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Why you should read this article: • UK care homes are an important example of a complex environment where research is essential but faces multiple challenges in terms of rigour and methodology • This paper offers a variety of important methodological strategies to identify and address challenges that could impact findings and the ability to carry out research • It highlights the importance of taking a critical stance with all elements of the research process and illustrates the need to identify and mitigate challenges when conducting research in complex environments. Background: The evidence base for hydration practice in care homes is underdeveloped. High-quality research is therefore needed to determine what practices support older people with dementia in drinking sufficient fluid. However, methodological developments are needed to be able to do this. Aim: To highlight the methodological issues researchers encountered during a feasibility cluster, randomised controlled trial of ThinkDrink, a hydration care guide for people with dementia living in UK care homes. Discussion: This is a challenging area because of the complexity of recruitment, participation and data collection in care homes. Researchers must pay extra attention to rigour and quality in the design of their studies. There may be multiple challenges, so various strategies may be required. Conclusion: It is important that researchers continue to reflect on rigorous approaches to develop evidence in a crucial area of care, despite these challenges. Implications for practice: Researchers working in complex environments face a variety of challenges to complete methodologically rigorous research. It is important for researchers to be critical of research processes and data, to mitigate and overcome these challenges. [ABSTRACT FROM AUTHOR]

Background: There are limited tools to measure the burden of disease and effectiveness of medical/surgical interventions in patients with cryptoglandular fistulas. The aim of this study was to explore concepts that are relevant and important to patients with complex cryptoglandular fistulas (CCF) and to develop a patient-centred, disease-specific, patient-reported outcome measure (PROM) to assess symptom burden and impacts of CCF. Methods: A targeted literature review was conducted, followed by one-to-one telephone interviews with five colorectal surgeons (USA, n = 3; UK, n = 1; Spain, n = 1) and 20 US adult patients with CCF to inform the development of a conceptual model and a CCF-specific PROM. The targeted literature review informed the development of the preliminary conceptual model and identified a PROM in the literature that was used as a reference to generate the draft CCF-specific PROM. The colorectal surgeon interviews provided insights on the experience of patients with CCF to refine the conceptual model, formulate probing questions for use in patient interviews, and to develop the draft CCF-specific PROM. Patients' descriptions of their experiences with symptoms and the impacts on their lives and evaluation of the draft CCF-specific PROM in concept elicitation and cognitive interviews were used to develop the final conceptual model and final CCF-specific PROM. Results: Ten symptoms (odour, pain during bowel movement, abscess, post-operative pain, discharge/drainage/leakage, anal/perianal pain, inflammation/swelling, skin irritation, bleeding and itchiness) and 11 impacts (discomfort, inability to exercise, embarrassment, difficulty sitting, worry about disease, adapted life to maintain hygiene, negatively impacted social life/isolation, inability to perform daily activities, reduced interest in sex, negatively impacted intimate relationships and negatively impacted mood) were reported as most salient by patients. The patient experience, clinician perspective, and literature review provided input to item generation. Evaluation of relevance and patient understanding through cognitive interviews with patients provided evidence for the content validity of the new patient-reported outcome measure: the 20-item Complex Cryptoglandular Fistula Questionnaire™ (CCFQ-20™). Conclusion: The CCFQ-20™ is a new clinician-guided, patient-validated, disease-specific patient-reported outcome measure that measures disease impact and quality of life in patients with CCF. [ABSTRACT FROM AUTHOR]

Background: Cold water swimming is growing in popularity, especially among women. We have previously reported that women felt that cold water swimming helps with their menstrual and menopause symptoms. But little is known about the habits of women who cold water swim. Objectives: To determine the habits of women who cold water swim. Design: This was a mixed-methods study. Methods: An online survey asked women who cold water swim about their experience of swimming and how this affected their menstrual and menopause symptoms. The survey was advertised for 2 months on social media, with a focus on advertising in cold water swimming Facebook groups. In this article, only the questions on the women's swimming habits were analyzed. Results: The analysis of 1114 women, mainly from the United Kingdom, revealed that most had been swimming for 1–5 years (79.5%). Most swim in the sea (64.4%), and only 15.5% swim alone. The majority (89.0%) swim all year around, swimming for mainly 30–60 min in the summer and 5–15 min in the winter. The women mostly swim wearing swimming costumes (skins) throughout the year. The majority of the free-text responses showed women found mental and physical benefits from cold water swimming. Conclusion: It was not surprising to learn that women swim for longer in the summer than the winter, but hearing how they feel cold water swimming helps their physical and mental health is important. With the limitations on access and safety of many wild swimming sites in the United Kingdom, it is time to ensure that cold water swimming is safer and more supported. [ABSTRACT FROM AUTHOR]

Aim. To explore how Black African international students adjust to their new university environment and gain insight into how they feel supported to engage in physical activity (PA). Background. People from ethnic minority backgrounds have poor physical activity levels compared with white populations in the UK. The Black population is known to have the lowest PA levels among the ethnic minority groups in the UK. This trend is suggested to be the case among university students, but no research has examined this. Ethnic minority students, including international students, encounter adaptation difficulties such as cultural barriers and social isolation which affect their university experiences and health behaviours such as physical activity. Methodology. This was a qualitative method, with in‐depth semistructured interviews conducted with five African students (two males and three females) aged between 21 and 40 years from a university in the West Midlands. The transcribed interviews were analysed using Braun and Clarke's thematic analysis. Results/Findings. Culture and lifestyle of physical activity; knowledge, experience, and self‐motivation; the effect of various social groups, activities, and services at the university; and weather variations and physical settings were the identified themes. The key finding of the study is that respondents engaged in PA to a greater extent at the British university than they did in their home countries. This was due to a combination of factors, including low‐cost gym memberships and events and a general lack of racial or gender‐based discrimination. Conclusions/Recommendations. Participants expressed satisfaction with the cultural and social support systems at their university, such as sports clubs and societies, and mental health support services that encouraged them to learn about and engage more in physical activity. Although some barriers, such as weather variations, were mentioned, various indoor options coupled with cheaper gymnasiums motivated students to remain or become active. Understanding the experiences of minority student groups in physical activity could help in reviewing current provisions and extending them to a wider population. [ABSTRACT FROM AUTHOR]

Background: Low socio-economic status can lead to poor patient outcomes, exacerbated by lack of integration between health and social care and there is a demand for developing new models of working. Aim: To improve connections between patients, local services and their communities to reduce unscheduled admissions. Design and setting: A primary care cluster with areas of high deprivation, consisting of 11 general practices serving over 74,000 people. Method: A multi-disciplinary team with representatives from healthcare, local council and the third sector was formed to provide support for people with complex or social needs. A discharge liaison hub contacted patients following hospital discharge offering support, while cluster pharmacists led medicine reviews. Wellbeing Connectors were commissioned to act as a link to local wellbeing and social resources. Advance Care Planning was implemented to support personalised decision making. Results: Unscheduled admissions in the over 75 age group decreased following the changes, equating to over 800 avoided monthly referrals to assessment units for the cluster. Over 2,500 patients have been reviewed by the MDT since its inception with referrals to social prescribing groups, physiotherapy and mental health teams; these patients are 20% less likely to contact their GP after their case is discussed. An improved sense of wellbeing was reported by 80% of patients supported by wellbeing connectors. Staff feel better able to meet patient needs and reported an increased joy in working. Conclusion: Improved integration between health, social care and third sector has led to a reduction in admissions, improved patient wellbeing and has improved job satisfaction amongst staff. [ABSTRACT FROM AUTHOR]

Many children with developmental language disorder (DLD) have emotion recognition and regulation difficulties, but there are currently no known interventions enhancing emotional awareness in this population. This study explores the impact of parents' perspectives regarding children with DLD emotional understanding through a parent-led online emotion recognition (ER) intervention. Ten parents of children with DLD aged 6–11 participated in the study. A nonconcurrent multiple baseline design was employed, allowing for a rigorous analysis of changes in parental beliefs over time. Weekly data were collected through the Parents' Beliefs About Children's Emotions Questionnaire. Interviews were also conducted to gain deeper insights into parents' perceptions regarding the ER skills of their children. Results indicated that parents' beliefs about the need for guiding and supporting their child's ER skills increased over the intervention. Interviews also supported this, and three main themes were generated. The intervention program increased parents' awareness of (a) the importance of ER for children with DLD, (b) emotion-focused communication and engagement with their child, and (c) the integration of emotions into daily life. This study is the first known study that explores parents' beliefs about children with DLD ER skills, highlighting the importance of supporting parents through accessible interventions. [ABSTRACT FROM AUTHOR]

