Health Expectations

BackgroundWomen with limited or no English proficiency experience persistent barriers to accessing maternity care in the UK, contributing to well-documented inequalities in maternal and perinatal outcomes. NHS parent education classes are predominantly delivered in English, and provision of multilingual classes within individual maternity units is often limited and duplicative. Evidence to inform collaborative, cross-trust service models remains scarce. ObjectiveTo assess womens access to, preferences for, and perceived relevance of NHS parent education classes, with particular focus on willingness to travel across London to attend classes delivered in a preferred language, in order to inform equitable and efficient service design. MethodsA cross-sectional, multilingual survey was conducted as a quality improvement initiative across multiple London maternity networks. The survey was translated into 18 languages and captured sociodemographic characteristics, access to parent education, preferences for delivery format, timing, location, and language, and perceived relevance of content. Quantitative data were analysed descriptively and thematically. ResultsA total of 97 women participated in the survey (n=97), the majority of whom reported speaking at least one non-English language at home (79.4%, n=77). Regarding mode of delivery, 51.6% of women preferred in-person parent education classes (n=50), 15.5% preferred online delivery (n=15), and 32.9% reported no preference (n=32). Most participants reported access to a suitable device and reliable internet (85.6%, n=83) and confidence using online platforms (77.3%, n=75). In relation to timing and format, weekends were the most commonly preferred time for classes (40.2%, n=39), followed by weekdays during school hours (35.1%, n=34) and weekday evenings (24.7%, n=24). Nearly half of women preferred delivery across two 2-hour sessions (48.5%, n=47), while 30.9% reported no preference regarding session length or number (n=30); fewer preferred two 3-hour sessions (11.3%, n=11) or a single 4-hour session (8.3%, n=8). Regarding willingness to travel, 67.0% of participants reported they would attend parent education classes delivered outside their booking maternity unit (n=65). Overall, 68.0% were willing to travel up to 45 minutes for in-person classes (n=66), while 29.9% preferred not to travel (n=29). With respect to language of delivery, 40.2% of women preferred classes delivered in their native language (n=39), and a further 40.2% reported English with an interpreter as acceptable (n=39); fewer were comfortable relying on a partner or friend to translate (19.6%, n=19). Most participants perceived that delivery by a native-speaking health professional would improve trust and learning (75.3%, n=73), and an equal proportion expressed a preference for a female interpreter (75.3%, n=73). ConclusionsWomen with limited English proficiency demonstrate clear willingness to travel across maternity networks to access antenatal education in their preferred language. These findings support the development of collaborative, cross-trust models that standardise core antenatal content while centralising multilingual provision, reducing duplication and improving equity of access across London maternity services.

BackgroundBetween May and December 2022, the UK Health Security Agency reported 3,585 cases of mpox. The 2022 global outbreak was characterised by transmission predominantly within sexual networks of gay and bisexual men (GBMSM). UK public health responses included information and vaccination campaigns, supported by behaviour change among GBMSM. We describe community reflections on the UK mpox outbreak and the responses to it. MethodsBetween August 2023 and April 2024, we conducted five focus groups with participants (n=27) recruited through community organisations in London and Manchester. Participants were predominantly gay men from ethnically diverse backgrounds. Data were analysed thematically. ResultsComing soon after COVID-19, the mpox outbreak intensified fears of returning to lockdown. Reports of GBMSM being most affected, and its framing in the media as a gay disease, coupled with warnings within GBMSM networks echoed earlier experiences of HIV. Those who had acquired mpox reported that media coverage had intensified their experiences of stigma and discrimination. Participants perceived vaccine roll out as inequitable; Furthermore, the perceived sudden cessation of public health messaging and advice left participants uncertain about ongoing risk and the need for prevention. ConclusionsParticipant reflections two years after the 2022 mpox outbreak demonstrate how previous pandemics shape emotional responses to new outbreaks. Key challenges included stigmatising media coverage, inequitable vaccine rollout, and sudden discontinuation of public health messaging. These findings highlight the importance of targeted, non-stigmatising and unambiguous communication from trusted sources during and after an outbreak. What is already known on this topicThe media response to the 2022 UK mpox outbreak led to stigma among GBMSM and public health measures were not equitably accessible What this study addsPeople from communities affected by the outbreak sought timely information from trusted sources. Communication needs do not end with outbreaks How this study might affect research, practice or policyThere is a need for ongoing public health work to build trusted networks who can maintain inter-outbreak communications and respond rapidly to outbreaks

