Search

Objective: The purpose of this study is to identify clinical and organisational quality indicators conducive to the optimal interdisciplinary management of acute-phase ischaemic stroke., Method: A scoping review based on the six-step methodological framework of Arksey and O'Malley (2005) was conducted including a Delphi process with an experts committee., Data Sources: MEDLINE, CINAHL, Academic search complete, Cochrane Library databases, in addition to Google Scholar and Google were searched through January 2015 to February 2023., Eligibility Criteria: French and English references, dealing with clinical and organisational indicators for the management and optimal care of adults with acute ischaemic stroke., Data Extraction and Synthesis: After duplicate removal, all publications were checked for title and abstract. The full text of articles meeting the inclusion criteria was reviewed. Two independent reviewers performed 10% of the study selection and data extraction. Data collected underwent descriptive statistics., Results: Of the 4343 references identified, 31 were included in the scoping review. About 360 indicators were identified and preliminary screened by two stroke experts. Fifty-four indicators were evaluated for validity, relevance and feasibility by a committee of experts including a partner patient using a Delphi method. A total of 34 indicators were selected and classified based on dimensions of care performance such as accessibility of services, quality of care and resource optimisation. Safety accounted for about one-third of the indicators, while there were few indicators for sustainability, equity of access and responsiveness., Conclusion: This scoping review shows there are many clinical and organisational indicators in the literature that are relevant, valid and feasible for improving the quality of care in the acute phase of ischaemic stroke. Future research is essential to highlight clinical and organisational practices in the acute phase., Registration Details: https://osf.io/qc4mk/., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To understand and report on the direct-to-consumer virtual care industry in Canada, focusing on how companies collect, use and value patient data., Design: Qualitative study using situational analysis methodology., Setting: Canadian for-profit virtual care industry., Participants: 18 individuals employed by or affiliated with the Canadian virtual care industry., Methods: Semistructured interviews were conducted between October 2021 and January 2022 and publicly available documents on websites of commercial virtual care platforms were retrieved. Analysis was informed by situational analysis, a constructivist grounded theory methodology, with a continuous and iterative process of data collection and analysis; theoretical sampling and creation of theoretical concepts to explain findings., Results: Participants described how companies in the virtual care industry highly valued patient data. Companies used data collected as patients accessed virtual care platforms and registered for services to generate revenue, often by marketing other products and services. In some cases, virtual care companies were funded by pharmaceutical companies to analyse data collected when patients interacted with a healthcare provider and adjust care pathways with the goal of increasing uptake of a drug or vaccine. Participants described these business practices as expected and appropriate, but some were concerned about patient privacy, industry influence over care and risks to marginalised communities. They described how patients may have agreed to these uses of their data because of high levels of trust in the Canadian health system, problematic consent processes and a lack of other options for care., Conclusions: Patients, healthcare providers and policy-makers should be aware that the direct-to-consumer virtual care industry in Canada highly values patient data and appears to view data as a revenue stream. The industry's data handling practices of this sensitive information, in the context of providing a health service, have implications for patient privacy, autonomy and quality of care., Competing Interests: Competing interests: The authors do not have financial conflicts of interest with relevant non-profit or for-profit entities to report. SS is an unpaid member of a Scientific Advisory Committee for a non-profit research network and data repository affiliated with her academic institution., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Although the sustainability of the health workforce has been identified as essential to achieving health and wider development objectives, challenges with securing and retaining the healthcare workforce persist. In the UK, there are notable shortages across a wide range of National Health Service (NHS) staff groups, with a high staff turnover indicating retention issues in the healthcare workforce. In addition, gaps exist in understanding the root cause of individual organisation's workforce deficiencies and how their practice environment factors interact to impact workforce recruitment and retention., Methods and Analysis: An exploratory mixed-methods approach will be conducted to investigate the impact of organisational practice environment factors on healthcare workforce recruitment and retention in two Integrated Care Systems (ICS) in the East of England. We will conduct an online survey of newly qualified and established nurses and allied health professionals using a questionnaire adapted from two validated instruments. Our calculation suggests a sample size of 373 participants, we will aim to surpass this in our recruitment to strengthen the statistical analyses. Multilevel linear regression models will be fitted to evaluate the association between organisational practice environmental factors and staff recruitment and retention. The qualitative interviews will explore the experiences and perspectives of staff and senior leaders to explain the survey results and any significant associations therein. Also, the interviews will explore how to strengthen the partnership between higher education institutions, Health Education England, health and care service providers, NHS nursing and allied health professional staff to enhance recruiting and retaining staff. An exploratory inductive coding and analysis will follow Braun and Clarke's recommendations to generate key themes from transcribed interview data., Ethics and Dissemination: Ethical approval has been obtained through the University of Suffolk Research Ethics Committee (approval number: RETH(S)22/051). Findings from our work will be disseminated through publications in peer-reviewed journals; presentations at stakeholders' events, professional and academic conferences; and short reports for stakeholders, including participating ICSs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: This article presents the study design of the qualitative part of the VersKiK study (Long-term care, care needs and wellbeing of individuals after cancer in childhood or adolescence: study protocol of a large scale multi-methods non-interventional study) aiming to explore actual follow-up needs of childhood and adolescence cancer survivors and their informal caregivers, gaps in current follow-up care provision and trajectories of cancer survivors' transition from paediatric to adult healthcare., Methods and Analysis: We will conduct up to 30 interviews with survivors of childhood and adolescence cancer and their informal caregivers with up