Health Expectations

Remote consultations, including telephone, video, text or web-based consultations, are now common in sexual and reproductive health services (SRHS) in England and Wales, offering convenience and efficiency but raising concerns about safeguarding service users compared to in-person care. Ensuring protection and support for individuals remain central to SRHS. While guidance exists, evidence on how safeguarding is enacted remotely is limited. This study explores how safeguarding is managed in remote SRHS, examining associated challenges, benefits, and perceptions of acceptability. This qualitative study, part of the CONNECT study (NIHR153151), explored safeguarding in remote delivery of SRHS across three diverse case study areas in England and Wales. Semi-structured interviews were conducted with service users and providers (March 2024-January 2025). Data were thematically analysed using inductive and deductive approaches. Eighty-nine interviews were conducted with 54 service users/potential service users and 35 professional stakeholders across three study sites. Four key themes were identified: (1) challenges of delivering remote safeguarding in practice, (2) importance of a safe space for the patient, (3) one size approach does not fit all, and (4) strategies to support remote safeguarding. Participants described difficulties identifying risks without visual cues, variable comfort with disclosure, and privacy concerns. Providers used adaptive, collaborative approaches to build trust, ensure safety, and tailor safeguarding to individual circumstances. Both service users and providers recognised the effectiveness of remote safeguarding largely depended on clinician judgement, structured questioning, and sensitive communication. While remote consultations offered flexibility, remote safeguarding relied on service users having access to safe, private space. People with language barriers or those less able to create a safe space at home, such as those experiencing housing instability or coercive control may also have greater safeguarding needs. Ensuring access to in-person options, clear safeguarding protocols, and appropriate clinician training is essential to mitigate these challenges. Author summaryDuring the COVID-19 pandemic, sexual and reproductive health services used more remote appointments, such as phone, video, or online consultations. These appointments can make it easier for some people to get care. But there are concerns about whether staff can spot safeguarding issues, such as people who may be at risk of harm, without seeing them in person. In this study, we spoke with people who use sexual and reproductive health services, people who had never used these services before, and staff who work in these settings. People described challenges with remote appointments, including not being able to see body language, feeling unsure about talking about sensitive issues, and worries about privacy at home. Staff described changing how they worked by asking careful questions, building trust, and making safeguarding fit each persons situation. Both service users and staff felt that keeping people safe during remote appointments depends on clear communication and professional judgement. It is harder when people do not have a private space, face language difficulties, or live in unsafe housing or controlling relationships. Our findings show the importance of keeping in-person appointments available and making sure staff have the right training and guidance.

BackgroundRemote consultations (via telephone or video) were critical during COVID-19 restrictions for Sexual and Reproductive Health Services (SRHS) in England and Wales and continue to be implemented widely. However, there remains limited evidence on their impact on outcomes and health inequalities. This study, guided by the Framework for Digital Health Equity, explores the equity implications of remote sexual health consultations in England and Wales, examining their acceptability and appropriateness. MethodsWe conducted semi-structured interviews with 54 service users and potential service users and 35 professional stakeholders across three diverse case study areas. Participants were purposively sampled to ensure diversity in socio-demographic profile and service experience. All participants provided informed consent, and ethical approval for the study was granted by NHS Research Ethics Committee (REC: 23/NS/0128). Data were thematically analysed into narrative themes, with findings interpreted collaboratively with public and patient involvement groups. ResultsThe study found that remote consultations have reshaped care delivery, improving efficiency but also generating additional clinical workload and, for some clinicians, reduced job satisfaction. While generally acceptable, remote models were perceived to affect rapport, extend care pathways for some service users, and impact privacy and safeguarding. We found the benefits of remote consultation are unevenly distributed, with those experiencing digital exclusion, who lack access to suitable private spaces, or who experience language barriers, being less able to take advantage of their convenience. ConclusionsRemote consultations transform SRHS delivery, improving efficiency for some but introducing challenges by impacting interaction, equity, and confidentiality. Benefits and burdens are unevenly distributed, reflecting structural, social, and individual factors influencing access. SRHS must ensure equitable access to appropriate care for all populations when implementing remote consultations. The findings show that a one-size-fits-all approach is not appropriate, and that giving service users choice in how they consult, including in-person, is important.

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.