Purpose: Human anatomy remains foundational to clinical practice, yet reduced instructional hours raise concerns about graduate competence and preparedness for patient care. Although trainees often report confidence, supervisors may perceive deficiencies, creating a gap between self-assessment and external evaluation. This study examined stakeholder perspectives on anatomical competence within physical therapy education to identify areas of discordance in perceived capability. Methods: A cross-sectional web-based survey collected responses from 165 stakeholders associated with an entry-level Doctor of Physical Therapy program featuring a 16-week dissection curriculum. Participants rated four domains of anatomical competence using a 5-point ordinal scale. Group differences were analyzed with the Kruskal-Wallis test appropriate for ordinal data. This methodology ensured robust assessment of stakeholder perceptions and comparative analysis. Results: Median ratings of preparedness and capability were 4 of 5 (quite prepared). Significant discordance emerged in three domains: recent graduates rated their foundational knowledge and ability to explain complex concepts to lay audiences higher than faculty or clinical instructors, whereas faculty expressed lower confidence in graduates' ability to explain patient symptoms using anatomical principles. No significant differences were observed in the ability to describe structures by location, suggesting shared perceptions of basic anatomical understanding despite variation in applied reasoning. Conclusions: Stakeholders generally viewed graduates as well prepared, yet disagreement persisted regarding clinical application of anatomical knowledge. Faculty skepticism about symptom explanation indicates that mastery of anatomy alone does not guarantee clinical reasoning. Curricular strategies emphasizing vertical integration and explicit connections between anatomical science and patient-centered reasoning may help bridge perception gaps and enhance professional competence.

BackgroundCommunication issues across the primary-secondary care interface are considered one of the most important challenges in improving patient safety in primary care in the UK. Teleconferencing offers a potential means of improving communication during referrals but is largely unevaluated. AimTo explore teleconferencing as an alternative to written Advice and Guidance (A&G) referrals for neurology cases, by assessing its impact on GP-specialist communication and relationships, and exploring implications for patient care. Design and SettingA qualitative case study of a primary care network (PCN) and a secondary care centre in East Anglia. Methods18 clinicians and 10 other stakeholders were interviewed. Observations of teleconferences and a focus group with five PCN staff provided additional data. Data collection and analysis were guided by the Consolidated Framework for Implementation Research and Reflexive Thematic Analysis. ResultsAdvantages of teleconferencing identified by participants included greater clinician satisfaction, mutual educational value, streamlined patient journeys and continuity of care. Teleconferences were also seen to build GP-specialist relationships and reduce unnecessary outpatient referrals. Perceived issues included time constraints, clinical governance and funding sustainability; teleconferences were not seen as appropriate for all referrals. Overall, participants welcomed the teleconference approach but stressed the need to robustly assess its cost-effectiveness and replicability in other settings. ConclusionTeleconferencing is a potentially promising alternative to written A&G referrals and was perceived by participants to help build GP-specialist relationships. However, further studies are needed to assess clinical effectiveness and costs, and to guide future development and implementation. How this fits inO_ST_ABSWhat is known?C_ST_ABSReferral interventions involving direct GP-specialist dialogue can enhance referral quality, reduce outpatient referrals and improve GP-specialist relationships, with some demonstrating improved clinical outcomes. However, they often face sustainability challenges, and their cost-effectiveness and mechanisms of impact require further assessment. What does this study add?This qualitative study identifies key mechanisms through which virtual GP-specialist dialogue may lead to downstream benefits: enabling shared decision-making and delivering consultant-level care closer to home; empowering GPs to manage complex cases; and reducing overall workload across primary and secondary care systems. The programme theory developed can be used to guide future intervention design, implementation and evaluation.

Electronic Health Records (EHRs) have not been widely implemented in mental health settings, representing a significant gap in digital health care transformation. A reason for underutilisation includes concerns from healthcare professionals regarding the collection and storage of patients sensitive information. Language use can positively influence clinician-patient relationships, and stigmatising language in EHRs viewed by patients could undermine trust. This is concerning as using EHRs have benefits which allow patients to feel safe and empowered regarding their care. Moreover, minority ethnic groups have been found to disengage with EHRs and are more likely to access mental health services through crisis pathways. This qualitative study in collaboration with Bradford District Care NHS Foundation Trust comprises two stages to explore minority ethnic perspectives on mental health EHRs and develop recommendations for their implementation. Stage one investigates minority ethnic service users perceptions on EHRs and explores mental health professionals understanding regarding the sharing of EHRs with service users from minority ethnic groups. The workshops in stage two will use an Experience-Based Co-Design approach to produce practical recommendations for EHR implementation in mental health settings. Participants include minority ethnic service users, mental health professionals, stakeholders, and relevant bodies such as mental health organisations and Information Technology experts utilising EHRs. Data will be gathered through semi-structured interviews, focus groups and workshops, and analysed using reflexive thematic analysis. The study was approved under the Integrated Research Application System (IRAS ID: 348764) and Health Research Authority and Health and Care Research Wales. Findings will be disseminated via social media, blogs, conferences, journals, academic articles, and community and staff meetings held by the Trust. An executive summary will be shared with participants who consented to receive the results.