Background and Aims: Communication is important in determining how patients understand the diagnostic process. Empirical studies involving direct observation of communication within diagnostic processes are relatively limited. This ethnographic study aimed to identify communicative practices facilitating or inhibiting shared understanding between patients and doctors in UK acute secondary care settings. Methods: Data were collected in acute medical sectors of three English hospitals. Researchers observed doctors as they assessed patients; semistructured interviews were undertaken with doctors and patients directly afterwards. Patients were also interviewed 2–4 weeks later. Case studies of individual encounters (consisting of these interviews and observational notes) were created, and were cross‐examined by an interdisciplinary team to identify divergence and convergence between doctors' and patients' narratives. These data were analysed thematically. Results: We conducted 228 h of observation, 24 doctor interviews, 32 patient interviews and 15 patient follow‐up interviews. Doctors varied in their communication. Patient diagnostic understanding was sometimes misaligned with that of their doctors; interviews revealed that they often made incorrect assumptions to make sense of the fragmented information received. Thematic analysis identified communicative practices that seemed to facilitate, or inhibit, shared diagnostic understanding between patient and doctor, revealing three themes: (1) communicating what has been understood from the medical record, (2) sharing the thought process and diagnostic reasoning and (3) closing the loop and discharge communication. Shared understanding was best fostered by clear communication about the diagnostic process, what had already been done and what was achievable in acute settings. Written information presents an underutilised tool in such communication. Conclusions: In UK acute secondary settings, the provision of more information about the diagnostic process often fostered shared understanding between doctor and patient, helping to minimise the confusion and dissatisfaction that can result from misaligned expectations or conclusions about the diagnosis, and the uncertainty therein. Patient/Public Contribution: A patient and public involvement group (of a range of ages and backgrounds) was consulted. They contributed to the design of the protocol, including the timing of interviews, the acceptability of a follow‐up telephone interview, the development of the interview guides and the participant information sheets. [ABSTRACT FROM AUTHOR]

Introduction: The impact of multiple health conditions on bowel cancer screening is currently unknown. We explored the impact of multiple health conditions on bowel cancer screening perceptions, experience and clinical management decisions following a positive stool test. Methods: Semi‐structured qualitative interviews were conducted remotely with Bowel Screening Wales staff (n = 16) stratified by regional location and role and with screening participants (n = 19) stratified by age, gender and comorbidity. Interview topics were guided by the Common‐Sense Model. Results: Screening participants, regardless of comorbidity status, placed great emphasis on the importance of early detection of cancer and completing the bowel screening process. Screening staff emphasised comorbidities in the clinical decision‐making process; however, screening participants had low awareness of the impact that comorbidities can have on bowel screening. Participants describe how the presence of multiple health conditions can mask potential bowel symptoms and influence beliefs about follow‐up. Conclusion: Bowel screening staff try to individualise the service to meet participant needs. The potential mismatch in screening staff and participant awareness and expectations of the bowel screening and diagnostic process needs to be addressed. Clearer and more regular communication with screening participants could support the screening process, particularly for those with significant coexisting health conditions or facing time delays. The possible masking effects and misattribution of symptoms because of comorbidities highlight an opportunity for education and raising awareness for screening participants and a potential area of focus for discussions in clinical consultations and staff training. Patient and Public Contribution: Project funding included costs for patients and public contributors to be compensated for their contributions to the project, in line with current standards. A patient and public contributor was involved in the design of the study, including protocol development, and the interpretation of key findings and implications for patients, which are subsequently reflected within the manuscript. [ABSTRACT FROM AUTHOR]

Background: The Baby Friendly Hospital Initiative (BFHI) was launched in 1991 as an intervention to support healthy infant feeding practices, but its global coverage remains around 10%. This study aimed to explore stakeholders' views of the Baby Friendly Initiative (BFI) programme, the barriers and facilitators to accreditation and its perceived impact. Methods: A mixed methods approach was used. An online survey was distributed through numerous professional networks from September 2020 to November 2020. Quantitative data were analyzed using descriptive statistics, with simple content analysis undertaken on open-ended responses. Individual semi-structured interviews were also undertaken and analyzed using inductive thematic analysis. Results: A total of 322 respondents completed the survey in part or in full, mainly from the United Kingdom. Fifteen key stakeholders and two maternity service users undertook interviews. Respondents were from various professional backgrounds and currently worked in different roles including direct care of women and their families, public health, education and those responsible for purchasing health services. Survey respondents viewed the BFI to have the greatest impact on breastfeeding initiation, duration, and infant health outcomes. Three overall themes were identified. The first was "BFI as an agent for change". Most participants perceived the need to implement the whole package, but views were mixed regarding its impact and the accreditation process. Secondly, BFI was regarded as only "one part of a jigsaw", with no single intervention viewed as adequate to address the complex cultural context and social and health inequities that impact breastfeeding. Finally, "cultural change and education" around breastfeeding were viewed as essential for women, staff and society. Conclusions: The BFI is not a magic bullet intervention. To create a more supportive breastfeeding environment within society a holistic approach is required. This includes social and cultural changes, increased education ideally starting at school age, and advancing positive messaging around breastfeeding within the media, as well as fully banning breastmilk substitute advertising. Although the BFI comprises a whole package, few survey respondents rated all aspects as equally important. Additional evidence for the effectiveness of each element and the importance of the whole package need to be established and communicated. [ABSTRACT FROM AUTHOR]

The Multi‐Action Plan (MAP) model presents an idiosyncratic framework for human performance. MAP research has categorised four Performance Types (PTs; T1–T4) using self‐paced activities. Specifically, T1–4 present four distinct mental states experienced by athletes during performance, differing, among other aspects, in the level of effort and perceived control. However, transitions between PTs are yet to be empirically investigated. This study aimed to examine MAP in the hyperdynamic open‐skill combat context of judo. We explored how judoka experienced PTs and the transition processes between these mental states. Six British, high‐level judoka (n = 6; Mdnage = 19) were interviewed using a retrospective semi‐structured interview schedule. Interpretative phenomenological analysis indicated that judo presents a hyperdynamic difficult‐to‐predict performance context due to the opponent and fighting rhythm. Second, participants strongly related to T2 and T3 and less to T1 and T4. They also reported experiences 'between' T2 and T3. Lastly, participants reported common transition pathways (e.g., T2–T3), typical transition cues, and specific trainable strategies to optimise performance. Findings are discussed in relation to existing literature. Lastly, we present limitations, applied, and research considerations. Highlights: The Multi‐Action Plan model presents four distinct mental states experienced by athletes during performance, differing, among other aspects, in the level of effort and perceived control.The study findings indicate that judo presents a complex and dynamic performance environment, in which judoka (judo practitioners) mostly experience effortful and controlled mental states.Judoka experience specific transitions and respective self‐regulatory processes between mental states during a fight, which can lead to optimal (upregulation) or suboptimal (downregulation) performance. [ABSTRACT FROM AUTHOR]

Background: The Deep End network in the North East and North Cumbria (NENC) was set up to tackle health inequalities in general practice. One aim is to address the inverse care law and improve recruitment of GPs, which is known to be especially challenging in areas of socioeconomic deprivation. Aim: To explore GP trainees’ experiences and perceptions of working in Deep End or Deprived Area Practices (DE/DAPs) to identify how GP recruitment can be improved. Design & setting: Qualitative study recruiting 13 doctors training to be GPs from the Northumbria training programme. Method: Audio-recorded, online, semi-structured interviews and discussion groups were undertaken, transcribed verbatim, and analysed with a grounded theory approach, using a process of thematic analysis. Results: Overall, seven interviews and two discussion groups (13 participants in total) were conducted. Three themes were identified. The first theme was working in areas of socioeconomic deprivation is challenging but has many advantages. The challenges of working in DE/DAPs were not deterring factors for GP trainees wanting to work in areas of socioeconomic deprivation. The second theme was trainees are willing to work in areas of socioeconomic deprivation but clinical experience is important. Training in DE/DAPs gives trainees the confidence to work in areas of deprivation. Familiarity with a practice also makes them more likely to stay post-training. The third theme was financial incentives are not an important attracting factor but support and development opportunities are. Non-pecuniary measures, such as clinical support and protected time for continuing professional development (CPD), were found to be important. Conclusion: To improve recruitment to DE/DAPs, investments should be made to increase the opportunities to train in these environments. This can be achieved by supporting more DE/DAPs to become training practices, and providing clinical support and protected time for CPD. [ABSTRACT FROM AUTHOR]

Background: Recent evidence suggests that anosognosia or unawareness of cognitive impairment in Alzheimer's Disease (AD) may be explained by a disconnection between brain regions involved in accessing and monitoring information regarding self and others. It has been demonstrated that AD patients with anosognosia have reduced connectivity within the default mode network (DMN) and that anosognosia in people with prodromal AD is positively associated with bilateral anterior cingulate cortex (ACC), suggesting a possible role of this region in mechanisms of awareness in the early phase of disease. We hypothesized that anosognosia in AD is associated with an imbalance between the activity of large-scale resting-state functional magnetic resonance imaging (fMRI) networks, in particular the DMN, the salience network (SN), and the frontoparietal network (FPN). Methods: Sixty patients with MCI and AD dementia underwent fMRI and neuropsychological assessment including the Anosognosia Questionnaire Dementia (AQ-D), a measure of anosognosia based on a discrepancy score between patient's and carer's judgments. After having applied Independent Component Analysis (ICA) to resting fMRI data we performed: (i) correlations between the AQ-D score and functional connectivity in the DMN, SN, and FPN, and (ii) comparisons between aware and unaware patients of the DMN, SN, and FPN functional connectivity. Results: We found that anosognosia was associated with (i) weak functional connectivity within the DMN, in posterior and middle cingulate cortex particularly, (ii) strong functional connectivity within the SN in ACC, and between the SN and basal ganglia, and (iii) a heterogenous effect concerning the functional connectivity of the FPN, with a weak connectivity between the FPN and PCC, and a strong connectivity between the FPN and ACC. The observed effects were controlled for differences in severity of cognitive impairment and age. Conclusion: Anosognosia in the AD continuum is associated with a dysregulation of the functional connectivity of three large-scale networks, namely the DMN, SN, and FPN. [ABSTRACT FROM AUTHOR]