to 20 participant observations of follow-up appointments. The results of these will be discussed in up to four focus groups with healthcare professionals and representatives of self-help groups. The study design aims to evaluate follow-up care after childhood cancer considering perspectives from survivors, their informal caregivers as well as healthcare providers. The combination of different data sources will allow us to get an in-depth understanding of the current state of follow-up care after paediatric cancer in Germany and to suggest recommendations for care improvement., Ethics and Dissemination: The VersKiK study was approved by the Ethics Committee Otto von Guericke University on 2 July 2021 (103/21), by the Ethics Committee of Johannes Gutenberg University Mainz on 16 June 2021 (2021-16035), by the Ethics Committee University of Lübeck on 10 November 2021 (21-451), by the Ethics Committee University of Hospital Bonn on 28 February 2022 (05/22). For each part of the qualitative study, a separate written informed consent is prepared and approved accordingly by the ethics committees named above., Trial Registration Number: Registered at German Clinical Trial Register, ID: DRKS00026092., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess the effect of an integrated intervention package compared with routine government health services on the frequency of health facility births., Setting: Three subcounties of Lira district in Northern Uganda., Design: A cluster randomised controlled trial where a total of 30 clusters were randomised in a ratio of 1:1 to intervention or standard of care., Participants: Pregnant women at ≥28 weeks of gestation., Interventions: Participants in the intervention arm received an integrated intervention package of peer support, mobile phone messaging and birthing kits during pregnancy while those in the control arm received routine government health services ('standard of care')., Primary and Secondary Outcome Measures: The primary outcome was the proportion of women giving birth at a health facility in the intervention arm compared with the control arm. Secondary outcomes were perinatal and neonatal deaths., Results: In 2018-2019, 995 pregnant women were included in 15 intervention clusters and 882 in 15 control clusters. The primary outcome was ascertained for all except one participant who died before childbirth. In the intervention arm, 754/994 participants (76%) gave birth at a health facility compared with 500/882 (57%) in the control arm. Participants in the intervention arm were 35% more likely to give birth at a health facility compared with participants in the control arm, (risk ratio 1.35 (95% CI 1.20 to 1.51)) and (risk difference 0.20 (95% CI 0.13 to 0.27)). Adjusting for baseline differences generated similar results. There was no difference in secondary outcomes (perinatal or neonatal mortality or number of postnatal visits) between arms., Conclusion: The intervention was successful in increasing the proportion of facility-based births but did not reduce perinatal or neonatal mortality., Trial Registration Number: NCT02605369., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The qualities of primary healthcare (PHC) make it a very relevant environment for research; however, there is still work to be done to enhance the research capabilities of family physicians in healthcare units. Considering there is no ongoing review that specifically addresses this objective, the proposed goal of this scoping review is to determine the depth of the literature on the current strategies that support research capacity building among family physicians in the context of PHC., Methods and Analysis: The scoping review will include studies from PubMed, Scopus, Web of Science, Cochrane Library and grey literature, published from 2008 to 2023, that address strategies to promote research capacity building among family physicians in the context of PHC. Only studies published in English, Portuguese or Spanish will be considered. All study designs, including quantitative, qualitative and mixed-methods studies, will be eligible for inclusion. The literature search will be performed from January to March of 2024 and data charting will employ a descriptive-analytical method, systematically summarising study objectives, methodologies, findings and implications. This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols and the review will employ the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews., Ethics and Dissemination: This review does not need ethical approval. Peer-reviewed publications, policy summaries, presentations at conferences and involvement with pertinent stakeholders are all part of our outreach approach., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: During the COVID-19 pandemic, hospital capacity was strained. Home-based care could relieve the hospital care system and improve patient well-being if safely organised.We designed an intervention embedded in a regional collaborative healthcare network for the home-based management of acutely ill COVID-19 patients requiring oxygen treatment. Here, we describe the design and pilot protocol for the evaluation of the feasibility of this complex intervention., Methods and Analysis: Following a participatory action research approach, the intervention was designed in four consecutive steps: (1) literature review and establishment of an expert panel; (2) concept design of essential intervention building blocks (acute medical care, acute nursing care, remote monitoring, equipment and technology, organisation and logistics); (3) safety assessments (prospective risk analysis and a simulation patient evaluation) and (4) description of the design of the pilot (feasibility) study aimed at including approximately 15-30 patients, sufficient for fine-tuning for a large-scale randomised intervention., Ethics and Dissemination: All patients will provide written, informed consent. The study was approved by the Medical Ethics Review Committee of the University Medical Center Utrecht, the Netherlands (protocol NL77421.041.21). The preparatory steps (1-4) needed to perform the pilot are executed and described in this paper. The findings of the pilot will be published in academic journals. If we consider the complex intervention feasible, we aim to continue with a large-scale randomised controlled study evaluating the clinical effectiveness, safety and implementation of the complex intervention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study examined the association between travel distance to the general practitioner's (GP) office and no face-to-face GP consultation within 1 year before an incident acute myocardial infarction (AMI)., Design: A prospective cohort study using multilevel spatial logistic regression analysis of nationwide register data., Setting: Nationwide study including contacts to GPs in Denmark prior to an incident AMI in 2005-2017., Participants: 121 232 adults (≥30 years) with incident AMI were included in the study., Primary and Secondary Outcomes Measures: The primary outcome was odds of not having a face-to-face GP consultation within 1 year before an incident AMI., Results: In total, 13 108 (10.8%) of the 121 232 individuals with incident AMI had no face-to-face consultation with the GP within 1 year before the AMI. Population density modified the association between travel distance and no face-to-face GP consultation. Increased odds of no face-to-face GP consultation was observed for medium (25th-75th percentile/1123-5449 m) and long (>75th