BackgroundCommunity safety is a key determinant of mental well-being, yet racially and ethnically minoritised communities in the UK often face higher exposure to violence alongside barriers to formal protection and support. In these contexts, informal support networks may play a critical role in shaping how safety is experienced and how distress is managed. Although such networks are widely recognised as protective for mental well-being, there is limited qualitative research examining how they operate in relation to community safety in settings shaped by structural inequality. This study explores how informal support networks influence experiences of community safety and mental well-being among racially and ethnically minoritised groups in South East London. MethodsThis qualitative study draws on semi-structured interviews (n = 31) with racially and ethnically minoritised participants aged 16+ living or working in Lambeth and Southwark [South East London]. Using a co-produced qualitative design, community consultations informed the development of interview topics. Interviews explored informal support networks, experiences of community safety and their intersections with mental well-being. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis. ResultsFour themes were identified: (1) experiences of community safety and their mental health impacts; (2) gendered experiences of safety and responsibility; (3) formal support and its barriers; and (4) community and peer-led initiatives as a response to institutional distrust. ConclusionInformal support networks are central to everyday safety and emotional well-being, yet they cannot substitute for adequately resourced, culturally informed public provisions. Strengthening public infrastructure must involve meaningful collaboration with trusted community networks and address the intersectional needs of racially and ethnically minoritised groups.

BackgroundLiving with multiple long-term conditions (MLTC) is becoming increasingly common with far-reaching consequences for individuals and healthcare systems. People with MLTC often face complex care pathways through health systems - especially hospitals, which are largely configured for specialist treatment of single conditions - yet evidence on people with MLTCs lived experience in the hospital setting is limited. This study aimed to understand the hospital care experiences of people living with MLTC who had recently had an inpatient stay. MethodsPeople with MLTC who had experienced an inpatient stay in hospital within the previous six months were recruited via three hospitals in England and via patient networks. Semi-structured one-to-one interviews were conducted with each participant, focussing on their experiences of care from admission to discharge. An inductive thematic analysis was undertaken. ResultsA total of 44 people (mean age 68.4 years, 23 women) who reported living with between 2 and 11 long-term conditions, the majority of whom (96%) reported that their most recent hospital stay was unplanned, participated in the study. Three themes were constructed from the interview data, reflecting perceptions at individual, interpersonal and organisational levels. Participants experiences were shaped by internalised narratives of hospital care, where care was expected to be focussed primarily on single conditions within a resource-constrained environment. Relationally, the degree of alignment between clinician and patient knowledge on conditions was a key contributor to whether hospital care was experienced positively or negatively, and participants perceptions of organisational constraints to holistic care gave insights into their views on system-level barriers shaping the provision of care for MLTC in the hospital setting. ConclusionExperiences of inpatient hospital care for people with MLTC are complex, diverse and shaped by expectations of care in a specialist setting configured to provide care for single conditions. Healthcare professionals should incorporate patients experiential expertise into decision-making processes through consultation with people with lived experience of MLTC. Redesigning hospital services to provide holistic care will require flexibility to respond to the wide spectrum of MLTC experiences.

BackgroundDementia affects over 57 million people worldwide. UK and international policy position personalised, conversation-based care planning as central to post-diagnostic support. However, delivery in primary care is inconsistent, and many practitioners lack dementia-specific communication training. Existing evidence focuses on single roles or settings, leaving a gap in understanding how communication operates across the primary care workforce. AimsTo identify what helps and hinders effective communication for integrated dementia care planning and determine the support and training needs of the wider primary care workforce. MethodsO_LISemi-structured interviews - 11 people with dementia, 13 family carers, and 19 primary care practitioners from diverse roles, exploring experiences of care planning conversations C_LIO_LIReflexive thematic analysis C_LI ResultsThree themes were developed, progressing from micro-level communication practices (Theme 1: Beyond the tick-box), through triadic dynamics (Theme 2: Balancing voices in the conversation), to organisational influences (Theme 3: From silos to meaningful shared care planning). Time and Conversation as intervention cut across all themes, shaping trust and disclosure. Participants reported reliance on tick box approaches, inconsistent preparation, and uncertainty about care plan purpose and ownership. Non-clinical roles were commonly viewed as well placed to support meaningful conversations, but were often described as constrained by unclear remit and weak integration. ConclusionsA persistent gap remains between policy ambitions and everyday practice. Time-pressured, checklist-driven encounters and fragmented systems undermine shared decision-making. The expanded primary care workforce offers untapped potential to address these gaps, but this requires clearer roles, formal integration, and targeted investment in communicative skills.

