trauma-informed principles. Results Co-production processes can require adaptation when working with people who have experienced trauma. We emphasise the need for close partnership working, flexibility and transparency around power dynamics, paying particular attention to aspects of power that are less readily visible. Sharing experiences can retrigger trauma. People conducting co-production work need to understand trauma and how this may impact upon an individual's sense of psychological safety. Long-term funding is vital to enable projects to have enough time for the establishment of trust and delivery of tangible results. Conclusions Co-production principles are highly suitable when developing trauma-informed services. Greater consideration needs to be given as to whether and how people share lived experiences, the need for safe spaces, honesty and humility, difficult dynamics between empowerment and safety and whether and when blurring boundaries may be helpful. Our findings have applicability to policy-making, funding and service provision to enable co-production processes to become more trauma-informed. Public Contribution Bridging Gaps was started by a group of women who have experienced complex trauma, including addiction, homelessness, mental health problems, sexual exploitation, domestic and sexual violence and poverty, with a general practitioner (GP) who provides healthcare to this population, alongside a support worker from the charity One25, a charity that supports some of the most marginalised women in Bristol to heal and thrive. More GPs and healthcare researchers joined the group and they have been meeting fortnightly for a period of 4 years with the aim of improving access to trauma-informed primary care. The group uses co-production principles to work together, and we aim to ensure that women who have experienced trauma are key decision-makers throughout our work together. This article is a summary of our learning, informed by discussion, observations and interviews with members of the group.
Models of care and the role of clinical pharmacists in UK primary care for older adults: A scoping review protocol
Introduction There has been global investment of new ways of working to support workforce pressures, including investment in clinical pharmacists working in primary care by the NHS in the England. Clinical pharmacists are well suited to support older adults who have multiple long-term conditions and are on multiple medications. It is important to establish an evidence base for the role of clinical pharmacists in supporting older adults in primary care, to inform strategic and research priorities. The aim of this scoping review is to identify, map and describe existing research and policy/guidance on the role of clinical pharmacists in primary care supporting older adults, and the models of care they provide. Methods and analysis A scoping review guided by the Joanne Briggs Institute methodology for scoping reviews, using a three-step strategy. We will search Medline, CINAHL, Scopus, EMBASE, Web of Science, PSYCHInfo, and Cochrane for English language articles, from 2015 –present day. Grey literature will be searched using Grey Matters guidelines, the Index of Grey Literature and Alternative Sources and Resources, and Google keyword searching. References of all included sources will be hand searched to identify further resources. Using the Population, Concept and Context framework for inclusion and exclusion criteria, articles will be independently screened by two reviewers. The inclusion and exclusion criteria will be refined after we become familiar with the search results, following the iterative nature of a scoping review. Data will be extracted using a data extraction tool using Microsoft Excel and presented using a narrative synthesis approach. Ethics and dissemination Ethical approval is not required for this review. Review findings will be disseminated in academic conferences and used to inform subsequent qualitative research. Findings will be published and shared with relevant local and national organisations.
UK research data resources based on primary care electronic health records: review and summary for potential users
Objectives To describe the current landscape of UK electronic health record (EHR) databases and considerations of access and use of these resources relevant to researchers. Design & setting Narrative review Data sources Information was collected from the Health Data Research Innovation Gateway, publicly available websites and other published data and from key informants. Eligibility criteria Population-based open-access databases sampling EHRs across the whole population of one or more countries in the UK. Data extraction and synthesis We extracted and summarised published database characteristics and corroborated these with resource providers. Results were synthesised narratively. Results Nine large national primary care EHR data resources were identified and summarised. These resources are enhanced by linkage to other administrative data to a varying extent. Resources are mainly intended to support observational research though some can support experimental studies. There is considerable overlap of populations covered. Whilst all resources are accessible to bona fide researchers, access mechanisms, costs, timescales, and other considerations vary across databases. Conclusion Researchers are currently able to access primary care EHR data from several sources. Choice of data resource is likely to be driven by project needs and access considerations. The landscape of data resources based on primary care EHRs in the UK continues to evolve.
Getting the most from freedom of information requests as part of a realist review: Finding treasure or futile endeavour?