percentile/5449 m) compared with short travel distance (<25th percentile/1123 m) among individuals living in small cities (OR (95% credible intervals) of 1.19 (1.10 to 1.29) and 1.19 (1.06 to 1.33), respectively) and rural areas (1.46 (1.26 to 1.68) and 1.48 (1.29 to 1.68), respectively). No association was observed for individuals living in large cities and the capital., Conclusions: Travel distance above approximately 1 km was significantly associated with no face-to-face GP consultation before an incident AMI among individuals living in small cities and rural areas. The structure of the healthcare system should consider the importance of geographical distance between citizens and the GP in remote areas., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: RE-TELL is a qualitative study, which aims to understand patient, support person, clinician and coordinator experiences and perspectives of chimeric antigen receptor (CAR) T-cell therapy, to inform design of a clinical CAR T-cell service in Aotearoa New Zealand., Design: Semistructured qualitative interviews focused on domains of: experience through treatment, elements that work well and those that could be improved on. Interviews used thematic analysis to identify key themes. A workshop was held to obtain participants' reflections on interim analysis and proposed improvements., Participants: New Zealanders with experience of CAR T-cell therapy, including recipients, support persons, clinicians and coordinators., Results: We interviewed 19 participants comprising 5 CAR T-cell recipients, 3 support persons, 6 clinicians and 5 coordinators. Four participants identified as Māori. Thematic analysis identified three global themes. The first, 'sociocultural factors impact CAR T access', identified potential sources of inequity including geographic, financial and informed consent barriers. The second, 'varying emotions, roles and enablers', identified an easier treatment experience compared with alternatives; an underwhelming cell administration process; frustration with inpatient monitoring; burden on support persons and importance of 'bridge' organisations such as charities and patient support groups. Lastly, 'golden opportunities: reimagining CAR T service delivery', suggested: improved geographical access to CAR T-cell therapy, while retaining consolidated clinician experience; a 'dashboard' with information on CAR T-cell treatment, time frames and manufacture; a health navigator to co-ordinate non-medical aspects of treatment and signpost care; embedding of indigenous data sovereignty and ownership of cells; a cell infusion ceremony, incorporating family involvement and Māori cultural elements and outpatient administration and monitoring where possible., Conclusion: This study documented the current experience of New Zealanders receiving CAR T-cell therapy and identified opportunities for future service development. These insights are relevant to service design within Aotearoa New Zealand, and other countries developing equitable CAR T-cell services., Competing Interests: Competing interests: RF, RW and DOS are employees of the Malaghan Institute of Medical Research, which received funding from Janssen-Cilag towards the cost of this research. OA, KK and MJ are employees of Deloitte, which received funding from Janssen-Cilag through a contract for services. Janssen-Cilag had no involvement in the conduct of the research, data collection, data analysis or in preparation or approval of the manuscript., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Access to comprehensive abortion care could prevent the death of between 13 865 and 38 940 women and the associated morbidity of 5 million women worldwide. There have been some important improvements in Latin America in terms of laws and policies on abortion. However, the predominant environment is still restrictive, and many women, adolescents and girls still face multiple barriers to exercise their reproductive rights. This research will systematically assess comprehensive abortion policies in five Latin American countries (Argentina, Colombia, Honduras, Mexico and Uruguay). The aim is to identify barriers, facilitators and strategies to the implementation of abortion policies, looking at four key dimensions-regulatory framework, abortion policy dynamics, abortion service delivery and health system and health outcomes indicators-to draw cross-cutting lessons learnt to improve current implementation and inform future safe abortion policy development., Methods and Analysis: A mixed-method design will be used in the five countries to address the four dimensions through the Availability, Accessibility, Acceptability and Quality of Care model. The data collection tools include desk reviews and semi-structured interviews with key actors. Analysis will be performed using thematic analysis and stakeholder analysis. A regional synthesis exercise will be conducted to draw lessons on barriers, facilitators and the strategies., Ethics and Dissemination: The project has been approved by the WHO Research Ethics Review Committee (ID: A66023) and by the local research ethics committees. Informed consent will be obtained from participants. Data will be treated with careful attention to protecting privacy and confidentiality. Findings from the study will be disseminated through a multipurpose strategy to target diverse audiences to foster the use of the study findings to inform the public debate agenda and policy implementation at national level. The strategy will include academic, advocacy and policy arenas and actors, including peer-reviewed publication and national and regional dissemination workshops., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Sexual violence (SV) is highly prevalent among university campuses across the globe, despite of several initiatives implemented to address it. Several studies have been published focusing on various aspects of SV on campuses. However, no review has been retrieved from the Joanna Briggs Institute (JBI) Database, Cochrane Library or Ovid examining evidence synthesis on prevalence, risk factors, victims and perpetrators, policies, laws and universities responses to SV in sub-Saharan Africa (SSA). This review aims to map the existing literature on SV victimisation among university students in SSA, related response strategies, and identify gaps in the evidence., Methods and Analysis: This review will follow JBI guidelines and will be conducted from 1 July 2023 to 31 December 2023. A team of five reviewers will screen eligible documents and articles for relevance from various data sources including electronic databases such as MEDLINE, EMBASE, PsycINFO, CINAHL, Google Scholar, PubMed and websites for government and agencies. Standard information for each study will be collected and a common analytical framework for all the primary documents will be conducted., Ethics and Dissemination: This review will involve analysis of published data only and therefore does not require ethics approval. The results will be published in a peer-reviewed journal., Registration: This review has been registered with the Open Science Framework., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Patient mental state deterioration impacts patient outcomes, staff and increases costs for healthcare organisations. Mental state is broadly defined to include not only mental health but a broad range of cognitive, emotional and psychological well-being factors. Mental state deterioration is inconsistently identified and managed within acute and tertiary medical