Introduction: The Covid‐19 pandemic dramatically altered the way cancer care services were accessed and delivered, including for colorectal cancer (CRC). In the United Kingdom, patients were discouraged from presenting in primary care, many consultations took place remotely, investigative procedures and screening programmes were temporarily suspended, and fewer operations and treatments were delivered. People had to face the practical consequences of having cancer during a pandemic and navigate never before seen pathways, often alone. We examined the experience of being diagnosed and treated for CRC during the pandemic, and the implications of this on people's cancer journeys. Methods: Semi‐structured interviews were undertaken with people diagnosed with CRC during the Covid‐19 pandemic (January 2020–May 2021), in the North East of England. An iterative topic guide was used during interviews, which took place remotely (telephone or Zoom), were audio recorded, pseudo‐anonymised and transcribed. Initial transcripts were independently coded by two researchers, and a code 'bank' developed for application across transcripts. Development of themes and overarching analytical constructs was undertaken collaboratively by the research team. Results: Interviews were conducted with 19 participants, analysed and four key themes identified: (1) The relative threats of Covid‐19 and Cancer were not comparable, with cancer seen as posing a far greater risk than Covid‐19; (2) Remote consultations were problematic, affecting patients' abilities to build rapport and trust with clinicians, assess nonverbal communication, and feel able to disclose, comprehend and retain information; (3) Stoma follow‐up care was seen to be lacking, with long wait times for stoma reversal experienced by some; Finally, (4) Being alone during consultations negatively impacted some peoples' abilities to absorb information, and left them without the support of loved ones at an emotionally vulnerable time. However, some participants preferred being alone at certain points in their pathways, including receiving a diagnosis, and most frequently when receiving in‐patient treatment. Conclusion: Being alone brought unexpected benefits, absolving people from undertaking emotions work for others, and instead focus on their recovery, however, remote consultations negatively impacted patients' experiences. This study highlights the complex benefits and burdens of pandemic‐located cancer journeys, including how these shifted at different points across cancer pathways. Patient or Public Contribution: Lorraine Angell, a cancer survivor, has been central to this study from idea conception, contributing to: development of study focus and design; securing funding; production of patient‐facing materials; development of interview topic guides; analysis and interpretation of data; and drafting of key findings and manuscripts. [ABSTRACT FROM AUTHOR]

Introduction: Over a fifth of pregnant women are living with multiple long‐term health conditions, which is associated with increased risks of adverse outcomes for mothers and infants. While there are many examples of research exploring individuals' experiences and care pathways for pregnancy with a single health condition, evidence relating to multiple health conditions is limited. This study aimed to explore experiences and care of women with multiple long‐term health conditions around the time of pregnancy. Methods: Semistructured interviews were conducted between March 2022 and May 2023 with women with multiple long‐term health conditions who were at least 28 weeks pregnant or had had a baby in the last 2 years, and healthcare professionals with experience of caring for these women. Participants were recruited from across the United Kingdom. Data were analysed using thematic analysis. Results: Fifty‐seven women and 51 healthcare professionals participated. Five themes were identified. Women with long‐term health conditions and professionals recognised that it takes a team to avoid inconsistent care and communication, for example, medication management. Often, women were required to take a care navigation role to link up their healthcare providers. Women described mixed experiences regarding care for their multiple identities and the whole person. Postnatally, women and professionals recognised a downgrade in care, particularly for women's long‐term health conditions. Some professionals detailed the importance of engaging with women's knowledge, and recognising their own professional boundaries of expertise. Many participants described difficulties in providing informational continuity and subsequent impacts on care. Specifically, the setup of care systems made it difficult for everyone to access necessary information, especially when care involved multiple sites. Conclusion: Pregnant women with long‐term health conditions can experience a substantial burden of responsibility to maintain communication with their care team, often feeling vulnerable, patronised, and let down by a lack of acknowledgement of their expertise. These results will be used to inform the content of coproduction workshops aimed at developing a list of care recommendations for affected women. It will also inform future interventional studies aimed at improving outcomes for these women and their babies. Patient or Public Contribution: Our Patient and Public Involvement group were involved in the design of the study and the analysis and interpretation of the data, and a public study investigator was part of the author group. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to uncover perspectives on the COVID‐19 pandemic and the responses implemented by the UK and Scottish Governments to help control the spread of infection. Such understanding could help to inform future responses to pandemics at individual, community and national levels. Method: Q methodology was used to elicit perspectives from people in England and Scotland with different experiences of the pandemic including public health officials, key workers, those on furlough, those who were unvaccinated or vaccinated to different levels, those who were 'shielding' because they were at higher risk and people with different scientific expertise. Participants rank‐ordered phrases about different aspects of COVID‐19 according to their viewpoint. Factor analysis was then conducted in conjunction with interview material from the same respondents. Results: A four‐factor solution was statistically supported and was interpretable alongside the qualitative accounts of participants loading on these factors. These four perspectives are titled Dangerous and Unaccountable Leadership, Fear and Anger at Policy and Public responses, Governing Through a Crisis and Injustices Exposed. Conclusion: The four perspectives demonstrate plurality and nuance in views on COVID‐19 and the associated policies and restrictions, going beyond a binary narrative that has been apparent in popular and social media. The four perspectives include some areas of common ground, as well as disagreement. We argue that understanding the detail of different perspectives might be used to build cohesion around policy initiatives in future. Patient or Public Contribution: The development of the statement set, which is rank‐ordered by participants in a Q study, and factor interpretations were informed by views of the general public. The statement set was initially developed using existing publicly available material based on members of the general public experiencing the pandemic first hand. It was then piloted with members of the public experiencing different challenges as a result of COVID‐19 and the subsequent lockdown and updated based on feedback. Finally, interpretations of the identified factors were presented publicly and edited according to their feedback. [ABSTRACT FROM AUTHOR]

Background: Healthcare and support workers play a pivotal role in delivering quality services and support to people seeking sanctuary who have experienced poor physical and mental health linked to previous trauma, relocation and loss of freedoms. However, they often encounter various challenges in their daily work, ranging from communication barriers to resource constraints. This qualitative study seeks to delve into the perspectives of healthcare and support workers' experience of workarounds, employed to overcome barriers to providing care. Aim: This study aims to describe healthcare providers', practitioners' and health and third sector support workers' views on barriers and workarounds to providing care for people seeking sanctuary, to inform policy and practice. Design: A qualitative study was carried out using semi‐structured telephone interviews. Setting: This study focused on primary, secondary, community and specialist National Health Service (NHS) support services for people seeking sanctuary in Wales, United Kingdom (2018). Method: We interviewed 32 healthcare providers, practitioners and support workers employed by primary care and third sector organisations. Our approach involved obtaining verbal informed consent before digitally recording and transcribing all interviews. To analyse the data, we used the Four Levels of Change for Improving Quality model as a guiding framework for interpretation. Results: Our study findings reveal that certain respondents expressed challenges in meeting the needs of people seeking sanctuary; notably, their experience of delivering care differed by care settings. Specifically, those involved in providing specialist NHS care believed that there was room for improvement. Mainstream primary, secondary and community health practitioners faced limitations due to resource constraints and lacked tailored information to address the unique circumstances and needs of sanctuary seekers. To address these gaps, workarounds emerged at both individual and local levels (team/departmental and organisational level). These included establishing informal communication channels between providers, fostering cross service collaboration to fill gaps and adapting existing services to enhance accessibility. Conclusion: Understanding healthcare providers', practitioners' and support workers' perspectives offers invaluable insights into ways to enhance healthcare delivery to sanctuary seekers. Acknowledging challenges and harnessing innovative workarounds can foster a more effective and compassionate service for this vulnerable population. Patient or Public Contribution: The HEAR study actively involved public contributors in the design, delivery and dissemination of the research. Two public contributors (S. M. and G. R.) who had personal experience of seeking asylum served as study co‐applicants. They played pivotal roles in shaping the research by participating in its development and securing funding. Alongside other co‐applicants, S. M. and G. R. formed the Research Management Group, overseeing study delivery. Their contributions extended to strategic decision‐making and specific feedback at critical junctures, including participant recruitment, data collection, analysis and reporting. Additionally, S. M. and G. R. were instrumental in recruiting and supporting a team of peer researchers, enhancing respondent participation among people seeking sanctuary. To facilitate effective public involvement, we provided named contacts for support (A. K. and R. F.), research training, honoraria, reimbursement of expenses and accessible information in line with best practice. [ABSTRACT FROM AUTHOR]

Background: People living with human immunodeficiency virus (HIV) are disproportionately impacted by socioeconomic deprivation and are at increased risk of developing other long‐term conditions (LTCs). These illnesses require transformative action to tackle the adverse effects on their health. Data on lived experiences of LTCs among people living with HIV of Black African and Black Caribbean ethnicities are sparse, and how people with LTCs are impacted by social determinants of health (SDoH). Methods: Through a phenomenological study design this qualitative study, conducted in 2022, comprised four focus group discussions (FGDs) with 20 people of Black ethnicities living with HIV were purposively invited from a community organisation (CO) in London, including four semistructured interviews with CO staff. Following transcription, qualitative data were analysed thematically and measures to validate the findings were implemented. Results: The findings are presented in terms of the following four levels of SDoH: (1) individual determinants (such as the impact of SDoH on lifestyle modification and self‐management); (2) interpersonal determinants (such as positive experiences of accessing healthcare for LTCs); (3) clinical determinants (such as care pathway barriers) and (4) systemic determinants (such as systemic barriers related to race/ethnicity). Conclusions: It is necessary to provide ongoing and interactive education to community members who live with HIV, focusing on risks and management of LTCs. Additionally, individuals would benefit from support to navigate increasingly complex and fragmented health services. Health Service staff require cultural competence when caring for patients of Black African and Black Caribbean ethnicities with complex health and psychosocial needs. Patient or Public Contribution: The research team collaborated with an HIV CO in South London from the very start of the project to agree the study design and learn about the realities of their daily lived experiences. Community collaborators helped to develop the semistructured interview and FGD topic guides, and were directly involved in the data gathering, analysis and validation. [ABSTRACT FROM AUTHOR]