What is a realist review? Realist reviews have emerged in recent decades as a way of using multiple sources of data on specific programmes to explain what works, for whom, in what circumstances and why. They are theory driven, seeking to identify and elucidate causal factors through: a) the iterative development of a programme theory (mapping how an intervention operates and brings about change), and b) context-mechanism-outcome configurations (CMOCs) (statements about how context can activate certain mechanisms that result in specific outcomes). A broad range of data is often included in realist reviews; quantitative projects may show patterns that can be explored and explained using data from qualitative research. Realist reviews can also include items such as commentaries, editorials and evaluations, if they contain data that offer an insight into how an intervention is proposed to work or further understanding of parts of a CMOC. Where do FOI requests fit in? CCGs are a potentially ripe avenue for data that can be used in a realist review. Obtaining such information has been notoriously challenging, unless published online. Often an email request goes to a generic inbox, manned by people who may be unclear about where to redirect it. Such requests have become slightly easier to make in light of the Freedom of Information Act. Now the responsibility lies with the researcher doing the asking to be clear about the data they are seeking. We tried contacting CCGs as a route to finding information to use in a couple of realist reviews we are working on, due to a lack of relevant data found from searches of traditional bibliographic databases. The reviews We are part of a team producing a series of realist reviews looking at service redesign in primary care. One focuses on early visiting services; these entail delegating traditional GP led home visits to other professionals (e.g. advanced nurse practitioners, paramedics, emergency care practitioners or locum GPs). CCGs were asked whether and how this service was operationalised within their practice, including implementation processes such as management of patient access, workforce recruitment and cost implications. Service evaluations were also requested. The other review is looking at care navigation, whereby people are supported to locate and access services, often in the voluntary and community sector, which can help address non-medical problems (e.g. loneliness, bereavement, housing problems) that have an impact on health and wellbeing. We invited CCGs to let us know whether this type of service was being provided in their area and, if so, who was providing it, for which patients and whether such services had been evaluated. Procedural issues We had 195 CCGs to contact. There is often one central email address for multiple regions, which is not always made clear online. It can be helpful, therefore, to group CCGs by region, rather than alphabetically, to cross-check points of contact. For example, there is one central email for all CCGs based in North London. By identifying an email address covering several CCGs, we could send one request, outlining precisely where and from whom the information was required. Not all CCGs had a designated FOI email address (e.g. a few had online forms to be completed with requested information). We recorded when this was the case, to be transparent in how information was accessed. We found that staggering requests in batches (of 30-40) every couple of days was necessary, to stop our email inbox from becoming unwieldy with responses. We learnt that when making requests alongside other tasks, it can be difficult to track responses (e.g. in an Excel spreadsheet) when a large volume of requests is sent at the same time. Staggering requests enabled us to log FOI reference numbers against the relevant CCG, which aided both the tracking of replies and ensured the relevant information was to hand when no reply was forthcoming. It was important within requests to outline clearly the nature of the service of interest. This can include the different names it might be labelled as and whether it tends to be operated within or outside of typical working hours. We included, in our requests, a brief paragraph defining the type of service we wished to learn about from each CCG. What information did we get back? The early visiting services review received a response from 184 CCGs. Many of these responses were brief, stating that the CCG did not commission the service we were requesting information on. 46 CCGs were able to reply providing some detail on the service. Given the newness of this intervention, many providers had not yet undertaken formal evaluations. Four additional documents were provided, one being a formal evaluation. This information fell under copyright protection and would require copyright permission to be published in digital form. Hence, retrieving information on early visiting services in this instance did not provide much additional data that was useful to our review. However, it did allow for some meaningful connections to be made with commissioners; several individuals at director level expressed an interest in our conclusions and may, in the future, be able to act as avenues for dissemination. For the care navigators review, we received responses from all but 2 CCGs. Another 29 stated they did not hold requested information and 2 returned unclear replies. This meant we received usable data from 162 CCGs, which has provided a perspective on the different ways in which care navigation is being implemented across England. Furthermore, as part of the responses, we received 31 evaluations that we had not identified from our previous online searches. We are in the process of working with these data, which we envisage will help us refine and strengthen CMOCs. Hence, sending out a FOI request, in this case, was worthwhile in deriving new data for the review. Conclusion Realist reviews incorporate broad searches for literature. Relevant documents may not always be listed on bibliographic databases, especially when looking at an area such as service redesign incorporating new interventions. We wondered how useful it would be to make a FOI request to CCGs in terms of finding material that could inform our understanding and development of CMOCs. The answer seems to be it depends on the area being explored (e.g. its newness versus established programme), how far CCGs see it as part of their remit and their ability to provide information that is not commercially sensitive. Deciding to make a FOI request may have to be balanced against the time this work takes to administer (e.g. devising and piloting the questions to ask, finding email addresses and sending out requests, tracking returns using Excel and dispatching reminders when required). However, it may also produce unintended outcomes such as meaningful connections that extend a researcher’s network for stakeholder engagement and dissemination avenues.