settings. This protocol aims to synthesise the evidence to test and refine initial programme theories that outline the functioning of a rapid response system., Methods and Analysis: This synthesis will be guided by Pawson's key steps in realist reviews. We will clarify the scope of synthesis through an initial literature search, focusing on understanding the functioning of rapid response system in managing patients presenting with mental state deterioration in acute hospital settings. Initial programme theories will be refined by developing a search strategy to comprehensively search electronic databases for relevant English language peer-reviewed studies. Additionally, we will search the grey literature for sources to supplement theory testing. An abstraction form will be developed to record the characteristics of literature sources. We will use spreadsheets to code and report contextual factors, underlying mechanisms, and outcome configurations., Ethics and Dissemination: As this study is a realist synthesis protocol, ethics approval is not required. Synthesis findings will be published in a peer-reviewed journal and presented at scientific conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The process of transitioning young people from children's or adolescents' health services into adults' services is a crucial time in the lives and health of young people and has been reported to be disjointed rather than a process of preparation in which they are involved. Such transitions not only fail to meet the needs of young people and families at this time of significant change, but they may also result in a deterioration in health, or disengagement with services, which can have deleterious long-term consequences. Despite the wealth of literature on this topic, there has yet to be a focus on what works for whom, in what circumstances, how and why, in relation to all young people transitioning from children's into adults' services, which this realist synthesis aims to address., Methods and Analysis: This realist synthesis will be undertaken in six stages: (1) the scope of the review will be defined; (2) initial programme theories (IPTs) developed; (3) evidence searched; (4) selection and appraisal; (5) data extraction and synthesis; and (6) finally, refine/confirm programme theory. A theory-driven, iterative approach using the 'On Your Own Feet Ahead' theoretical framework, will be combined with an evidence search including a review of national transition policy documents, supplemented by citation tracking, snowballing and stakeholder feedback to develop IPTs. Searches of EMBASE, EMCARE, Medline, CINAHL, Cochrane Library, Web of Science, Scopus, APA PsycINFO and AMED will be conducted from 2014 to present, supplemented with grey literature, free-text searching (title, abstract and keywords) and citation tracking. Data selection will be based on relevance and rigour and extracted and synthesised iteratively with the aim of identifying and exploring causal links between contexts, mechanisms and outcomes. Results will be reported according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards Quality and Publication Standards., Ethics and Dissemination: This realist synthesis forms part of the National Transition Evaluation Study, which has received ethical and regulatory approval (IRAS ID: 313576). Results will be disseminated through peer-review publication, conference presentations and working with healthcare organisations, stakeholder groups and charities., Trial Registration Number: NCT05867745., Prospero Registration Number: CRD42023388985., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Integrated care is seen as an enabling strategy in organising healthcare to improve quality, finances, personnel and sustainability. Developments in the organisation of maternity care follow this trend. The way care is organised should support the general aims and outcomes of healthcare systems. Organisation itself consists of a variety of smaller 'elements of organisation'. Various elements of organisation are implemented in different organisations and networks. We will examine which elements of integrated maternity care are associated with maternal and neonatal health outcomes, experiences of women and professionals, healthcare spending and care processes., Methods and Analysis: We will conduct this review using the JBI methodology for scoping reviews and the reporting guideline PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews). We will undertake a systematic search in the databases PubMed, Scopus, Cochrane and PsycINFO. A machine learning tool, ASReview, will be used to select relevant papers. These papers will be analysed and classified thematically using the framework of the Rainbow Model of Integrated Care (RMIC). The Population Concept Context framework for scoping reviews will be used in which 'Population' is defined as elements of the organisation of integrated maternity care, 'Context' as high-income countries and 'Concepts' as outcomes stated in the objective of this review. We will include papers from 2012 onwards, in Dutch or English language, which describe both 'how the care is organised' (elements) and 'outcomes'., Ethics and Dissemination: Since this is a scoping review of previously published summary data, ethical approval for this study is not needed. Findings will be published in a peer-reviewed international journal, discussed in a webinar and presented at (inter)national conferences and meetings of professional associations.The findings of this scoping review will give insight into the nature and effectiveness of elements of integrated care and will generate hypotheses for further research., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objective: This study aims to evaluate whether the first wave of the COVID-19 pandemic resulted in a deterioration in the quality of care for socially and/or clinically vulnerable stroke and ST-segment elevation myocardial infarction (STEMI) patients., Design: Two cohorts of STEMI and stroke patients in the Aquitaine neurocardiovascular registry., Setting: Six emergency medical services, 30 emergency units, 14 hospitalisation units and 11 catheterisation laboratories in the Aquitaine region in France., Participants: This study involved 9218 patients (6436 stroke and 2782 STEMI patients) in the neurocardiovascular registry from January 2019 to August 2020., Primary Outcome Measures: Care management times in both cohorts: first medical contact-to-procedure time for the STEMI cohort and emergency unit admission-to-imaging time for the stroke cohort. Associations between social (deprivation index) and clinical (age >65 years, neurocardiovascular history) vulnerabilities and care management times were analysed using multivariate linear mixed models, with an interaction on the time period (pre-wave, per-wave and post-first COVID-19 wave)., Results: The first medical contact procedure time was longer for elderly (p<0.001) and 'very socially disadvantaged' (p=0.003) STEMI patients, with no interaction regarding the COVID-19 period (age, p=0.54; neurocardiovascular history, p=0.70; deprivation, p=0.64). We found no significant association between vulnerabilities and the admission imaging time for stroke patients, and no interaction with respect to the COVID-19 period (age, p=0.81; neurocardiovascular history, p=0.34; deprivation, p=0.95)., Conclusions: This study revealed pre-existing inequalities in care management times for vulnerable STEMI and stroke patients; however, these inequalities were neither