BackgroundApproximately 300 million people worldwide live with a rare disease, and the majority of rare diseases manifest in childhood. For families, the period before diagnosis is often protracted and distressing, marked by repeated consultations, inconclusive investigations, conflicting medical opinions, and the absence of a recognisable name for their childs condition. While the clinical and epidemiological dimensions of the diagnostic odyssey have been documented, the narrative and experiential dimensions of how parents live through and make sense of prolonged diagnostic uncertainty remain underexplored, particularly in low- and middle-income country contexts. AimTo explore the narrative experiences of parents navigating diagnostic uncertainty for children with rare diseases in Brazil. MethodsA narrative inquiry informed by the three-dimensional narrative space framework of Clandinin and Connelly was conducted. Sixteen parents (twelve mothers and four fathers) of children who had experienced a diagnostic delay of at least two years were recruited from two rare disease referral centres in Sao Paulo and Belo Horizonte. Data were collected through two narrative interviews per participant, supplemented by participant-produced timelines and family photographs. Analysis followed a narrative analytical approach attending to temporality, sociality, and place. FindingsThree narrative threads were woven across the parents stories: (a) "Living in the space before the name," capturing the disorienting experience of caring for a child whose suffering could not be categorised, explained, or predicted; (b) "Fighting to be believed," describing the relentless advocacy required to sustain medical attention in a system that struggled to accommodate conditions falling outside familiar diagnostic categories; and (c) "Rewriting the story," illuminating how the eventual arrival (or non-arrival) of a diagnosis reshaped parents understanding of their child, their family, and themselves. ConclusionDiagnostic uncertainty for parents of children with rare diseases is not a passive waiting period but an active, effortful, and identity-transforming experience. The findings highlight the need for healthcare systems to provide structured psychosocial support during the pre-diagnostic period and for clinicians to develop communication practices that acknowledge, rather than dismiss, the legitimacy of undiagnosed suffering.

BackgroundGynecological cancers and their treatments can compromise fertility, with profound psychosocial consequences for women of reproductive age. Yet, womens lived experiences of cancer-related infertility remain underexplored in low-resource settings, including Ghana. This study examined the impact of gynecological cancers on fertility among reproductive-aged women receiving care at Ho Teaching Hospital, Ghana. MethodsA qualitative descriptive design was used. Fourteen women aged 15-49 years with gynecological cancers who had completed or were undergoing treatment were purposively recruited until saturation. Semi-structured interviews (30-45 minutes) were conducted face-to-face or by telephone in English, Twi, or Ewe, audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Strategies to enhance rigor included independent coding, member checking, reflexivity, and peer debriefing. ResultsFive themes and eighteen subthemes emerged. Participants described infertility as a threat to womanhood and future life plans, expressed as a sense of incompleteness, fear of rejection, denial, and shattered aspirations. Social consequences included stigma and impaired intimate relationships. Treatment-related burdens, menstrual changes, pain, fatigue, and anxiety compounded distress. Economic hardship and educational disruption were common. Women also demonstrated resilience through adherence to treatment, dietary and lifestyle modifications, faith-based coping, and family support. ConclusionGynecological cancer-related infertility is a multidimensional survivorship burden. Integrating fertility counseling, psychosocial support, symptom management, and financial/social protection into cancer care is critical in Ghanaian settings.

Social prescribing has assumed increasing dominance in policy and practice internationally, including in the UK, where it has an increasing role in addressing social needs such as isolation, and social determinants of ill health. Although General Practitioners are perceived as key referral sources, social workers in one locality were found to play a significant role in referral. This suggests that the social work role in this context has been under recognised and under explored. This study sought to explore social workers' perceptions and experiences of social prescribing through an online survey conducted from January to June 2022. All UK social workers were eligible to participate, regardless of whether they had made referrals. A total of 105 responses were collected from all UK nations. Data was analysed using inductive thematic analysis. Four key themes were generated: contended and contested boundaries; complementary spaces; delineated spaces of simplicity and complexity; social work under threat. Participants recognised that social prescribing could provide valuable client support and could be a useful resource for social workers. However, they also expressed concerns about overlapping professional boundaries and the potential for social prescribing to encroach on social work, perceiving it as most appropriate for the delivery of support to those with 'low level' needs.

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.