Background: There is a rising prevalence of type 2 diabetes among older people. This population also suffers from co-morbidity and a greater number of diabetes related complications, such as visual and cognitive impairment, which can potentially affect their ability to manage insulin regimens. Understanding the experiences of older people when they transition to insulin will help the development of healthcare interventions to enhance their diabetes outcomes, overall health and quality of life. Aims: The aims of this exploratory study were to (1) understand the experiences of older people with type 2 diabetes in relation to insulin treatment initiation and management and (2) use this understanding to consider how the insulin management support provided to older people by healthcare providers could be more tailored to their needs. Method: A qualitative study using semi structured (remote) interviews with older people with diabetes (n = 10) and caregivers (n = 4) from the UK. Interviews were audio recorded and transcribed, and framework analysis was used to analyse the data. Results: Three main themes, along with six subthemes, were generated from the study data. Participants generally felt at ease with insulin administration following training, yet some reported feelings of failure at transitioning to insulin use. Participants were also frustrated at what they perceived were insufficient resources for effective self-management, coupled with a lack of professional interest in optimising their health as older people. Some also expressed dissatisfaction regarding the brevity of their consultations, inconsistent information from different healthcare professionals and poor treatment coordination between primary and secondary care. Conclusion: Overall, the study emphasised that older people need better support, education and resources to help manage their insulin use. Healthcare professionals should be encouraged to adopt a more individualised approach to supporting older people that acknowledges their prior knowledge, physical and psychological capabilities and motivation for diabetes self-management. In addition, better communication between different services and greater access to specialist support is clearly needed for this older population. Practice implications: An integrated care pathway for insulin use in older people could be considered. This would include an assessment of the older person's needs and capacity on their initiation to insulin; targeted education and training in self-management; timely access to appropriate emotional and peer support resources; care plans developed collaboratively with patients; and individualised glucose targets that recognise the needs and preferences of the older person. [ABSTRACT FROM AUTHOR]

Background: Healthcare workers (HCWs) in the United Kingdom (UK) have faced many challenges during the COVID-19 pandemic, some of these arising out of their social positions. Existing literature explicating these challenges (e.g., lack of appropriate PPE, redeployment, understaffing) have highlighted inequities in how these have been experienced by HCWs based on ethnicity, gender or, job role. In this paper, we move a step ahead and examine how the intersection of these social positions have impacted HCWs' experiences of challenges during the pandemic. Methods: We collected qualitative data, using interviews and focus groups, from 164 HCWs from different ethnicities, gender, job roles, migration statuses, and regions in the United Kingdom (UK) between December 2020 and July 2021. Interviews and focus groups were conducted online or by telephone, and recorded with participants' permission. Recordings were transcribed and a hybrid thematic analytical approach integrating inductive data-driven codes with deductive ones informed by an intersectional framework was adopted to analyse the transcripts. Results: Thematic analysis of transcripts identified disempowerment, disadvantage and, discrimination as the three main themes around which HCWs' experiences of challenges were centred, based on their intersecting identities (e.g., ethnicity gender, and/or migration status). Our analysis also acknowledges that disadvantages faced by HCWs were linked to systemic and structural factors at the micro, meso and macro ecosystemic levels. This merging of analysis which is grounded in intersectionality and considers the ecosystemic levels has been termed as 'intrasectionalism'. Discussion: Our research demonstrates how an intrasectional lens can help better understand how different forms of mutually reinforcing inequities exist at all levels within the healthcare workforce and how these impact HCWs from certain backgrounds who face greater disadvantage, discrimination and disempowerment, particularly during times of crisis like the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Effective public health interventions rely on understanding how individuals access, interpret, and utilise health information. Studying the health information-seeking behaviour (HISB) of a community can provide valuable insights to inform strategies that address community health needs and challenges. This study explored the online HISBs of People of African Descent (PoAD) in the United Kingdom (UK), a demographic that comprises four percent of the UK population and has a 92.8% active Internet usage rate. Data on the HISB were collected from 21 PoAD across various UK regions through online semi-structured interviews before being analysed using reflexive Thematic Analysis (TA). The participants ranged in age from 20 to 70 years and had a mean age of 42.8 (SD ± 11.4). Our analysis of the interview transcripts revealed five key themes: Internet usage and preferences, attitudes toward social media, barriers to seeking health information online, trust in online health information, and cultural influences on online HISB. Our findings indicate a proactive engagement among PoAD in seeking health information online that is underscored by a preference for professional sources over ethnic congruence. However, concerns about misinformation exist, and there are barriers to accessing health information online, including data privacy, unreliable information, and information relevance and overload. We also found that cultural factors and traditional beliefs impact the adoption of Internet-based interventions among PoAD, highlighting the need for culturally sensitive approaches. Preferences regarding the frequency and delivery of online health information varied among participants, with a majority preferring a weekly update. This study emphasises the critical need for accessible, culturally appropriate, secure, and reliable online health resources tailored to the needs and preferences of the PoAD. [ABSTRACT FROM AUTHOR]

Background: The UK National Health Service (NHS) is one of the largest employers in the world and employs around 360,000 registered nurses. Following a protracted pay dispute in December 2022 NHS nurses engaged in industrial action resulting in the largest nurse strikes in the 74-year history of the NHS. Initially it appeared these strikes were a direct consequence of pay disputes but evidence suggests that the situation was more complex. This study aimed to explore what the key factors were in driving UK NHS nurses' decision to strike. Methods: A convergent parallel mixed methods design was used. The study was conducted throughout the UK and involved participants who were nurses working for the NHS who voted in favour of strike action. Data collection involved the use of an online survey completed by 468 nurses and 13 semi-structured interviews. Descriptive and inferential statistics were used for quantitative data analysis and a process of inductive thematic analysis for the qualitative data. The quantitative and qualitative data were analysed separately and then integrated to generate mixed methods inferences. Results: The quantitative findings showed that patient safety, followed by staff shortages, pay, and unmanageable work demands were the most important factors encouraging nurses' decision to strike. The qualitative findings served to further the understanding of these factors particularly in relation to participants' perception of the NHS and the consequences of inadequate pay and staff shortages. Three overarching and overlapping themes represented the qualitative findings: Save our NHS, Money talks, and It's untenable. Integration of the findings showed a high level of concordance between the two data sets and suggest that the factors involved are interconnected and inextricably linked. Conclusions: The UK NHS is a challenging and demanding work environment in which the well-being of its patients is dependent on the well-being of those who care for them. Concerns relating to patient welfare, the nursing profession and the NHS played a large part in driving UK NHS nurses' decision to strike. In order to address these concerns a focus on recruitment and retention of nurses in the NHS is needed. [ABSTRACT FROM AUTHOR]

Background: Despite vast levels of underreporting, sexual assault remains an issue at scale in the UK, necessitating the presence of statutory and voluntary organisations in the support of victims. Understanding the experiences of all parties within this context is important for the resilience of support that can be provided at a systems level. This study examines the barriers faced by service providers when working with victims of sexual assault. Methods: Semi-structured interviews took place with eleven professionals working in or in conjunction with a Sexual Assault Referral Centre (SARC) in Southeast England, which were subsequently analysed using inductive thematic analysis. Results: Five themes were identified exploring SARC staff's experiences with (i) communication breakdowns with external services; (ii) delivering support in an underfunded system; (iii) tailoring support to survivors' needs; (iv) the Criminal Justice System fails victims of sexual assault; and (v) reckoning with burnouts and vicarious trauma. Conclusion: Significant gaps in UK service provision for sexual assault victims are identified, particularly within the criminal justice system, where legal and investigative processes are cited as retraumatizing. The results emphasize the urgency of enhanced training, coordination, resources, and trauma-informed practices across organizations to better serve victims and support overwhelmed providers. Prioritizing systemic improvements is crucial to address the complex needs of both victims and service professionals. [ABSTRACT FROM AUTHOR]