accentuated nor reduced during the first COVID-19 wave. Measures implemented during the crisis did not alter the structured emergency pathway for these patients., Trial Registration Number: NCT04979208., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Hospitals remain the cornerstone of health systems in European countries. Therefore, the financial sustainability of hospitals constitutes an important determinant of healthcare provision security. The fragmentary data available indicate that hospitals in many European countries are continuously facing financial deficits and/or insolvency problems. Yet a comparative analysis of hospital financial performance across European countries has been lacking. The proposed review will, therefore, fill in an important research gap and build a knowledge base on the topic of assessing and monitoring the financial sustainability of hospitals in Europe. The general objective is to identify, synthetise and map existing evidence on hospital financial performance across European countries., Methods and Analysis: This scoping review will follow six stages: (1) defining the research question, (2) identifying relevant literature, (3) studies selection, (4) data extraction, (5) collating, summarising and reporting of results and (6) consultation process and involvement of knowledge users. The following databases will be searched:(1) Medline via PubMed, (2) Web of Science Core Collection, (3) Scopus and (4) ProQuest Central. In addition, a Google Engine search will also be performed. Furthermore, reference lists of relevant papers will be visually scanned to identify further studies of interest. The review will include both quantitative and qualitative empirical studies as well as theoretical papers and technical reports. The PRISMA extension for a Scoping Review checklist will be used for reporting., Ethics and Dissemination: Formal ethical approval is not required because no primary data will be collected in this study. Results will be published in a peer-reviewed journal. The findings will also be disseminated through conference presentations and summaries to key stakeholders., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Chronic pain disproportionately affects medically and psychosocially complex patients, many of whom are at high risk of hospitalisation. Pain prevalence among high-risk patients, however, is unknown, and pain is seldom a focus for improving high-risk patient outcomes. Our objective is to (1) evaluate pain frequency in a high-risk patient population and (2) identify intensive management (IM) programme features that patients and providers perceive as important for promoting patient-centred pain care within primary care (PC)-based IM., Design: Secondary observational analysis of quantitative and qualitative evaluation data from a multisite randomised PC-based IM programme for high-risk patients., Setting: Five integrated local Veterans Affairs (VA) healthcare systems within distinct VA administrative regions., Participants: Staff and high-risk PC patients in the VA., Intervention: A multisite randomised PC-based IM programme for high-risk patients., Outcome Measures: (a) Pain prevalence based on VA electronic administrative data and (b) transcripts of interviews with IM staff and patients that mentioned pain., Results: Most (70%, 2593/3723) high-risk patients had at least moderate pain. Over one-third (38%, 40/104) of the interviewees mentioned pain or pain care. There were 89 pain-related comments addressing IM impacts on pain care within the 40 interview transcripts. Patient-identified themes were that IM improved communication and responsiveness to pain. PC provider-identified themes were that IM improved workload and access to expertise. IM team member-identified themes were that IM improved pain care coordination, facilitated non-opioid pain management options and mitigated provider compassion fatigue. No negative IM impacts on pain care were mentioned., Conclusions: Pain is common among high-risk patients. Future IM evaluations should consider including a focus on pain and pain care, with attention to impacts on patients, PC providers and IM teams., Competing Interests: Competing interests: We have read and understand the BMJ policy on competing interest and all authors have completed the ICMJE COI disclosure form. To the best of our knowledge, all authors report no competing interests, financial or other, that exist, apart from one author who reported receiving personal fees from Behavioral Health Services, Inc, outside the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose Of the Study: To examine junior doctors' experience and perceptions of medical errors in which they had been involved.Study Design: A mixed-methods design, consisting of an error survey and critical incident technique (CIT) interviews, was used. The survey asked doctors in the first year of postgraduate training in Ireland whether they had made a medical error that had 'played on (their) mind', and if so, to identify factors that had contributed to the error. The participants in the CIT interviews were asked to describe a medical error in which they had been involved.Results: A total of 201 out of 332 (60.5%) respondents to the survey reported making an error that 'played on their mind'. 'Individual factors' were the most commonly identified group of factors (188/201; 93.5%), with 'high workload' (145/201; 72.1%) the most commonly identified contributory factor. Of the 28 CIT interviews which met the criteria for analysis, 'situational factors' (team, staff, task characteristics, and service user factors) were the most commonly identified group of contributory factors (24/28; 85.7%). A total of eight of the interviews were judged by subject matter experts (n=8) to be of medium risk to patients, and 20 to be of high-risk to patients. A significantly larger proportion of high-risk scenarios were attributed to 'local working conditions' than the medium-risk scenarios.Conclusions: There is a need to prepare junior doctors to manage, and cope with, medical error and to ensure that healthcare professionals are adequately supported throughout their careers. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to develop a simulation model to support orthopaedic elective capacity planning., Methods: An open-source, generalisable discrete-event simulation was developed, including a web-based application. The model used anonymised patient records between 2016 and 2019 of elective orthopaedic procedures from a National Health Service (NHS) Trust in England. In this paper, it is used to investigate scenarios including resourcing (beds and theatres) and productivity (lengths of stay, delayed discharges and theatre activity) to support planning for meeting new NHS targets aimed at reducing elective orthopaedic surgical backlogs in a proposed ring-fenced orthopaedic surgical facility. The simulation is interactive and intended for use by health service planners and clinicians., Results: A higher number of beds (65-70) than the proposed number (40 beds) will be required if lengths of stay and delayed discharge rates remain unchanged. Reducing lengths of stay in line with national benchmarks reduces bed utilisation to an estimated 60%, allowing for additional theatre activity such as weekend working. Further, reducing the proportion of patients with a delayed discharge by 75% reduces bed utilisation to below 40%, even with weekend working. A range of other scenarios can also be investigated directly by NHS planners using the interactive web