ObjectivesEvaluate the impact of online symptom checker formats on symptom management knowledge, symptom checker trust and acceptability, and behavioural intentions. DesignTwo 5-arm parallel-group online randomised controlled trials. SettingOnline survey. Participants2110 Australian adults recruited through online research panel in June 2025. Almost half identified as man/male (49%) and woman/female (51%), median age 49 years (IQR=28). Participants viewed a hypothetical health scenario (fever and vomiting) followed by a screenshot of an online symptom checker from national health service provider, healthdirect. InterventionsParticipants were randomised to symptom acuity level (low: self-care at home; or moderate: see a General Practitioner (GP) in 24 hours) and one of five symptom checker formats. The standard format showed the existing healthdirect symptom checker advice. The remaining formats were AI-enhanced versions. These included an AI-enhanced version with e.g. more tailored advice, rationale for acuity level, and AI disclosure statement. The other AI-enhanced formats had additional features: numbered steps, multimedia, and more detailed information about the use of AI. Main outcome measuresPrimary outcomes were intentions to follow the symptom checkers self-care advice and intentions to see a GP in 24 hours. Secondary outcomes were trust in advice, knowledge of symptom management, and acceptability of the tool. All outcomes were assessed immediately post-intervention; knowledge was also assessed after 2 weeks. ResultsWhen advised to self-care at home, the AI-enhanced groups reported lower intentions to see a GP in 24 hours (median 3.00 out of 5), compared to the standard (original) tool (median 4.00; adjusted p = 0.003). There were no other significant effects on intentions. Immediately following the intervention, participants who viewed an AI-enhanced format reported greater knowledge about how to manage current and changing symptoms, across both acuity levels (adjusted ps <0.001). Knowledge gains were not sustained at 2 week follow-up. There were no significant effects on trust or acceptability. ConclusionsParticipants who viewed the more tailored information in the AI-enhanced formats demonstrated stronger knowledge for managing symptoms than those who viewed the standard format. There was also some evidence that an AI-enhanced format may be more effective at reducing use of primary care for symptoms that can be managed at home. Trust and acceptability were high across formats, and the explicit use of AI did not impact significantly on these outcomes. Future research should investigate these formats using interactive prototypes across a wider variety of health contexts. RegistrationACTRN ACTRN12625000474459p Key messagesO_LIWhat is already known on this topic: Although online, evidence-based symptom checkers have been widely available from reputable health organisations for over a decade, they often face poor uptake and may not adequately meet health literacy needs of diverse users. C_LIO_LIWhat this study adds: Symptom checker features that could be implemented with AI, such as tailored information and a clear rationale for triage advice, may help support appropriate symptom management. Statements about the tools use of AI did not appear to impact trust or acceptability of the symptom checker tool. C_LIO_LIHow this study might affect research, practice or policy: Findings from this study suggest that using AI to enhance symptom checker advice may not impact negatively on trust and acceptability of the tool, and may improve appropriate symptom management. Further research is needed to investigate AI-enhanced symptom checker formats using interactive prototypes across a wider variety of health contexts. C_LI

BackgroundPrimary care practitioners are well-positioned to support people of reproductive age in preparing for pregnancy and parenthood. Such "preconception care" is ideally delivered opportunistically during routine consultations, although limited time presents a barrier. AimTo achieve consensus on priority topics for opportunistic preconception care in general practice. Design and settingA three-step consensus study involving UK-based primary care practitioners and people of reproductive age. MethodThe consensus process involved: 1) identifying potential topics through literature and guideline reviews, workshops with people of reproductive age (n=15), and interviews with primary care practitioners who work in general practice (n=14); 2) prioritising topics using a Delphi survey (n=85 participants completing round one, n=63 completing all three rounds); and 3) agreeing on priority topics during an online consensus workshop (n=21 participants). Participants were recruited through a Public Advisory Group, charities, and professional organisations. ResultsReviews and workshops/interviews with people of reproductive age and practitioners identified 37 potential topics. The Delphi survey and consensus workshop identified 16 priority topics. These were combined into four overarching topic areas for discussion during relevant consultations: O_LIPatient knowledge of preconception health and pregnancy C_LIO_LIIdeas, concerns and expectations (e.g. pregnancy intention, prior pregnancy experiences) C_LIO_LIHealth conditions (e.g. medication use, mental/physical health, immunisation) C_LIO_LIHealth behaviours (e.g. folic acid supplement use, smoking, alcohol consumption). C_LI ConclusionThe agreed priority topic areas offer a structured foundation for delivering patient-centred, opportunistic preconception care in primary care. The findings support future co-development of practical tools and resources to enable routine implementation. How this fits inPreconception care improves pregnancy outcomes, but in UK general practice it is inconsistently delivered, partly due to limited time and guidance that offers little prioritisation for opportunistic consultations. This study identifies four overarching topic areas for preconception care, based on consensus among people of reproductive age and primary care practitioners. The resulting priority list offers clinicians a practical, flexible way to initiate patient-centred preconception care discussions within routine consultations.