Background: End-of-life (EoL) care volunteers in hospitals are a novel approach to support patients and their close ones. The iLIVE Volunteer Study supported hospital volunteer coordinators from five European countries to design and implement an EoL care volunteer service on general wards in their hospitals. This study aimed to identify and explore barriers and facilitators to the implementation of EoL care volunteer services in the five hospitals. Methods: Volunteer coordinators (VCs) from the Netherlands (NL), Norway (NO), Slovenia (SI), Spain (ES) and United Kingdom (UK) participated in a focus group interview and subsequent in-depth one-to-one interviews. A theory-inspired framework based on the five domains of the Consolidated Framework for Implementation Research (CFIR) was used for data collection and analysis. Results from the focus group were depicted in radar charts per hospital. Results: Barriers across all hospitals were the COVID-19 pandemic delaying the implementation process, and the lack of recognition of the added value of EoL care volunteers by hospital staff. Site-specific barriers were struggles with promoting the service in a highly structured setting with many stakeholders (NL), negative views among nurses on hospital volunteering (NL, NO), a lack of support from healthcare professionals and the management (SI, ES), and uncertainty about their role in implementation among VCs (ES). Site-specific facilitators were training of volunteers (NO, SI, NL), involving volunteers in promoting the service (NO), and education and awareness for healthcare professionals about the role and boundaries of volunteers (UK). Conclusion: Establishing a comprehensive EoL care volunteer service for patients in non-specialist palliative care wards involves multiple considerations including training, creating awareness and ensuring management support. Implementation requires involvement of stakeholders in a way that enables medical EoL care and volunteering to co-exist. Further research is needed to explore how trust and equal partnerships between volunteers and professional staff can be built and sustained. Trial registration: NCT04678310. Registered 21/12/2020. [ABSTRACT FROM AUTHOR]

Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and undertreated, resulting in reduced quality of life. The development of a standardised paediatric breakthrough pain assessment, based on healthcare professionals' insights, could improve patient outcomes. This study aimed to explore how healthcare professionals define and assess breakthrough pain in paediatric palliative care and their attitudes towards a validated paediatric breakthrough pain assessment. This was a descriptive qualitative interview study. Semi-structured interviews were conducted with 29 healthcare professionals working in paediatric palliative care across the UK. An inductive thematic analysis was conducted on the data. Five themes were generated: 'the elusive nature of breakthrough pain', 'breakthrough pain assessment', 'positive attitudes towards', 'reservations towards' and 'features to include in' a paediatric breakthrough pain assessment. The definition and assessment of breakthrough pain is inconsistent in paediatric palliative care. There is a clear need for a validated assessment questionnaire to improve assessment, diagnosis and management of breakthrough pain followed by increased healthcare professional education on the concept. [ABSTRACT FROM AUTHOR]

The EA-QOL questionnaire measures quality-of-life specifically for children born with esophageal atresia (EA) aged 8–18 and was completed in Sweden and Germany. This study aimed to describe an international collaborative initiative to establish a semantically equivalent linguistic version of the EA-QOL questionnaires in 12 new countries. The 24-item EA-QOL questionnaire was translated into the target languages and the translated questionnaire was evaluated through cognitive debriefing interviews with children with EA aged 8–18 and their parents in each new country. Participants rated an item as to whether an item was easy to understand and sensitive/uncomfortable to answer. They could choose not to reply to a non-applicable/problematic item and provide open comments. Data were analyzed using predefined psychometric criteria; item clarity ≥80%, item sensitive/uncomfortable to answer ≤20%, item feasibility(missing item responses ≤5%). Decision to improve any translation was made by native experts–patient stakeholders and the instrument developer. Like in Sweden and Germany, all items in the cross-cultural analysis of child self-report (ntot = 82, 4–10 children/country) met the criteria for item clarity in all 12 new countries, and in parent-report (ntot = 86, 5–10 parents/country) in 8/12 countries. All items fulfilled the criteria for sensitive/uncomfortable to answer (child-report 1.2–9.9%; parent-report 0–11.6%) and item feasibility. Poor translations were resolved. Hence, this study has established semantically equivalent linguistic versions of the EA-QOL questionnaire for use in children aged 8–18 with repair of EA in and across 14 countries. [ABSTRACT FROM AUTHOR]

Background: Healthcare systems are operating under substantial pressures, and often simply cannot provide the standard of care they aspire to within the available resources. Organisations, managers, and individual clinicians make constant adaptations in response to these pressures, which are typically improvised, highly variable and not coordinated across clinical teams. The purpose of this study was to identify and describe the types of everyday pressures experienced by surgical teams and the adaptive strategies they use to respond to these pressures. Methods: We conducted interviews with 20 senior multidisciplinary healthcare professionals from surgical teams in four major hospitals in the United Kingdom. The interviews explored the types of everyday pressures staff were experiencing, the strategies they use to adapt, and how these strategies might be taught to others. Results: The primary pressures described by senior clinicians in surgery were increased numbers and complexity of patients alongside shortages in staff, theatre space and post-surgical beds. These pressures led to more difficult working conditions (e.g. high workloads) and problems with system functioning such as patient flow and cancellation of lists. Strategies for responding to these pressures were categorised into increasing or flexing resources, controlling and prioritising patient demand and strategies for managing the workload (scheduling for efficiency, communication and coordination, leadership, and teamwork strategies). Conclusions: Teams are deploying a range of strategies and making adaptations to the way care is delivered. These findings could be used as the basis for training programmes for surgical teams to develop coordinated strategies for adapting under pressure and to assess the impact of different combinations of strategies on patient safety and surgical outcomes. [ABSTRACT FROM AUTHOR]

The last three census data highlighted that UK Bangladeshi communities have the worst health outcomes. This includes a higher risk of type two diabetes and heart diseases; both are risk factors for developing vascular dementia. However, little is known about Bangladeshi community members' understandings of dementia, including cultural myths. This paper focuses on the cultural myths, superstitions, and stigma surrounding dementia in an English Bangladeshi community from the direct experiences of people living with dementia, their caregivers, and the views of dementia service providers/stakeholders. This qualitative research was undertaken with three distinct participant groups using semistructured interviews (n = 25), who were recruited from community settings. The first and second participant groups explored the experiences of people with dementia (n = 10) and their family caregivers (n = 10). The third group examined stakeholders'/service providers' views (n = 5). Interviews were recorded digitally and transcribed verbatim. Findings were reached using an interpretive approach, emphasising the sense people make in their own lives and experiences and how they frame and understand dementia. The study revealed that participants with dementia and their caregivers have "alternative" knowledge about dementia and do not necessarily understand dementia in a Westernised scientific/biomedical context. Misconceptions about dementia and belief in various myths and superstitions can lead people to go to spiritual healers or practice traditional remedies rather than to their GPs, delaying their dementia diagnosis. This paper concludes that there is a lack of awareness among the Bangladeshi participants and a need for targeted awareness about dementia to help dispel cultural myths and combat the stigma surrounding dementia within the Bangladeshi community. [ABSTRACT FROM AUTHOR]

Background: Cognitive impairment is common in Parkinson's disease and is associated with poorer quality of life and increased caregiver distress, but little qualitative information is available on lived experiences of people with Parkinson's who also have cognitive impairment. Objectives: The aim of this study was to explore the challenges of cognitive impairment in Parkinson's, triangulating the perspectives of people with Parkinson's, caregivers and healthcare professionals. Methods: Semistructured interviews were conducted with 11 people with Parkinson's and cognitive impairment, 10 family caregivers and 27 healthcare professionals, using purposive sampling in the United Kingdom (2019–2021). Cognitive impairment was identified by healthcare professionals and required subjective symptoms. Relevant cognitive diagnoses were recorded. Interviews were audio‐recorded, transcribed and analysed using reflexive thematic analysis. Results: An overarching concept of the compound impact of cognitive and physical decline was developed, with six themes. Four themes describe the experience of living with cognitive impairment in Parkinson's: (1) Challenges in Daily Activities, (2) Psychological Impact and (3) Evolving Communication Difficulties together contributing to (4) Social Shift, encompassing a reduction in wider social activities but intensification of close relationships with increased dependence. A fifth theme (5) Living Well describes positive influences on these experiences, encompassing intrinsic motivation, self‐management strategies and supportive relationships. Furthermore, underlying and shaping the whole experience was the sixth theme: (6) Preconceptions about Cognitive Impairment, describing fear and denial of symptoms and poor understanding of the nature of cognitive impairment in Parkinson's, with differences to other dementia pathologies. Conclusions: Cognitive impairment superimposed on the existing challenges of Parkinson's has a multifaceted impact and makes living with the condition arduous. Increased understanding of the experiences of this group and employing the identified facilitators for living well may be able to improve patient and caregiver experiences. Patient or Public Contribution: Two people with Parkinson's and cognitive impairment and three caregivers contributed to the study. Between them they contributed throughout the entirety of the project, giving input at conceptualisation as well as advice and review of interview questions, participant information leaflets, recruitment, interpretation of findings and summaries of the project. [ABSTRACT FROM AUTHOR]

Introduction: Ethnic minority populations experience significant health and social care disparities; despite experiencing a greater burden of diseases, these groups are underrepresented in health and social care research. Consequently, related research can be less applicable to these population groups. The REPRESENT study aims to explore the health and social care experiences of ethnic minorities and other minoritised populations, their research interests and appropriate research practices. Methods: Focus groups and semistructured interviews were conducted between May and September 2022 with members of a number of ethnic minority communities in England. Data were audio recorded, transcribed and thematically coded using NVivo 12. Rigour was determined through extensive sampling, iterative data collection and analysis. Findings: Fifty‐two ethnic minority members were engaged in group interviews and one‐to‐one interviews. Participants included representatives of the following groups: African Caribbean, Eastern European, Gypsy Travellers, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual+, Refugee/Asylum Seekers, Somali and South Asian communities. Interviews were also conducted with ethnic minority healthcare providers and researchers. Three overarching categories were identified: health information, medical service experiences, health and social care concerns and health research. Health and social care services challenges were mostly attributed to discrimination, delayed services, poor cultural relevance and language and cultural barriers. The most influential information sources were local community organisations and word‐of‐mouth. The main health and social care concerns were chronic long‐term health conditions, mental health, maternal health and child development. Recommendations for research involved understanding the motivations for participation, improving communication and empowering communities. Top research priorities were long‐term health conditions, health promotion and education, early care interventions and understanding community needs. Interpretation: Discrimination and bias in health and social care provision have severe implications for worsening ethnic health inequalities. Healthcare commissioning authorities and policymakers can leverage the preference of ethnic minority groups for pharmacy services and community organisations to improve access to care. Improving research interest and engagement requires understanding individual community needs, community sensitivity, research relevance and cultural appropriateness. Patient or Public Contribution: Members of ethnic minority Patient and Public Involvement and Engagement group and Community Advisory Board supported the REPRESENT study design, conceptualisation and report development. [ABSTRACT FROM AUTHOR]