BackgroundInfertility affects approximately one in six people globally and is associated with diminished quality of life (QoL). In Uganda, an estimated 6.4% of women experience infertility, yet evidence on fertility-specific QoL and its determinants remains limited. We assessed fertility-related QoL and associated factors among individuals seeking fertility care in public and private hospital settings in Kampala to inform patient-centred services. MethodologyWe conducted a hospital-based cross-sectional study (May 2024-January 2025) among 332 individuals aged 18-49 years attending fertility clinics at Kawempe National Referral Hospital (public; n=175) and St. Francis Hospital Nsambya (private; n=157). QoL was measured using the validated Core FertiQoL questionnaire, generating overall and domain scores (emotional, mind/body, relational, and social), transformed to a 0-100 scale (higher scores indicate better QoL). Mean scores were compared using independent-samples t-tests and one-way ANOVA. Multivariable linear regression identified factors independently associated with FertiQoL (=0.05). ResultsMost participants were female (87.1%) and [&le;]40 years (88.0%). Secondary infertility was reported by 50.3%, and 58.4% had infertility duration <5 years. The overall mean FertiQoL score was 61.9 (SD 14.7), with similar totals across hospitals. Mind/body scores were comparatively higher, while emotional scores were lowest (mean 54.3, SD 21.3). In adjusted analyses, male gender ({beta}=8.49; 95% CI 3.95-13.02; p<0.001) and secondary infertility ({beta}=7.45; 95% CI 4.41-10.49; p<0.001) were associated with higher FertiQoL scores. ConclusionsFertility-related QoL among patients seeking care in Kampala was moderate and did not differ by facility type. Gender and infertility type were key correlates, underscoring the need for integrated, gender-sensitive psychosocial support alongside clinical infertility care.

BackgroundDespite recommendations in clinical guidelines, clinical experience indicates that engagement with splints and orthotics varies amongst people after stroke. ObjectivesThe aim of the study was to understand the factors that influence engagement with splints and orthotics in people after stroke. MethodsPeople after stroke who had been wearing a splint or orthotic (also known as devices) for at least 2 months under the care of one Community Neurosciences Team in the UKs National Health Service were included. Semi structured interviews based on the constructs of Banduras Social Cognitive Theory (SCT) were used to gather participants views, and a framework analysis applying the constructs of SCT was completed using NVIVO software. ResultsFour key themes were identified: 1. Self-Regulation; difficulties applying the device and aesthetic acceptability. 2. Self-Efficacy; increased confidence when wearing the device and reduced motivation to wear the device. 3. Outcomes Expectation; reduced falls risk, improved gait, improved balance, maintaining range of movement, and negative effects such as discomfort, pain, itching. 4. Social Support; support needed to apply the device and the burden on family members/carers to apply the device correctly. ConclusionsThe findings of this study highlight key factors that influence engagement with orthotics and splints. These include difficulty applying the device after stroke, device aesthetics, comfort, and the importance of continued support from carers. Manufacturers should consider how people after stroke can independently don and doff devices. Education of carers and family members also appears key to support their engagement.

PurposeRobotic walkers are a new and novel technology with growing evidence of benefits for children living with mobility impairments. However, little is known about how using these devices at home impacts families. This study aims to explore parents perceptions of home-based robotic walking and the impacts on their family and their child living with a mobility impairment. Materials and MethodsQualitative interviews were conducted with seven parents who have a child who used a robotic walker in their home for at least six months. Thematic analysis was used to analyze all interviews. Themes were then mapped to the F-words for child development. ResultsUsing a robotic walker at home led to family bonding and created new ways for parents and siblings to interact with the child living with a mobility impairment. Many children enjoyed using the robotic walker. This, combined with being able to direct its use in their own environments, contributed to less parental stress than was associated with other rehabilitation interventions. However, some parents discussed an increase in parental stress due to certain logistical aspects, getting their child in and out and transporting the robotic walker. Finally, parents discussed that obtaining the device was a financial burden for them. ConclusionRobotic walking in the home environment impacts family relationships and parental stress. Understanding families experiences can inform decision-making by families and practitioners around the appropriateness of robotic walker use for a child living with a disability.