Background Advice and Guidance (A&G) enables primary care clinicians to seek specialist input, supporting decision making and avoiding unnecessary referrals. The use of A&G has significantly expanded, accelerated by COVID19 and contractual changes. While A&G is intended to streamline elective care, concerns persist regarding workload shift, variable responsiveness, and system usability. Despite growing policy emphasis, little is known about why clinicians choose to use A&G. Aim Explore the current use of A&G within primary care, focusing on decision making processes which underpin PCCs' decision to use A&G. Design and Setting Qualitative study set in English Primary Care Method Twenty semi structured video interviews were conducted with primary care clinicians purposively sampled for maximum variation. Topic guides were developed with PPIE input and refined iteratively. Data were analysed using reflexive thematic analysis within an interpretive description framework, with themes developed collaboratively and refined through discussion with researchers and PPIE contributors. Ethical approval was obtained (REC 333799). Results Four overarching themes encapsulate clinicians' decisions to use A&G: clinical presentation (acuity and complexity), navigating healthcare pathways, previous experiences of A&G, and using A&G to validate clinical decision making. Barriers included delayed responses and uncertainty about inequitable workload distribution. These factors shape how effectively A&G could be integrated into routine practice. Conclusion Primary care clinicians use A&G to support patient care and aid decision-making, but its effectiveness depends on timely, clinically helpful responses. Ensuring responses remain appropriate to primary care remit and capacity will be essential if A&G becomes the main route into elective care.

Background Parenting practices shape children's emotional, social, and cognitive developmental wellbeing. Yet, many families face complex challenges that increase the risk of poor outcomes and demand on social care. The Sutton Parenting Offer (SPO) is a universal, peer-led parenting offer that provides early, non-stigmatising support to families with children aged 0-25 years. It combines evidence-based programmes with informal workshops and peer networks delivered through Family Hubs. This present study is an evaluation protocol of the parenting offer. Aim This evaluation aims to explore how, why, and in what contexts SPO supports families in engaging, sustaining positive change, and generating wider system value. Methods A mixed-methods realist evaluation approach will be used to evaluate SPO across four work packages: engagement pathways, early changes and peer-led ecosystems, long-term change, and system value for money. Data sources will include attendance data (anonymised service records), survey data (entry and exit), and qualitative data (dyad interviews, story circles, and stakeholder-value mapping workshops). The COM-B and the Theoretical Domains Framework (TDF) will guide the analysis of behavioural data. Quantitative data will be analysed descriptively and using paired parametric and non-parametric tests, while qualitative data will be analysed thematically following a realist-informed approach to refine context-mechanism-outcome (CMO) configurations. Discussion This protocol presents the first realist informed evaluation of a universal parenting program in a local authority setting. The evaluation will generate evidence on how, when and why a universal, community-based, and peer-led model such as the Sutton Parenting Offer engages families and generates change. The findings will be useful to inform future parenting service design and implementation in local contexts in England.