Introduction: People with vestibular disorders frequently experience reduced quality of life and challenges with activities of daily living. Anxiety, depression and cognitive problems often co‐present with vestibular disorders and can aggravate symptoms and prolong clinical recovery. We aimed to gain in‐depth insights into the impact of vestibular disorders and the contribution of psychological factors by exploring multistakeholder perspectives. Methods: Semistructured interviews were conducted between October 2021 and March 2022 with 47 participants in the United Kingdom including: 20 patients (age M = 50.45 ± 13.75; 15 females), nine family members (age M = 61.0 ± 14.10; four females), and 18 healthcare professionals. Data were analysed using framework analysis. Results: Vestibular disorders impact diverse aspects of patients' lives including work, household chores, socialising, and relationships with family and friends. Being unable to engage in valued activities or fulfil social roles contributes to feelings of grief and frustration, affecting identity, confidence, and autonomy. Anxiety and low mood contribute to negative thought processes, avoidance, and social withdrawal, which can impede clinical recovery through reduced activity levels, and end engagement with treatment. Coping strategies were thought to help empower patients to self‐manage their symptoms and regain a sense of control, but these require oversight from healthcare providers. Conclusions: Daily activity limitations, social participation restrictions, and psychological distress can interact to impact quality of life, sense of self, and clinical recovery amongst people with vestibular disorders. Information and resources could aid societal awareness of the impact of vestibular disorders and help patients and families feel understood. An individualised and comprehensive approach that concurrently addresses mental, physical, social, and occupational needs is likely to be beneficial. Patient or Public Contribution: Two group meetings were held at the beginning and end of the study with a patient and public involvement network formed of people with vestibular disorders and family members. These individuals commented on the study aims, interview schedule, participant recruitment practices, and interpretation of the themes identified. Two core patient members were involved at all stages of the research. These individuals contributed to the formulation of the interview schedule, development and application of the coding scheme, development and interpretation of themes, and preparation of the final manuscript. [ABSTRACT FROM AUTHOR]

Background: General practice in the UK is under substantial pressure and practices are increasingly including paramedics as part of their workforce. Little is known about how different models of paramedic working may affect successful implementation of the role, as viewed from patient, clinician and system perspectives. This realist synthesis developed theories about 'models of paramedic working in general practice' in different UK contexts to understand their impact. Methods: The rapid realist synthesis comprised data from: (1) empirical and grey literature searches; (2) semi-structured realist interviews with system leaders involved with the implementation of the role; and (3) a stakeholder event with healthcare professionals and the public, to develop initial programme theories that can be tested in future work. Sources were analysed using a realist approach that explored the data for novel or causal insights to generate initial programme theories. Results: Empirical sources (n = 32), grey sources (n = 95), transcripts from system leader interviews (n = 7) and audio summaries from the stakeholder event (n = 22 participants) were synthesised into a single narrative document. The findings confirmed the presence of a wide variety of models of paramedic working in UK general practice. The perceived success of models was influenced by the extent to which the paramedic service was mature and embedded in practice, and according to four theory areas: (1) Primary care staff understanding and acceptance of the paramedic role; (2) Paramedic induction process, including access to training, supervision and development opportunities; (3) Patient understanding and acceptance of the role; (4) Variations in paramedic employment models. Conclusions: Variability in how the paramedic role is operating and embedding into general practice across the UK affects the success of the role. These findings provide a theoretical foundation for future research to investigate various 'models of paramedic working' in different contexts. [ABSTRACT FROM AUTHOR]

Purpose: The Weight-Specific Adolescent Instrument for Economic Evaluation (WAItE) is a physical weight-specific patient reported outcome measure for use in adolescence. The purpose of this study was to use the Time Trade-Off (TTO) methodology, administered using an online interviewer-assisted remote survey, to obtain utility values for several health states from the WAItE descriptive system from a sample of the UK adult general population. Methods: The adult sample was gathered using a market research company and a sample of local residents. All participants completed the same interviewer-assisted remote survey, which included rating WAItE states of varying impairment using the TTO. Results: 42 adults completed the survey. Utility values were gathered for four health states, ranging from low impairment to the most severe health from the WAItE descriptive system (the Pits state). Consistent orderings of the WAItE health states were observed; the health state with the lowest level of impairment was valued highest and the Pits state was valued lowest. Several respondents (n = 7, 17%) considered the Pits state to be worse than death; however, the mean value of this health state was 0.23. Conclusions: The utility value of the Pits state relative to death generated from this study will be used to anchor latent values for WAItE health states generated from a Discrete Choice Experiment onto the 0 = death, 1 = full health Quality Adjusted Life Year (QALY) scale as part of a valuation study for the WAItE in the UK population. This study also provides further evidence that interviewer-assisted digital studies are feasible for collecting TTO data. [ABSTRACT FROM AUTHOR]

Introduction: Social Prescribing has an established recognition regarding the benefits provided to the health-related social needs of adults, but little is known about how the intervention addresses young people's needs. There is optimism regarding the central role of two core mechanisms that allows social prescribing to be effective, such as the empathetic role of Link Workers and the connection with community resources. This paper aims to describe the role played by Link Workers working a Social Prescribing intervention targeting young people. Description: This paper adopts a case study methodology to describe the role of Link Workers addressing young people's needs and implementing Social Prescribing scheme in Sheffield (UK). Data were collected through semi-structured interviews with four of the seven link workers of one organisation based in Sheffield. Data were analysed through an inductive approach for emerging themes. Discussion: We provided a description of the profiles and background of Link Workers and described the three models of referral pathways into the intervention. The paper also shows how Link Workers identify young people's needs and how they connect with the community. Conclusion: Based on the insights and the internationally accepted definition of Social Prescribing, we provide a visual representation of the Social Prescribing model and discuss challenges. The paper highlights lessons learned and future directions regarding the role of Link Workers from the case study. [ABSTRACT FROM AUTHOR]

Background: Mental ill-health in older adults (aged 60 years and over) is often underdiagnosed and undertreated. Older adults are less likely to access mental health services owing to perceived stigma and fear of being a burden. Non-traditional providers of health care, such as the Fire and Rescue Services (FRS), provide a possible solution to facilitate early detection of problems and help-seeking among older adults, especially in the context of pressured statutory services. Aim: To examine whether and how FRS Home Fire Safety Visits (HFSV) could be optimised to include detection and signposting for mental health problems -- particularly anxiety and depression -- in older adults. Design & setting: This mixed-method qualitative study took place in the West Midlands, UK in 2022. Method: This study involved focus groups (n = 24) and interviews with FRS staff (n = 4) to develop an in-depth contextual understanding of he acceptability and feasibility of expanding HFSV to include identification of anxiety and depression. Results: FRS staff were open to expanding their HFSVs to include mental health, provided they had sufficient training and support from partner agencies in primary and social care settings to accept referrals for service users presenting with symptoms of anxiety and/or depression. Conclusion: The positive reputation of FRS staff and engagement with older adults suggests that HFSV could support the detection of anxiety and depression in older adults, and appropriate signposting to other services including primary care. [ABSTRACT FROM AUTHOR]

Background. Following the dramatic impact of tyrosine kinase inhibitor (TKI) drugs on chronic myeloid leukaemia (CML) survival, research interest has grown into the long-term impact of treatment, identifying difficulties with medication adherence and ongoing side effects. Qualitative studies suggest the disease has a significant physical and psychological impact on patients, and medication management may be complex. However, only one study worldwide has examined healthcare practitioner (HCP) experiences of managing CML treatment and very little UK qualitative research exists exploring the patient experience. Purpose. Our qualitative study aimed to investigate both patient and HCP experiences of managing CML treatment in the UK. Methods. Patients and HCPs were purposively sampled from within the Haematological Malignancy Research Network (HMRN), a UK population-based patient cohort. Qualitative interviews were carried out with seventeen patients and thirteen HCPs, and data were analysed using thematic analysis. Results. Four themes were developed from interview analysis: "Importance of optimal clinical management," "Multiple adherence strategies," "Inconsistent management of adherence," and "Controlling side effects is complex." HCPs tended to focus on sometimes complex, clinical decision-making. Patients described various strategies to support adherence and manage side effects, some of which HCPs seemed to be less aware of. Several patients did not discuss non-adherence or side effects with their HCP, who tended to avoid direct enquiry regarding adherence and could be uncertain about adherence advice, whilst relying on medical strategies to manage side effects. Conclusions. Despite HCPs focusing on the medical management of CML treatment, patients may opt to use self-management techniques to control adherence and side effects and can be reluctant to discuss related difficulties. Increased clinic time and clear adherence advice guidance may support such discussion, in addition to adjusting the context of follow-up care through the introduction of shared care with GP services. [ABSTRACT FROM AUTHOR]