BackgroundArticle 5.3 of the WHO Framework Convention on Tobacco Control requires Parties to protect policies from tobacco industry interference, yet implementation remains weak internationally. Aotearoa New Zealands (Aotearoa NZ) is seen as a leader in tobacco control, yet little is known about its implementation of Article 5.3 protections. This study examines these protections as well as existing transparency measures in light of the 2024 repeal of world-leading tobacco control policies. MethodsInterviews with current and former: public health experts, politicians, officials and political journalists, and analysis of key texts. ResultsAotearoa NZs Article 5.3 implementation and scope is constrained, leaving invisible and exploitable paths of influence. Public health experts argued protections have been neglected from the start. Politicians were unaware of Article 5.3 obligations, and reported limited guidance on industry interactions. These gaps are compounded by non-existent lobbying laws and ill-equipped transparency measures. ConclusionDespite the countrys reputation for strong tobacco controls, structural policy and implementation failures leave Aotearoa NZs health policies vulnerable to industry interference. Aotearoa NZ and other Parties should consider institutionally embedding comprehensive Article 5.3 protections to safeguard policy decisions from tobacco industry influence. WHAT THIS PAPER ADDSO_ST_ABSWhat is already known on this topicC_ST_ABSTobacco industry interference remains the biggest barrier to tobacco control policies, with evidence consistently identifying gaps in Parties implementation of Framework Convention on Tobacco Control Article 5.3 protections. Parties often rely on pre-existing measures such as lobbying laws. What this study addsThis is the first study examing Aotearoa NZs implementation of Article 5.3. It shows that despite its reputation as a tobacco control leader, implementation is severely limited and pre-existing measures are inadequate, enabling a system in which industry interference can go on unseen. How this study might affect research, practice or policyBy identifying how structural policy gaps enable industry interference, this study highlights the need for comprehensive institutional embedding of Article 5.3 protections across government, and consideration of its codification into law.

IntroductionWith global populations ageing, demand for palliative care is increasing. Population-level assessments of unmet palliative care needs are essential for strategic planning, yet rigorous methods to estimate unmet needs are lacking. This study aimed to develop methods and estimate current and future population-level prevalence of unmet palliative care needs among adults in England and Wales. MethodsSecondary analyses of data from a nationally representative post-bereavement survey in England and Wales in 2022 (n=1,194). Unmet needs in the survey sample were estimated using two methods: (1) reported unresolved symptoms and concerns using Integrated Palliative care Outcome Scale scores, cutoff [&ge;]34/68; and (2) reported insufficient care provision from general practitioners. These methods were combined to further provide a conservative estimate (1 and 2) and a broad estimate (1 or 2). We examined associations with unmet needs using modified Poisson regression. Age-, gender- and nation-specific sample estimates were applied to mortality data for 2022 and projections from the Office for National Statistics to calculate population-level estimates and prevalence from 2025 to 2050. ResultsIn 2022, 247,993 (46%) adult decedents in England and 17,209 (49%) in Wales had unmet palliative care needs using method 1; 244,612 (46%) and 15,280 (43%), respectively, using method 2. According to conversative and broad estimates, 32% and 61% could have unmet needs in England, and 29% and 62% in Wales. By 2050, prevalence of unmet needs are projected to rise by 21-26% in England and 14-19% in Wales depending on estimate used, with the largest absolute increase among those aged [&ge;]85 years. ConclusionsUnmet palliative care needs are high in England and Wales and projected to increase by 2050, regardless of method. We contrast methods based on unresolved symptoms and concerns or insufficient care provision, or both, to inform the planning and evaluating of equitable care. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIAlthough understanding population-level unmet palliative care needs is critical for effective service planning, robust and standardised methods to estimate these needs remain limited. C_LI What this study addsO_LIWe use two methods to provide four estimates of population-level prevalence of unmet palliative care needs and discuss their strengths and limitations. C_LIO_LIRegardless of estimate, prevalence of unmet palliative care needs is high, ranging 32-61% in England and in 29-62% in Wales; the number of people with unmet needs is anticipated to increase by 21-26% in England and 14-19% in Wales by 2050. C_LI How this study might affect research, practice or policyO_LIThis advancement in methods to estimate unmet palliative care needs can inform the development and evaluation of population-level strategies to improve end-of-life care. C_LIO_LIOur population-level estimates do not account for multiple long-term conditions which are rising and will likely increase the complexity of needs. C_LIO_LIThere needs to be more investment in primary and community-based services to ensure high-quality symptom management and support for people and their families towards the end of life. C_LI