Objectives: Endometriosis affects approximately 10% of reproductive age women worldwide, yet care pathways remain fragmented and treatments have limitations. This study aimed to identify and categorize key stakeholders in endometriosis care in Ireland, assess their influence and interest in the digital health initiative, and identify drivers and barriers affecting uptake of innovative approaches to care. Methods: A virtual stakeholder mapping workshop was conducted with participants from healthcare, policy, education, technology, academia, and patient communities. Using a structured MS Teams Whiteboard, participants generated a stakeholder list, positioned stakeholders on an Influence-Interest Matrix, and provided qualitative insights on factors enabling or constraining engagement with digital health innovation. Results: Stakeholders were distributed across all four quadrants of the matrix. High-interest/high-influence stakeholders included the HSE, specialist centres, general practitioners, and the Endometriosis Association of Ireland. High-interest/low-influence groups comprised patients, families, and online communities, while policymakers, hospital managers, and the education sector were identified as high-influence but low-interest actors. Key drivers included strong patient advocacy, institutional support such as engagement from the HSE, and growing awareness of digital health tools. Major barriers encompassed prolonged diagnostic delays, resource constraints, gaps in clinical knowledge, technology anxiety, and challenges sustaining engagement. Conclusions: Stakeholder mapping provided an evidence-informed foundation for the VendoR project, revealing engagement gaps and leverage points critical for improving endometriosis care innovation. The findings highlight the need for intentional, well-resourced strategies that elevate patient voices, address systemic barriers, and ensure balanced representation, supporting the co-design, co-creation, and co-production of digital health interventions for sustainable, patient-centred care.

BackgroundThe COVID-19 pandemic significantly accelerated the adoption of telemedicine, but it also exposed gaps in effective remote clinical assessment, particularly for medically vulnerable patients in rural areas. The ORCHARD intervention aimed to address this by providing patients with a Medical Self-Assessment Box to enable self-reporting of vital signs during remote consultations. MethodsA single-centre randomised mixed-methods feasibility trial recruited medically vulnerable patients from a rural general practice in Northeast Scotland. Participants in intervention group received a home medical equipment box for use during telemedicine consultations over six months. Patients and GPs were interviewed and transcripts were analysed using Framework Analysis. ResultsTwelve (15%) of 82 eligible invited patients enrolled. Six each were allocated to intervention and control group. 50%(n=3)patients in intervention group used equipment in 45%(5 of 11)teleconsultations and rated it helpful in all 5 uses (100%). The intervention group had 18% fewer primary care contacts than controls. All remote consultations were by telephone. Framework Analysis of patient interviews identified facilitators such as ease of use, improved triage access, reassurance, and barriers related to GP non-engagement and written instructions. GP interviews identified clinical value in patient-generated readings, alongside concerns regarding workload and patient over-monitoring. ConclusionsHalf of intervention participants used the medical-equipment box during remote consultations, all finding it useful, though frequency of use varied among particpants.A randomised controlled trial to evaluate the effectiveness of the Medical Self-Assessment Box for optimising remote consulting in medically vulnerable rural patients is feasible.Prior to a definitive trial refinements are recommended to patient labelling, GP engagement, and training materials.

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.

Abstract Background Musculoskeletal conditions, such as back pain and osteoarthritis, are common and disabling disorders. Musculoskeletal conditions are closely related to chronic disease risk factors like smoking/vaping, poor nutrition, alcohol misuse and physical inactivity and impact a person's risk of falling (SNAPF). Preventive care for SNAPF risks is often overlooked. Online delivery of preventive care may increase the provision of this care. We aimed to assess if an online tool for SNAPF risks would be used by and acceptable to patients waiting for an orthopaedic consultation. Methods We completed a multi-method study to test an online health risk self-assessment tool. A random sample of 300 people on the orthopaedic outpatient waiting list aged 18-64 years were sent the tool in batches of 20-50. The tool assessed SNAPF risks and provided feedback against national guidelines. After each batch, we completed feedback interviews with participants to assess acceptability and updated the tool. We summarised quantitative data using descriptive statistics and qualitative data using thematic analysis. Results Of the 300 participants sent the tool, 51.3% were female, 8.6% identified as Aboriginal and/or Torres Strait Islander, with a mean (SD) age of 52.0 years (11.2). There were 170 participants (59.2%) who completed the tool, 117 who did not complete it, and 13 participants who were excluded from analysis because they did not receive the SMS. We conducted 184 feedback interviews, including 125 'completers' and 59 'non-completers'. The percentage of participants who felt that SMS was an appropriate way to receive the tool was 84.7% of 'completers' and 50% of 'non-completers'. The two most common reasons for not completing the tool were due to perceived risk (13/59, 22.0%), and the SMS was received at an inconvenient time (11/59, 18.6%). Qualitative data from the feedback interviews captured three enablers: i) design, ii) high importance, and iii) engagement with health service, along with four barriers: i) design, ii) risk, iii) relevance, and iv) engagement with health service. Conclusion Our study found that an online health risk self-assessment tool appears to be an acceptable way to assess chronic disease and falls risk factors for people on an orthopaedic waitlist.