BACKGROUND: Multiple sclerosis (MS) is a chronic, progressive autoimmune inflammatory disorder. Its impact is felt not only by individuals but also by their families; however, little is known about the effect on their parents. This study of a cohort from the United Kingdom aimed to develop a conceptual understanding of the parental role and how it changes over time when an adult son or daughter has MS via firsthand accounts. METHODS: Twelve parents of adults with MS were recruited from a UK hospital providing outpatient services to people with MS and a branch of a national MS charity. A social constructivist grounded theory approach informed audio-recorded semistructured interviews and subsequent data analysis. RESULTS: In this sample, parents of adults with MS strove to limit the impact of MS on their son or daughter by undertaking practical caring activities and providing emotional support. The developed theoretical model illustrates how, in their efforts to meet this aim, parents experienced competing demands between prioritizing their child's needs and managing the effects on their life, between managing the emotional experience and protecting their child from the burden of their experience, and between an intensified instinct/desire to help while maintaining their child's independence. CONCLUSIONS: Findings indicate that parents may be uniquely affected by their adult son or daughter having MS, advocating for their inclusion in research and clinical interventions addressing family adjustment to MS. Further research is needed to ascertain the generalizability of these findings in comparable samples and to determine the impact of sociodemographic and cultural variables on the observed phenomena. [ABSTRACT FROM AUTHOR]

INTRODUCTION During the pandemic, smokers who wished to access support to quit faced additional barriers. A smoking cessation service which utilized pharmacist independent prescribers working within community pharmacy was implemented. Clients received behavioral advice via a consultation with an advisor and then three consultations with a pharmacist, who prescribed varenicline, where appropriate. Consultations were by phone or video. This evaluation assessed the self-reported outcomes and experiences of clients and pharmacists. METHODS A mixed-methods approach was used involving both on-line questionnaires to clients and interviews with a sample of questionnaire respondents and participating prescribing pharmacists. RESULTS The questionnaire was completed by 85 clients with 59% reporting they had quit. Eleven clients and seven out of eight pharmacists were interviewed. Varenicline had been received by 96% of clients. The best aspects of the service reported by clients in the questionnaire and at interview were support received from the pharmacist and ease of access to varenicline. Clients regarded the service as being 'safe' to access during the pandemic. Nearly three-quarters of client respondents (72%) stated no service improvements were required. However, national supply challenges made collection of varenicline from the nominated pharmacy an issue. Some clients experienced a long wait-time before accessing the service. For pharmacists, the service offered flexibility including the opportunity to contact clients 'out of office' hours without distractions. However, not being physically in the pharmacy could result in them not being able to access the client's medicine history. Pharmacists identified that remote consultations were not ideal for all clients. CONCLUSIONS Pharmacist prescribers can deliver effective smoking cessation services through remote consultations. Greater flexibility would allow the service to be tailored to the client's need. [ABSTRACT FROM AUTHOR]

Background: The Emergency Department (ED) is not always the optimal place for people with palliative care needs but is the most common route for treatment when urgent care is sought. The aim of this study,"REasons for PalLIative Care Admissions (REPLICA)' was to explore the perspectives of ED healthcare professionals of hospital admission or discharge via ED for palliative care patients. Methods: This is a sequential mixed methods study comprising (i) quantitative descriptive analysis of Hospital Episode Statistics (HES) of palliative care patients (code Z51.5) who were admitted through ED in a West Midlands Hospital and for the rest of England; (ii) in-depth semi-structured interviews with 17 ED staff which were analysed using thematic content analysis. Results: Over the four years (2013–2017), 430,116 people admitted through ED were identified with a Z51.5 diagnosis code, 0.6% (n = 2736) of whom were from the West Midlands Hospital. The most common reasons for palliative care patients' admission to hospitals across England were for care of chronic kidney disease, cancers and urinary tract infections. Five themes were elicited from the qualitative analysis: (1) Providing palliative care in ED is challenging, due to factors including lack of training in palliative care and the unsuitable environment. (2) Patients go to ED due to challenges in community management such as inappropriate referrals and no care plan in place. (3) Health system influences admission and discharge decisions, including bed availability and being unable to set up community services out-of-hours. (4) Discussion with patient about treatment and end of life care needs to be outside of ED whilst the patient is still well enough to express their wishes. (5) Improving services for patients with palliative care needs. Recommendations include short training sessions for ED staff and accessing palliative care professionals 24/7. Conclusions: A large number of palliative care patients visit ED and are admitted to hospital for care; there is an urgent need to prevent patients attending the hospital through the establishment of a coordinated and dedicated service to support palliative care patients in the community. [ABSTRACT FROM AUTHOR]

Background: The potential of the electronic health record to support safety netting has been recognised and a number of electronic safety-netting (E-SN) tools developed. Aim: To establish the most important features of E-SN tools. Design & setting: User-experience interviews followed by a Delphi study in a primary care setting in the UK. Method: The user-experience interviews were carried out remotely with primary care staff who had trialled the EMIS E-SN toolkit for suspected cancer. An electronic modified Delphi approach was used, with primary care staff involved in safety netting in any capacity, to measure consensus on tool features. Results: Thirteen user-experience interviews were carried out and features of E-SN tools seen as important formed the majority of the features included in the Delphi study. Three rounds of Delphi survey were administered. Sixteen responders (64%) completed all three rounds, and 28 out of 44 (64%) features reached consensus. Primary care staff preferred tools that were general in scope. Conclusion: Primary care staff indicated that tools that were not specific to cancer or any other disease, and had features that promoted their flexible, efficient, and integrated use, were important. However, when the important features were discussed with the patient and public involvement (PPI) group, they expressed disappointment that features they believed would make E-SN tools robust and provide a safety net that is difficult to fall through did not reach consensus. The successful adoption of E-SN tools will rely on an evidence base of their effectiveness. Efforts should be made to assess the impact of these tools on patient outcomes. [ABSTRACT FROM AUTHOR]

Background. Cognitive impairment is common in Parkinson's disease (PD) and associated with lower quality of life. Cognitive impairment in PD manifests differently to other dementia pathologies. Provision of optimal care requires knowledge about the support needs of this population. Methods. Eleven people with PD and cognitive impairment (PwP), 10 family caregivers, and 27 healthcare professionals were purposively sampled from across the United Kingdom. Semistructured interviews were conducted in 2019–2021, audio-recorded, transcribed, and analysed using reflexive thematic analysis. Results. Cognitive impairment in PD conveyed increased complexity for clinical management and healthcare interactions, the latter driven by multifactorial communication difficulties. Techniques that helped included slow, simple, and single messages, avoiding topic switching. Information and emotional support needs were often unmet, particularly for caregivers. Diagnostic pathways were inconsistent and awareness of cognitive impairment in PD was poor, both contributing to underdiagnosis. Many felt that PwP and cognitive impairment fell through service gaps, resulting from disjointed, nonspecific, and underresourced services. Personalised care was advocated through tailoring to individual needs of PwP and caregivers facilitated by flexibility, time and continuity within services, and supporting self-management. Conclusions. This study highlights unmet need for people with this complex condition. Clinicians should adapt their approach and communication techniques for this population and provide tailored information and support to both PwP and caregivers. Services need to be more streamlined and collaborative, providing more time and flexibility. There is a need for wider awareness and deeper understanding of this condition and its differences from other types of dementia. [ABSTRACT FROM AUTHOR]

Delayed discharge from hospital is a global healthcare problem with negative impacts on patient outcomes and the wider health system. Delays to discharge can arise when a patient remains in hospital even when they are medically fit due to nonmedical reasons such as a lack of appropriate housing or social care. However, whilst several nonmedical interventions have been developed to facilitate timely hospital discharge, there remains a lack of evidence on their impact. This study reports on findings from a mixed-methods process evaluation of a newly integrated housing and health service in two United Kingdom- (UK-) based hospitals (one mental health hospital and one general hospital). The service involved housing support coordinators (HSCs) being based within hospitals and supporting inpatients with their housing-related needs. We employed qualitative interviews with service users and hospital/housing staff (N = 16) and routine data analysis (n = 488) to understand the impact of the service and any challenges to service delivery. Service users faced different housing barriers, for example: 28.3% experienced homelessness (n = 136) whilst 80 (16.4%) faced challenges with their accommodation no longer meeting their physical needs. Service users received support for a variety of issues such as assistance with medical priority applications, support to apply for social housing, and referral to other support services. Healthcare professionals at all levels credit the service for improving hospital discharge processes and reducing stress on clinical staff, enabling them to concentrate more effectively on clinical tasks. Key to success is experienced housing staff providing patient-centred support, being integrated within a multidisciplinary team with management and oversight from the health service, and the availability of appropriate housing stock and wider services to support people after discharge. Our findings indicate that other hospitals may benefit from implementing similar housing and health integrated services. [ABSTRACT FROM AUTHOR]

Short breaks help maintain caring relationships, enabling people to remain living in their own homes and contributing significant economic benefit to public services. However, relatively little is known about the added social value generated by community-based short breaks. To address this evidence gap, we explored the feasibility of using a social return on investment (SROI) evaluation to explore a day support service in North Wales for people living with dementia and their unpaid carers. Following good practice for evaluating complex interventions, we developed a logic model based on the literature and interviews to understand the mechanisms and outcomes of the day support service. Using questionnaires, we quantified outcomes for the current service cohort, which included people living with dementia, unpaid carers, and paid companions. Seven people living with dementia, three unpaid carers, and four companions completed questionnaires. By following the SROI analysis approach, three key learning points were identified. The first was around ways to capture outcomes from all stakeholder subgroups expected to experience material change. The second concerned the importance of collecting longitudinal data. This included the need to consider how to adapt the SROI method to work with small populations. The third concerned how to value "maintenance" of wellbeing as well as improved wellbeing. [ABSTRACT FROM AUTHOR]