app., Conclusions: The simulation model is intended to support capacity planning of orthopaedic elective services by identifying a balance of capacity across theatres and beds and predicting the impact of productivity measures on capacity requirements. It is applicable beyond the study site and can be adapted for other specialties., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Faith-based organisations (FBOs) and religious actors increase vaccine confidence and uptake among ethnoracially minoritised communities in low-income and middle-income countries. During the COVID-19 pandemic and the subsequent vaccine rollout, global organisations such as the WHO and UNICEF called for faith-based collaborations with public health agencies (PHAs). As PHA-FBO partnerships emerge to support vaccine uptake, the scoping review aims to: (1) outline intervention typologies and implementation frameworks guiding interventions; (2) describe the roles of PHAs and FBOs in the design, implementation and evaluation of strategies and (3) synthesise outcomes and evaluations of PHA-FBO vaccine uptake initiatives for ethnoracially minoritised communities., Methods and Analysis: We will perform six library database searches in PROQUEST-Public Health, OVID MEDLINE, Cochrane Library, CINAHL, SCOPUS- all, PROQUEST - Policy File index; three theses repositories, four website searches, five niche journals and 11 document repositories for public health. These databases will be searched for literature that describe partnerships for vaccine confidence and uptake for ethnoracially minoritised populations, involving at least one PHA and one FBO, published in English from January 2011 to October 2023. Two reviewers will pilot-test 20 articles to refine and finalise the inclusion/exclusion criteria and data extraction template. Four reviewers will independently screen and extract the included full-text articles. An implementation science process framework outlining the design, implementation and evaluation of the interventions will be used to capture the array of partnerships and effectiveness of PHA-FBO vaccine uptake initiatives., Ethics and Dissemination: This multiphase Canadian Institutes of Health Research (CIHR) project received ethics approval from the University of Toronto. Findings will be translated into a series of written materials for dissemination to CIHR, and collaborating knowledge users (ie, regional and provincial PHAs), and panel presentations at conferences to inform the development of a best-practices framework for increasing vaccine confidence and uptake., Competing Interests: Competing interests: The authors declare no competing interests., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The study sought to explore the perspectives of vaccinators on the health system factors that impacted the COVID-19 vaccination campaign., Design: The study employed an exploratory-descriptive qualitative design. Key-informants' interviews were conducted using semi-structured guide to gather the data. Thematic analysis following the steps of Braun and Clark was conducted using ATLAS.ti software., Setting: The study setting was the Cape Coast Metropolis where the Central Regional Health Directorate is located. The Directorate initiates and implements policy decisions across the region. It is also the only metropolis in the region that recorded about 5970 of the total COVID-19 cases recorded in Ghana., Participants: Eleven vaccinators who had been trained for the COVID-19 vaccination and had participated in the campaign for at least 6 months were purposively sampled through the Regional Public Health Unit., Results: Four themes were derived from the data after analysis; 'vaccine-related issues'; 'staffing issues'; 'organising and planning the campaign' and 'surveillance and response systems'. Subthemes were generated under each major theme. Our results revealed the health service promoted the COVID-19 vaccination campaign through public education and ensured access to COVID-19 vaccines through the use of community outreaches. Also, the health service ensured adequate logistics supply for carrying out the campaign as well as ensured vaccinators were adequately equipped for adverse incidence reporting and management. Dissatisfaction among COVID-19 vaccinators attributed to low remuneration and delays in receiving allowances as well as shortfalls in efforts at securing transportation and a conducive venue for the vaccination exercise also emerged. Other challenges in the vaccination campaign were attributed to poor data entry platforms and limited access to internet facilities., Conclusion: This study highlights the health system's strategies and challenges during the COVID-19 vaccination campaign, emphasising the need for critical interventions to prevent low vaccination rates., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study described older patients receiving hospitalisation-at-home (HaH) services and identified factors associated with 30-day hospital readmission., Design: 3-year retrospective study in 2017-2019 in France., Participants: 75 108 patients aged 75 years and older who were discharged from hospital medical wards (internal medicine and geriatric units) and admitted to HaH., Primary Outcome Measure: 30-day hospital readmission., Results: The mean age of patients was 83.4 years (SD 5.7), 52.3% were male and 88.4% lived in a private household. Patients were primarily discharged from the internal medicine unit (85.3%). The top four areas of care in the HaH were palliative care, complex dressing, intravenous therapy and complex nursing care. Overall, 23.5% of patients died during their HaH stay and 27.8% were readmitted to the hospital at 30 days. In the multivariate model, male (OR 1.19, 95% CI 1.16 to 1.23), supportive cancer HaH care (OR 1.78, 95% CI 1.51 to 2.11) and very high intensity care during the previous in-person hospitalisation (OR 1.45, 95% CI 1.34 to 1.57) increased the risk of hospital readmission at 30 days. Older age (OR 0.97, 95% CI 0.97 to 0.98), living in a nursing home (OR 0.51, 95% CI 0.48 to 0.54), postsurgery HaH care (OR 0.49, 95% CI 0.41 to 0.58) and having been previously hospitalised in a geriatric unit (OR 0.81, 95% CI 0.77 to 0.85) decreased the risk of hospital readmission at 30 days., Conclusions: HaH provides complex care to very old patients, which is associated with high mortality. Several factors are associated with rehospitalisation within 30 days that could be avoided with better integration of different services with higher geriatric skills., Trial Registration Number: CNIL:2228861., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Dynamic ambulance relocation means that the operators at a dispatch centre place an ambulance in a temporary location, with the goal of optimising coverage and response times in future medical emergencies. This study aimed to scope the current research on dynamic ambulance relocation., Design: A scoping review was conducted using a structured search in PubMed, Scopus and Web of Science. In total, 21 papers were included., Results: Most papers described research with experimental designs involving the use of mathematical models to calculate the optimal use and temporary relocations of ambulances. The models relied on several variables, including distances, locations of hospitals, demographic-geological data, estimation of new emergencies, emergency medical services (EMSs) working hours and other data. Some studies used historic ambulance dispatching data to develop models. Only one study reported a