BackgroundThe University of Limericks Allied Health Community Engaged Placement (CEP) model promotes interprofessional teamwork, enabling allied health students to learn with, from, and about each other through shared community placements. CEPs complement traditional clinical placements by offering socially responsive experiences, fostering community partnerships, and preparing students for diverse practice settings. MethodologyThis mixed method study used a qualitative dominant design, underpinned by social constructivism. Data was collected via focus groups and an online survey. Five focus groups were conducted with students (n=9), practice educators (n=6), and community partners (n=5). Reflexive thematic analysis underpinned qualitative analysis. The survey included an 8-item, 6-point Likert scale to assess perceived skill development, distributed to all three groups. FindingsSix themes were generated: (i) lifting the veil of the social determinants of health, (ii) not your traditional placement, (iii) developing skills to serve communities, (iv) rolling with resistance, sense of growth, and (vi) beyond placement beyond academia. Students valued interprofessional and collaborative skills developed, though some noted clinical skills gaps. Educators observed improved communication and teamwork, while community partners highlighted students leadership, professionalism, and meaningful contributions to the community. DiscussionCommunity engaged placements support development of teamwork, adaptability, and cultural responsiveness skills essential for addressing health inequities. These competencies are achieved through transformative experiences with community members, which cultivate shared learning and growth for students, practice educators, and partners. To maximise impact for all three groups guidelines are needed to support understanding, preparation, and sustainability of placements.

BackgroundImplementation research relies on accurate measurement of early implementation outcomes such as acceptability, appropriateness, and feasibility. However, instruments developed in high income settings may demonstrate limited cross-cultural validity when applied in different health systems. In postpartum family planning, differences in counselling routines, workload, and service organisation mean that unadapted measures can overlook important aspects of provider experience. This study aimed to culturally adapt and psychometrically evaluate the Acceptability of Intervention Measure, the Intervention Appropriateness Measure, and the Feasibility of Intervention Measure when applied to postpartum family planning counselling and use of the World Health Organization Medical Eligibility Criteria mobile application among midwives and family planning nurses in Ghana. MethodsA sequential exploratory mixed methods design was employed. Three focus group discussions with 18 midwives and family planning nurses were conducted to culturally adapt the original measures developed by Weiner and colleagues. Insights from the qualitative phase informed revisions to the survey instrument. The adapted tool was subsequently administered to 150 midwives who had used the Medical Eligibility Criteria mobile application during one-on-one postpartum family planning counselling. Psychometric evaluation included assessment of internal consistency reliability, exploratory and confirmatory factor analysis, predictive validity, and tests of convergent and discriminant validity. ResultsThe adapted implementation outcome measures demonstrated strong internal consistency, with Cronbach alpha coefficients ranging from 0.82 to 0.93 across the three constructs for both the counselling intervention and the mobile application. Confirmatory factor analysis indicated acceptable model fit following minor modifications, supporting the unidimensional structure of the acceptability, appropriateness, and feasibility constructs. Predictive validity was demonstrated through significant associations between implementation outcome scores and providers preferences regarding counselling practices and use of digital tools. Although the expanded adapted scales showed high reliability, only the abridged versions consisting of four acceptability items and three items each for appropriateness and feasibility demonstrated full convergent and discriminant validity. ConclusionCulturally adapted versions of the Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure can be reliably applied to evaluate postpartum family planning interventions among midwives and family planning nurses in Ghana. The findings suggest that the abridged versions of these measures retain stronger construct validity than expanded adapted versions, highlighting the importance of balancing contextual adaptation with preservation of the underlying measurement structure. Contributions to the literatureThis study advances the field of implementation science by demonstrating the process and value of culturally adapting and validating the acceptability, appropriateness and feasibility measures for use in a low- and middle-income country context. It provides empirical evidence supporting the reliability and construct validity of these measures in assessing the implementation of postpartum family planning interventions, including mobile health applications. The findings contribute to the broader goal of strengthening implementation measurement strategies in resource-constrained settings and offer a replicable model for adapting psychometric tools across diverse healthcare environments.