BackgroundDespite widespread recognition that patient safety learning can transcend national boundaries, no international patient safety learning system (PSLS) currently exists. There is no expert consensus on the purpose, key requirements, or feasibility of such a system. ObjectiveTo gain consensus from an international panel of healthcare experts regarding the key requirements and feasibility of a potential international PSLS, with or without an incident reporting function. MethodsA two-round modified online Delphi study was conducted with 21 international healthcare experts in patient safety and learning systems, representing all six continents. The study was informed by a prior systematic literature review and semi-structured key-informant interviews with safety-critical industry experts. Panellists rated statements on a 9-point Likert-like scale. Consensus was defined a priori as [&ge;]70% agreement (ratings 7-9) with an interquartile range (IQR) [&le;]2.00. A post-hoc threshold of [&ge;]80% was applied to identify the strongest areas of consensus. ResultsOf 73 experts invited, 21 completed round one (29% response rate) and 15 completed round two (71% retention). Across two rounds, 103 statements were evaluated; consensus was achieved on 85 (83%) at the [&ge;]80% threshold across all four domains: purposes (15/19 statements); key functions and features (17/22); patient safety incidents and criteria for international concern (19/24 combined); and enablers and challenges (34/38). The panel endorsed a proposed framework for an international PSLS and generated novel consensus-based lists of patient safety incidents and criteria for determining what should be shared internationally. ConclusionsInternational healthcare experts broadly agree on the purposes, key functions, and feasibility of an international PSLS. The consensus-derived framework provides a foundation for future feasibility research and potential pilot implementation. Validation with frontline end-users is an essential next step. KEY MESSAGESO_ST_ABSWhat is already known on this topicC_ST_ABSNational patient safety learning systems vary considerably in design, governance, and the degree to which they generate actionable learning, and no international system currently exists to enable systematic cross-border sharing and learning from patient safety data. What this study addsThis is the first Delphi study to establish international expert consensus on the purposes, key functions and features, and feasibility of an international Patient Safety Learning System (PSLS), producing novel consensus-based lists of patient safety incidents relevant to international sharing and criteria for determining what constitutes a risk of international concern. How this study might affect research, practice or policyThe proposed framework and consensus-derived criteria provide a starting point for feasibility research and potential pilot implementation by organisations such as the World Health Organization (WHO), in alignment with the Global Patient Safety Action Plan 2021-2030. The findings also highlight the structural prerequisites -- including a standardised international taxonomy, governance frameworks, and equitable participation mechanisms -- that must be addressed before implementation can proceed.

IntroductionDespite being curable, leprosy-related stigma in Pakistan persists, undermining dignity, delaying care, and hindering progress toward zero-leprosy targets. Empowerment is critical in counteracting stigma and restoring agency among affected persons. Participatory, contact-based storytelling has potential to reduce stigma and strengthen empowerment, but evidence remains limited. This study evaluates a participatory storytelling intervention involving persons affected by leprosy in Karachi.Objectives This study investigates how a participatory storytelling intervention influences stigma and empowerment among persons affected by leprosy in Pakistan. It explores changes in participants experiences, examines the mechanisms through which storytelling engages with stigma and identifies practical insights to strengthen future intervention design. MethodsWe conducted a qualitative study following the 2024-25 participatory storytelling pilot at MALC, Karachi. Persons affected by leprosy who participated in the intervention were purposively sampled (age 30-65 years); sixteen participated in photovoice and fourteen completed in-depth interviews (IDIs) (thirteen of which had also participated in photovoice) (total n= 17). Data were analysed thematically using the Social Ecological Model (SEM). ResultsThe programme supported a shift from shame and concealment to greater self-acceptance, confidence and openness. Peer groups and creative storytelling built solidarity, a sense of belonging and transferable skills, while organisational endorsement enhanced participants visibility and roles. However, stigma remained reinforced by community misconceptions, gender norms and practical barriers. Overall, the interventions greatest effect was at the individual level, reducing self and anticipated stigma, with intrapersonal empowerment emerging as the primary gain. ConclusionParticipatory storytelling enhanced identity and empowerment, but broader social change remained constrained by gender norms, visible disability, and structural barriers. Strengthening impact requires sustained community contact, supported peer educators, inclusive outreach to women and persons with visible impairments, and links to socioeconomic opportunities. Embedding peer-led storytelling within skin NTD services and national and WHO strategies can support community ownership and sustainability. Author summaryLeprosy is a curable disease, yet many people affected by it continue to experience stigma that affects their mental health, confidence, relationships and health seeking behaviour. In Pakistan, stigma remains a major barrier to achieving zero-leprosy goals and improving quality of life. Our study explored the degree to which a participatory storytelling intervention, where persons affected by leprosy share their experiences through creative methods, supported empowerment and reduced stigma. We conducted a qualitative study with participants involved in a storytelling pilot intervention in Karachi, using interviews and photovoice to explore their experiences. Participants described the transition from shame and secrecy toward openness, greater self-confidence and self-acceptance. The storytelling process encouraged peer support, strengthened social connections and helped participants develop new skills and a stronger sense of identity. However, persistent community misconceptions, gender norms, visible disability and economic constraints limited broader social change. Our findings suggest that participatory storytelling interventions present a promising approach for reducing internalised stigma and strengthening individual empowerment among persons affected by leprosy. To achieve wider impact, storytelling initiatives should be combined with sustained community engagement, inclusive outreach and integration into skin neglected tropical disease (NTD) services and broader social support programmes.