prospective, real-time evaluation of the models and the development of technical systems. No study reported on either positive or negative patient outcomes or real-life chain effects from the dynamic relocation of ambulances., Conclusions: Current knowledge on dynamic relocation of ambulances is dominated by mathematical and technical support data that have calculated optimal locations of ambulance services based on response times and not patient outcomes. Conversely, knowledge of how patient outcomes and the working environment are affected by dynamic ambulance dispatching is lacking. This review has highlighted several gaps in the scientific coverage of the topic. The primary concern is the lack of studies reporting on patient outcomes, and the limited knowledge regarding several key factors, including the optimal use of ambulances in rural areas, turnaround times, domino effects and aspects of working environment for EMS personnel. Therefore, addressing these knowledge gaps is important in future studies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Despite their widespread use, the evidence base for the effectiveness of quality improvement collaboratives remains mixed. Lack of clarity about 'what good looks like' in collaboratives remains a persistent problem. We aimed to identify the distinctive features of a state-wide collaboratives programme that has demonstrated sustained improvements in quality of care in a range of clinical specialties over a long period., Design: Qualitative case study involving interviews with purposively sampled participants, observations and analysis of documents., Setting: The Michigan Collaborative Quality Initiatives programme., Participants: 38 participants, including clinicians and managers from 10 collaboratives, and staff from the University of Michigan and Blue Cross Blue Shield of Michigan., Results: We identified five features that characterised success in the collaboratives programme: learning from positive deviance; high-quality coordination; high-quality measurement and comparative performance feedback; careful use of motivational levers; and mobilising professional leadership and building community. Rigorous measurement, securing professional leadership and engagement, cultivating a collaborative culture, creating accountability for quality, and relieving participating sites of unnecessary burdens associated with programme participation were all important to high performance., Conclusions: Our findings offer valuable learning for optimising collaboration-based approaches to improvement in healthcare, with implications for the design, structure and resourcing of quality improvement collaboratives. These findings are likely to be useful to clinicians, managers, policy-makers and health system leaders engaged in multiorganisational approaches to improving quality and safety., Competing Interests: Competing interests: The Michigan Quality Collaboratives are supported by Blue Cross and Blue Shield of Michigan. MJE receives salary support from Blue Cross and Blue Shield of Michigan as well as the NIH and the Michigan DHHS. DAC, GLK and MJE’s institution (University of Michigan) receives a partial salary paid for by the Blue Cross Blue Shield of Michigan Value Partnerships for the Michigan Surgical Quality Collaborative. GLK, DAC and MJE are employed by the Michigan Surgical Quality Collaborative. MJE and JBD were interviewed as participants in the study., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care., Methods and Analysis: In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events., Ethics and Dissemination: We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The advanced access model is highly recommended to improve timely access to primary healthcare (PHC). However, its adoption varies among PHC providers. We aim to identify the advanced access profiles of PHC providers., Design: A cross-sectional study was conducted between October 2019 and March 2020. Latent class analysis (LCA) measures were used to identify PHC provider profiles based on 14 variables, 2 organisational context characteristics (clinical size and geographical area) and 12 advanced access strategies., Setting and Participants: All family physicians, nurse practitioners and nurses working in the 49 university-affiliated team-based PHC clinics in Quebec, Canada, were invited, of which 35 participated., Primary Outcome Measure: The LCA was based on 335 respondents. We determined the optimal number of profiles using statistical criteria (Akaike information criterion, Bayesian information criterion) and qualitatively named each of the six advanced access profiles., Results: (1) Low supply and demand planification (25%) was characterised by the smallest proportion of strategies used to balance supply and demand. (2) Reactive interprofessional collaboration (25%) was characterised by high collaboration and long opening periods for appointment scheduling. (3) Structured interprofessional collaboration (19%) was characterised by high use of interprofessional team meetings. (4) Small urban delegating practices (13%) was exclusively composed of family physicians and characterised by task delegation to other PHC providers on the team. (5) Comprehensive practices in urban settings (13%) was characterised by including as many services as possible on each visit. (6) Rural agility (4%) was characterised by the highest uptake of advanced access strategies based on flexibility, including adjusting the schedule to demand and having a large number of open-slot appointments available in the next 48 hours., Conclusion: The different patterns of advanced access strategy adoption confirm the need for training to be tailored to individuals, categories of PHC providers and contexts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs., Methods: We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed., Results: The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation., Conclusions: We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: In Aotearoa New Zealand (NZ), integration across the healthcare continuum has been a key approach to strengthening the health system and improving health outcomes. A key example has been four regional District Health Board (DHB) groupings, which, from 2011 to 2022, required the country's 20 DHBs to work together regionally. This research explores how this initiative functioned, examining how, for whom and in what circumstances regional DHB groupings worked to deliver improvements in system integration and health outcomes and equity., Design: We used a realist-informed evaluation study design. We used documentary analysis to develop programme logic models to describe the context, structure, capabilities, implementation activities and impact of each of the four regional groupings and then conducted interviews with stakeholders. We developed a generalised context-mechanisms-outcomes model, identifying key commonalities explaining how regional work 'worked' across NZ while noting important regional differences., Setting: NZ's four regional DHB groupings., Participants: Forty-nine stakeholders from across the four regional groupings. These included regional DHB governance groups and coordinating regional agencies, DHB senior leadership, Māori and Pasifika leadership and lead clinicians for regional work streams., Results: Regional DHB working was layered on top of an already complex DHB environment. Organisational heterogeneity and tensions between local and regional priorities were key contextual factors. In