Progression of stroke risk in patients aged <65 years diagnosed with atrial fibrillation: a cohort study in general practice
Background As a result of new technologies, atrial fibrillation (AF) is more likely to be diagnosed in people aged <65 years. Aim To investigate the risk of someone diagnosed with AF aged <65 years developing an indication for anticoagulation before they reach 65 years. Design and setting Population-based cohort study of patients from English practices using the Clinical Practice Research Datalink, a primary care database of electronic medical records. Method The study included patients aged <65 years newly diagnosed with AF. The CHA2DS2-VASc score was derived at time of diagnosis based on patients’ medical records. Patients not eligible for anticoagulation were followed up until they became eligible or turned 65 years old. The primary outcome of interest was development of a risk factor for stroke in AF. Results Among 18 178 patients aged <65 years diagnosed with AF, 9188 (50.5%) were eligible for anticoagulation at the time of diagnosis. Among the 8990 patients not eligible for anticoagulation, 1688 (18.8%) developed a risk factor during follow-up before reaching 65 years of age or leaving the cohort for other reasons, at a rate of 6.1 per 100 patient-years. Hypertension and heart failure were the most common risk factors to occur, with rates of 2.65 (95% CI = 2.47 to 2.84) and 1.58 (95% CI = 1.45 to 1.72) per 100 patient-years, respectively. The rate of new diabetes was 0.95 (95% CI = 0.85 to 1.06) per 100 patient-years. Conclusion People aged <65 years with AF are at higher risk of developing hypertension, heart failure, and diabetes than the general population, so may warrant regular review to identify new occurrence of such risk factors.
Why do people choose not to take part in screening? Qualitative interview study of atrial fibrillation screening nonparticipation
Introduction While screening uptake is variable, many individuals feel they ‘ought’ to participate in screening programmes to aid the detection of conditions amenable to early treatment. Those not taking part in screening are often presented as either hindered by practical or social barriers or personally at fault. Why some people choose not to participate receives less consideration. Methods We explored screening nonparticipation by examining the accounts of participants who chose not to participate in screening offered by a national research trial of atrial fibrillation (AF) screening in England (SAFER: Screening for Atrial Fibrillation with ECG to Reduce stroke). AF is a heart arrhythmia that increases in prevalence with age and increases the risk of stroke. Systematic screening for AF is not a nationally adopted programme within the United Kingdom; it provides a unique opportunity to explore screening nonparticipation outside of the norms and values attached to existing population-based screening programmes. We interviewed people aged over 65 (n = 50) who declined an invitation from SAFER and analysed their accounts thematically. Results Beyond practical reasons for nonparticipation, interviewees challenged the utility of identifying and managing AF earlier. Many questioned the benefits of screening at their age. The trial's presentation of the screening as research made it feel voluntary—something they could legitimately decline. Conclusion Nonparticipants were not resistant to engaging in health-promoting behaviours, uninformed about screening or unsupportive of its potential benefits. Instead, their consideration of the perceived necessity, legitimacy and utility of this screening shaped their decision not to take part. Patient or Public Contribution The SAFER programme is guided by four patient and carer representatives. The representatives are embedded within the team (e.g., one is a co-applicant, another sits on the programme steering committee) and by participating in regular meetings advise on all aspects of the design, management and delivery of the programme, including engaging with interpreting and disseminating the findings. For the qualitative workstream, we established a supplementary patient and public involvement group with whom we regularly consult about research design questions.
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