BackgroundMultiple long-term conditions (MLTC) are increasingly common and place significant strain on healthcare systems designed around single-organ conditions, often resulting in fragmented and reactive care for people living with MLTC. There is limited understanding of how health care professionals (HCPs) make decisions for and with individuals with MLTC at the point of hospital presentation. This study examined how HCPs in emergency and acute settings make decisions around pathways and places of care for people with MLTC, exploring the factors that shape clinical judgement, the challenges HCPs navigate in practice and structures that influence clinical decision-making. MethodsWe conducted semi-structured, individual interviews with 40 NHS professionals working in emergency departments (EDs) and acute assessment units across multiple regions, roles, and specialties. Participants included consultant physicians, resident doctors, senior nursing staff and allied health professionals. Interviews focused on how decisions were made around referrals, admissions, and care planning for people with MLTC. Data were analysed thematically using an inductive approach. ResultsFour themes were identified: A journey of uncertainty, Within and beyond limitations, Structures of care and Implementing relational care. Clinical decision-making is shaped by clinical uncertainty, limited resources, care approaches, and interpersonal relationships and communication. Fragmented services and single-disease pathways complicate care, but participants highlighted the value of continuity, communication, and relational approaches. Challenges include resource limitations, rigid pathways and limited community support. Key enablers of clinical decision-making include integrated care, ownership, and early conversations about priorities. ConclusionsClinical decision-making by HCPs in hospitals for patients with MLTC is complex and shaped by systemic misalignment, where clinical realities clash with health system structures. Improving clinical decision-making around referrals, admissions and care planning for people with MLTC will require adapting systems and training to reflect the realities of MLTC. Potentially beneficial adaptations include strengthening relational and multidisciplinary approaches and expanding intermediate care to reduce avoidable admissions.

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.

BackgroundAdvance care planning in older persons with palliative care needs is often not (timely) initiated. Certified nursing assistants are closely involved in the (daily) care for older persons and have important insights regarding their clients care preferences and quality of life. However, their role in advance care planning is currently overlooked. AimTo examine the perspectives of nursing assistants on their role in advance care planning for older persons. DesignA qualitative descriptive study design using semi-structured interviews. Setting/participantsFifteen nursing assistants working in community care and nursing homes in the Netherlands were interviewed between March and December 2023. A combined inductive and deductive thematic analysis was performed using the Capability, Opportunity, Motivation Behavioral model. ResultsMost nursing assistants were not structurally involved in advance care planning and were in need of additional knowledge and skills (capability). The team culture affected nursing assistants opportunities and motivation to participate in advance care planning both positively and negatively. The opportunity was further shaped by nursing assistants relationship with clients and relatives and time management, while motivation also depended on personal circumstances. ConclusionThis study found several barriers and facilitators affecting nursing assistants role in advance care planning for older persons. Structurally involving nursing assistants in advance care planning, supporting their work environment, and empowering them can foster equal collaboration with other healthcare professionals. This might contribute to the timely initiation of advance care planning and palliative care for older persons. Key statementsi) What is already known about the topic?O_LIAdvance care planning enables patients, relatives, and involved healthcare professionals to define and discuss goals and preferences for current and future medical treatment and care. C_LIO_LICertified nursing assistants are often closely involved in the (daily) care for older persons and their relatives, providing important insights into their preferences and quality of life. C_LIO_LINursing assistants are currently not structurally involved in the interprofessional collaboration regarding advance care planning. C_LI ii) What this paper addsO_LIVariation was observed in nursing assistants roles in advance care planning across care teams and settings, with most indicating a need for additional knowledge and skills (capability). C_LIO_LIThe team culture affected nursing assistants opportunities and motivation to participate in advance care planning both positively and negatively. C_LIO_LIThe opportunity was further shaped by nursing assistants relationship with clients and relatives and time management, while motivation was also depended on personal circumstances. C_LI iii) Implications for practiceO_LIStructural involvement of certified nursing assistants in advance care planning can contribute to timely initiation of advance care planning and palliative care for older persons. C_LIO_LIA supportive work environment that enables nursing assistants to develop their skills and grow professionally can facilitate an advance care planning process involving the expertise of all healthcare professionals. C_LIO_LIThe empowerment of nursing assistants could help them to become a more equal partner in advance care planning in collaboration with other involved professionals. C_LI