Research suggests that feedback in Emergency Medical Services (EMS) positively affects quality of care and professional development. However, the mechanisms by which feedback achieves its effects still need to be better understood across healthcare settings. This study aimed to understand how United Kingdom (UK) ambulance services provide feedback for EMS professionals and develop a programme theory of how feedback works within EMS, using a mixed-methods, realist evaluation framework. A national cross-sectional survey was conducted to identify feedback initiatives in UK ambulance services, followed by four in-depth case studies involving qualitative interviews and documentary analysis. We used qualitative content analysis and descriptive statistics to analyse survey responses from 40 prehospital feedback initiatives, alongside retroductive analysis of 17 interviews and six documents from case study sites. Feedback initiatives mainly provided individual patient outcome feedback through "pull" initiatives triggered by staff requests. Challenges related to information governance were identified. Our programme theory of feedback to EMS professionals encompassed context (healthcare professional and organisational characteristics), mechanisms (feedback and implementation characteristics, psychological reasoning) and outcomes (implementation, staff and service outcomes). This study suggests that most UK ambulance services use a range of feedback initiatives and provides 24 empirically based testable hypotheses for future research. [ABSTRACT FROM AUTHOR]

Background: Over the next two decades, the numbers of people who will need palliative care in the United Kingdom and Ireland is projected to increase. Hospices play a vital role supporting people who require specialist palliative care input through community-based and inpatient palliative care services. Evidence is needed to understand the role of these different services to inform future service development. Objectives: To describe the reasons for admission, and outcomes at the end of the stay, for patients admitted to two hospice inpatient units (IPUs). Design: This was a mixed-methods study using a convergent, parallel mixed-methods design. Methods: We reviewed the case notes of all patients admitted to two hospice inpatient units from July to November 2019; conducted semi-structured interviews with patients and families; as well as brief structured interviews with inpatient unit staff. Results: Two hundred fifty-nine patients were admitted to a hospice IPU, accounting for 276 admissions in total. Overall, 53% were female; median age was 71 years (range: 26–95 years). Most patients (95%) were White British or Scottish, and 95% had a cancer diagnosis. Most patients were admitted from the community, under one-third were admitted from hospital. Most (85%) had previous palliative care involvement. Nearly, half had district nurse support (48%). Worry and anxiety was frequently reported as a reason for admission, alongside physical concerns. Median length of stay was 12 days, and 68% died during their stay. Hospice was recorded as the preferred place of care for 56% of those who died there. Conclusions: Sustained efforts to promote the hospice as place of care for people with conditions other than cancer are needed alongside greater clarity regarding of the role of the hospice IPU, and who would benefit most from IPU support. [ABSTRACT FROM AUTHOR]

Background/Objective: As the health services were reorganized during the COVID-19 restricting access to family caregivers, we explored the experience of women in the perinatal period, attending a specialist perinatal mental health service. Methods: Patients (n = 38) in the outpatient list for review were assessed over phone based on a predesigned, semi-structured questionnaire, comprising both quantitative (demographic, clinical variables) and qualitative open-ended questions regarding their experience of services during COVID-19. Results: The responses provided insight into how the pandemic affected the experience of pregnancy of mentally ill women and the impact of changes in perinatal mental health services. The main concerns centered around reduced support from close family members during the perinatal period due to the lockdown, anxiety regarding COVID transmission, absence of a supporting persons in antenatal clinics, difficulty accessing support from midwives, and health visitors as well as the use of virtual clinics for mental health consultations. Conclusions: The results suggested possible methods of improving perinatal mental health support during challenging times, which included ensuring in-person consultations, access to family even remotely, increasing accessibility through alternative means; providing and close monitoring of additional psychosocial support when needed. [ABSTRACT FROM AUTHOR]

Background: Autistic children and adolescents are 40–80% more likely to experience sleep disturbances than their neurotypical peers. In the United Kingdom, melatonin is licensed for short-term usage in adults at age 55 years and above; however, it is often prescribed to autistic children and adolescents to help manage their sleep. The current study sought to understand parental experiences and their motivation of using melatonin to manage sleep disturbances of their autistic children. Methods: The sample included 26 parents who took part in online focus groups answering questions regarding their experiences of using melatonin as a sleep treatment for their children diagnosed with autism between 4 and 18 years old. Results: Four main themes were identified: (i) parental perception of melatonin used as 'a naturally produced hormone'; (ii) perceived benefits of using melatonin to improve their child's sleep; (iii) administration of melatonin: dosage amount, timing and pulverising; and (iv) expectation and apprehension over melatonin use. Conclusion: Some parents reported success with the use of melatonin, and others reported the effects being limited or diminishing in time. Suggestions for healthcare professionals and families regarding melatonin usage in the UK are made with respect to setting clear guidelines for usage, whilst ensuring expectations are set and managed appropriately. [ABSTRACT FROM AUTHOR]

Background: People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context. Methods: We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically. Results: Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers. Conclusions: The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care. Trial registration: This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687. [ABSTRACT FROM AUTHOR]

Background: Electronic templates are frequently used in long-term condition (LTC) reviews (for example, asthma) to act as reminders and improve documentation; however, they can restrict patient-centred care and opportunities for patients to discuss concerns and self-management. Aim: The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) programme aimed to develop a patient-centred asthma review template that encourages supported self-management. Design & setting: This was a mixed-methods study, which integrated qualitative and systematic review data, primary care Professional Advisory Group feedback, and qualitative data from clinician interviews. Method: Aligned with the Medical Research Council complex intervention framework, a template was developed in the following three phases: (1) development phase, which consisted of a qualitative exploration with clinicians and patients, a systematic review, and prototype template development; (2) feasibility pilot phase, which involved feedback from clinicians (n = 7); and (3) pre-piloting phase, which consisted of delivering the template within the IMP2ART implementation strategy (incorporating the template with patient and professional resources) and eliciting clinician feedback (n = 6). Results: Template development was guided by the preliminary qualitative work and the systematic review. A prototype template was developed with an opening question to establish patient agendas, and a closing prompt to confirm agendas have been addressed and an asthma action plan provided. The feasibility pilot identified refinements needed, including focusing the opening question on asthma. Pre-piloting ensured integration with the IMP2ART strategy. Conclusion: Following the multi-stage development process, the implementation strategy, including the asthma review template, is now being tested in a cluster randomised controlled trial. [ABSTRACT FROM AUTHOR]

Background: Despite a growing drive to improve diversity in medical schools, those from state schools and less-advantaged sociodemographic backgrounds remain underrepresented. We explore applicants' approaches to preparing for medical school selection, considering the complexity of sociodemographic disadvantage in this highly competitive process. Methods: Narrative interviews were undertaken with applicants to a United Kingdom medical school, exploring experiences of preparation for selection (n = 23). Participants were purposively sampled based on involvement in widening participation schemes, school background, gender, and ethnicity. Transcribed data were analyzed using Labov and Waletzky's analytic framework. Bourdieu's concepts of cultural capital and habitus provided a lens to constraints faced and variable experiences. This informed a consideration of the ways applicants approached and navigated their preparation, in the face of various constraints. Results: Constraints to resources and support were often apparent for those from state nonselective (SNS) schools. These applicants and those beginning their preparation later (12-18 months before application) appeared particularly vulnerable to myths and misunderstandings about the application process and appeared less confident and less discerning in their navigation of preparation. Some of the applicants, particularly those from independent and state selective schools, appeared confident and competent in navigating the complexities of the application process, while others (often from SNS schools) were more frequently lost or stressed by the process. Discussion: Those who lack particular preparatory tools or resources (materially, culturally, or perceptually) must "make do" as they prepare for medical school selection, In doing so, they may risk a haphazard, ill-informed or ill-equipped approach. Constraints to opportunities, more typically experienced by those from SNS schools, appeared to motivate the process of bricolage for a number of the applicants. Perversely, medical schools have introduced nonacademic requirements to level the playing field of disadvantage, yet applicants in this group appear to experience challenges as they prepare for selection. [ABSTRACT FROM AUTHOR]

There is increasing research interest in the experiences of new fathers taking paternity leave, but less insight into men's experiences of returning to work after the birth of their first baby. For many men in the UK context, this could take place immediately after the birth or after one or two weeks of paternity leave. This paper utilizes data from a UK-based study whilst also drawing on international literature and policy contexts. A constructivist grounded theory method was adopted to generate theory from the data gathered. Twelve new fathers shared their experiences in this study by participating in audio-recorded, semi-structured interviews. This paper focuses on fathers' experiences of negotiating the workplace as part of an overall theoretical framework related to broader transitions to fatherhood and sheds light on the distress, guilt and psychological challenges that the participants experienced when they initially returned to work. Whether fathers did or did not explicitly describe distress at this time, they all described a change in their worker identity, which for some participants led to uncertainty in the workplace. Men returning to work at this time in the postnatal period are vulnerable to experiencing distress. Flexibility and support in the workplace could be protective of their mental health. Finally, policy and practice developments are offered to support men's transitions to fatherhood in the workplace context. [ABSTRACT FROM AUTHOR]