BackgroundThis study developed and validated a primary care assessment tool (SL-PCAT) for evaluating patients experiences in the Sri Lankan healthcare setting. MethodsThe study was conducted from April 2021 to August 2023 inside a medical faculty and selected communities in the Anuradhapura District. The tool was validated through item development, scale development, and scale evaluation processes. Items were selected through focused-group interviews, a literature review, and an expert review. Two language experts translated the tool into the Sinhala language. The scales construct was evaluated parallel to a cross-sectional household survey in 32 villages. First, 633 valid data were randomly split into two groups (Subsample-1 [n=320] and Subsample-2 [n=313]). Exploratory factor analysis was performed in Subsample-1 with principal component analysis (PCA), followed by reliability assessment with Cronbachs alpha. A confirmatory factor analysis (CFA) was performed on Subsample-2. Likert scale assumption testing and descriptive statistics were performed in the final factor structure. ResultsThe four factor solution from PCA explained 66.8% variance in data. Domains identified were contextual care at family and community with continuity, accessibility, patient-centred care, and comprehensive and coordinated care. The domains reported Cronbachs alpha values between 0.719 and 0.859. The goodness of fit index of the CFA improved after allowing a few modifications (X2=199, p<0.001, RMSEA= 0.079, GFI=0.916, SRMR=0.066, CFI=0.916). The corresponding convergent and discriminant validity of the Likert scale assumptions was optimum, with Item-scale correlations between 0.346 and 0.830 and scaling success rates over 70%. Three domains, except contextual care at family and community with continuity, reported positively skewed scores, indicating more positive responses. ConclusionsSL-PCAT is a feasible, valid, and reliable tool for assessing patients experiences of primary care in Sri Lanka.

Structured AbstractO_ST_ABSObjectiveC_ST_ABSThis mixed-methods study investigated the lived-experience perspectives of receiving a novel, brief digital mental health intervention after psychological trauma. The online gamified imagery-competing task intervention (ICTI) involves one researcher-guided session followed by self-use. Tested in two randomised controlled trials (GAINS-01; GAINS-02), ICTI led to fewer intrusive memories at week-4, with the reduction sustained over 24 weeks, alongside reductions in post-traumatic stress. Here, we contrasted user experiences of ICTI with an Active Control (AC; music-listening task), and explored longer-term impact in qualitative interviews to contextualise GAINS-02 findings. Methods and AnalysisThe GAINS-02 trial randomised healthcare staff experiencing intrusive memories after work-related trauma to ICTI (N=40), AC (N=39), or treatment-as-usual (TAU; N=20). Expectancy was assessed before the researcher-guided session (Day 0), acceptability at week-4, and usage tracked for 24-weeks. Semi-structured interviews (N=27) were conducted in ICTI and AC arms only (15 at week-4; 12 during 12-24-weeks). Interviews were analysed using reflexive thematic analysis. ResultsPrior to use, many trial participants did not think the intervention would work, favouring AC over ICTI. However, after completing the tasks, participants found ICTI more acceptable and relevant to intrusive memories than AC. After the one guided session, median ICTI usage the next four weeks was 4.00 times with little additional use (once more) over the next 20 weeks because of lack of need. Potential implementation facilitators included ease of use, and advantages over existing interventions due to not needing to talk about the trauma, brevity, and lesser resource commitment. Perceived barriers included a lack of staff and manager education about the nature and consequences of intrusive memories, with a need for workplace buy-in and demonstration of organisational benefits. ConclusionHealthcare staff experiencing workplace-related trauma found ICTI to be acceptable and effective for reducing intrusive memories with low effort and emotional burden, even among participants who initially expressed scepticism. Participants highlighted implementation considerations including offering ICTI both within and outside the workplace, and providing a self-guided version of ICTI with optional support. Future work should assess cost-effectiveness, impacts on presenteeism and retention, and real-world implementation including the feasibility and effectiveness of a self-guided ICTI. Summary BoxO_ST_ABSWhat is already known on this topicC_ST_ABSIn a previous randomised controlled trial (GAINS-01) with Intensive Care Unit (ICU) staff exposed to work-related trauma, a brief online gamified imagery-competing task intervention (ICTI) reduced intrusive memories compared to usual care at four-weeks. What this study addsThe GAINS-02 randomised controlled trial replicated GAINS-01 and extended results by comparing ICTI to an active control (AC; music listening) task, enrolling hospital staff from outside ICU, and a follow-up period of 24-weeks. Qualitative interviews found that, despite initial scepticism from healthcare staff prior to using the intervention, ICTI was more acceptable than an AC due to specific effects on swiftly reducing intrusive memories and requiring minimal support or usage after an initial researcher-guided session. After one guided session, ICTI was used 4 more times in the first four weeks, with little additional usage (once) thereafter because of lack of need (i.e., no longer experiencing intrusive memories). How this study might affect research, practice or policyICTI is an efficacious scalable intervention to relieve staff of intrusive memories with effects sustained for at least 6-months. It was found to be more acceptable to participants than alternatives, requiring less time commitment than standard psychological treatments.

Young people are increasingly remaining in the parental home for longer - a trend associated with poorer mental health. There is little evidence on this transition for young people with disability. We used three waves of the Australian Census Longitudinal Dataset, a 5% sample of linked Census records. Two analyses compared transitions between 2011-2016 and 2016-2021 among people 15-34y living with parents at baseline with complete data on disability and housing. The proportion of people no longer living with parents at follow-up was calculated, comparing people with and without disability, along with absolute and relative inequalities. Young people with disability were half as likely to leave the parental home as their peers without disability. Inequalities were greatest for people 25-29y (relative difference 0.41 (95%CI 0.36-0.45), living outside major cities (0.48, 0.44-0.52), or with higher income (0.53 (0.47-0.59). Patterns were consistent over time. Targeted supports are needed to enable independent living. Points of interestO_LIWe found that less people with disability leave the parental home than people without disability C_LIO_LIWe also found the gap between people with and without disability was biggest outside major cities. C_LIO_LIThis may mean people with disability in rural, regional and remote areas find it more difficult to move out of home C_LIO_LIBetter housing and income supports are needed to help young people with disability live in the way they choose C_LI

BackgroundA Hospital Medicine Advanced Practice Provider (HMAPP)-led care model developed in response to the high acuity and increased patient volumes associated with the Covid-19 pandemic. Although anecdotally perceived as a successful model, questions remained if there was adequate pre-planning and formal implementation strategy for stakeholder buy-in. ObjectiveTo elicit HM physicians and APPs perceptions of the HMAPP-led care model implementation and consider necessary steps for optimal future APP care model development and operation. Design, Setting and ParticipantsThis qualitative study used 10 (5 physicians and 5 APPs involved in the care model pre- and post-implementation) individual semi-structured, virtual interviews based on the Consolidated Framework for Implementation Research (CFIR). Deductive and inductive rapid analysis was utilized to analyze the data. ResultsTwo themes emerged as strengths: 1) Experienced APPs delivered the care model, 2) Acceptance of the care model evolved over time. Four themes suggested opportunities for future development: 1) Guidelines should expand from patient distribution to include minimal collaboration and escalation expectations, 2) Culture change was a barrier to model implementation and acceptance, 3) Intentional collaboration between APPs and Physicians is necessary, 4) Investment in standardized onboarding enhances buy-in of the care model. ConclusionThe impact of an APP care model can be elevated if implemented with key principles and strategies. This is critical in an evolving health care landscape where all providers need to collaborate and practice with their full expertise to maximize safe, efficient and quality patient care.

1.AI is already finding its way into the diagnostic radiology realm of various regions around the world, but there is still a lack of evidence on the situation in LMICs. This qualitative study examined the research problem through the perspectives of clinicians regarding the adoption of AI-Radiology in Karachi, Pakistan, using the Technology Acceptance Model and interpreting the results into practice and policy using the Problem Driven Iteration Adaptation lens. 13 clinicians (radiologists, tertiary care hospitals) were interviewed between May and August 2025. The semi structured interviews were audio recorded, transcribed and coded in NVivo 14. TAM constructs of perceived usefulness and perceived ease of use were analyzed in a deductive content analysis, and interpretation of implementation pathways was informed by PDIA. Four themes emerged. Implementation attitudes were realistic optimism. The subjects put AI in terms of an assistant and second reader, and clinical judgment and accountability could not be delegated. Issues centered on privacy of data, and over dependence. Perceived ease of use was based on training, infrastructure, fit in workflow and trust. Costs, poor connectivity, the lack of institutional capacity, and generational resistance were the barriers whereas triage acceleration, mass screening support, workload reduction, and time saving were the facilitators. For adoption, education, practical upskilling, guidelines, and local clinical approval were requirements. The greatest perceived usefulness was in situations where AI was applied to specific bottlenecks like quick screening, quantitative measurements, remote-area reporting, and trainees decision support; the constraints included data quality, generalizability, and algorithm error, the risk of confidentiality, and the impossibility to substitute contextual clinical reasoning. Such priorities as national and institutional data protection policies, formal vetting of tools, smooth integration with radiology information systems and AI literacy in the curriculum were included. The sample is limited to one city and the qualitative design does not enhance generalizability but the results provide practical recommendations. The mixed resource setting of Karachi is a potential place where AI can be a reliable collaborator in the field of radiology in case of adequate infrastructure and training of clinicians and a long-term human control. Perceived usefulness can be converted to routine and safe clinical use with strategic and staged implementation.