response, regional DHB groupings leveraged a combination of 'hard' policy and planning processes, as well as 'soft', relationship-based mechanisms, aiming to improve system integration, population health outcomes and health equity., Conclusion: The complexity of DHB regional working meant that success hinged on building relationships, leadership and trust, alongside robust planning and process mechanisms. As NZ reorients its health system towards a more centralised model underpinned by collaborations between local providers, our findings point to a need to align policy expectations and foster environments that support connection and collegiality across the health system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Disease self-management and medication therapy can cause burden to patients that can influence adherence. The conceptual model 'patients' lived experience with medicine' (PLEM) brings new insights into medication-related burden (MRB) from patient perspective. This study aimed to test the applicability of the PLEM model by interviewing chronically ill patients in Finland and to investigate the MRB experienced by the Finnish patients., Design: Focus group discussion study conducted online via Zoom. Directed qualitative content analysis guided by the PLEM model., Setting: Outpatient primary care in Finland., Participants: Chronically ill outpatients (n=14) divided into five focus groups according to their chronic condition: asthma (n=3), heart disease (n=3), diabetes (n=6), intestinal disease (n=2)., Results: Our findings were mainly in line with the PLEM model although some new contributing factors to MRB emerged. In general, the participants were satisfied with their medication, and that it enabled them to live normal lives. The most common causes of MRB were medication routines and the healthcare system. The participants introduced two new aspects contributing to MRB: medication-related environmental anxiety associated with the waste resulting from medicine use, and the effect of medication use on their working life. Our findings are consistent with previous findings that a higher level of MRB may lead to independently modifying the medication regimen or not taking the medicine., Conclusions: Our findings provide further evidence that the PLEM model is an applicable tool also in the Finnish context for gaining better understanding of MRB in chronically ill patients self-managing their long-term medications. The model provides a promising tool to understand the connection between MRB and the rationale for not always taking medicines as prescribed. Further research is needed to explore the potential of the model in extending patient perspectives in chronic disease management., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Child mortality rates remain high in sub-Saharan Africa, including Ethiopia. We are conducting a cluster randomised control trial in the Gondar zone of the Amhara region to determine the impact of pairing Orthodox priests with community health workers, known locally as the Health Development Army (HDA), on newborns' nutritional status, early illness identification and treatment, and vaccination completeness.Ensuring intervention efficacy with scientific rigour is essential, but there are often delays in adopting evidence into policy and programmes. Here, we present a protocol for conducting parallel implementation research alongside an efficacy study to understand intervention implementability and scalability. This will help develop a scale-up strategy for effective elements of the intervention to ensure rapid implementation at scale., Methods and Analysis: We will conduct a stakeholder analysis of key implementation stakeholders and readiness surveys to assess their readiness to scale up the intervention. We will conduct semistructured interviews and focus group discussions with stakeholders, including HDA members, health workers, Orthodox priests, and caregivers, to determine the core intervention elements that need to be scaled, barriers and facilitators to scaling up the intervention in diverse sociocultural settings, as well as the human and technical requirements for national and regional implementation. Finally, to determine the financial resources necessary for sustaining and scaling the intervention, we will conduct activity-based costing to estimate implementation costs from the provider's perspective., Ethics and Dissemination: The study received approval from the University of Gondar Institutional Review Board (approval no: VP/RTT/05/1030/2022) and the University of Washington Human Subjects Division (approval no: STUDY00015369). Participants will consent to participate. Results will be disseminated through workshops with stakeholders, local community meetings, presentations at local and international conferences, and journal publications. The study will provide evidence for factors to consider in developing a scale-up strategy to integrate the intervention into routine health system practices., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The inadequate provision of language interpretation for people with limited English proficiency (LEP) is a determinant of poor health, yet interpreters are underused. This research explores the experiences of National Health Service (NHS) staff providing primary care for people seeking asylum, housed in contingency accommodation during COVID-19. This group often have LEP and face multiple additional barriers to healthcare access. Language discrimination is used as a theoretical framework. The potential utility of this concept is explored as a way of understanding and addressing inequities in care., Design: Qualitative research using semistructured interviews and inductive thematic analysis., Setting: An NHS primary care service for people seeking asylum based in contingency accommodation during COVID-19 housing superdiverse residents speaking a wide spectrum of languages., Participants: Ten staff including doctors, nurses, mental health practitioners, healthcare assistants and students participated in semistructured online interviews. Some staff were redeployed to this work due to the pandemic., Results: All interviewees described patients' LEP as significant. Inadequate provision of interpretation services impacted the staff's ability to provide care and compromised patient safety. Discrimination, such as that based on migration status, was recognised and challenged by staff. However, inequity based on language was not articulated as discrimination. Instead, insufficient and substandard interpretation was accepted as the status quo and workarounds used, such as gesticulating or translation phone apps. The theoretical lens of language discrimination shows how this propagates existing social hierarchies and further disadvantages those with LEP., Conclusions: This research provides empirical evidence of how the inadequate provision of interpreters forces the hand of healthcare staff to use shortcuts. Although this innovative 'tinkering' allows staff to get the job done, it risks normalising structural gaps in care provision for people with LEP. Policy-makers must rethink their approach to interpretation provision which prioritises costs over quality. We assert that the concept of language discrimination is a valuable framework for clinicians to better identify and articulate unfair treatment on the grounds of LEP., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study aimed to evaluate primary care networks (PCNs) in the English National Health Service. We ask: How are PCNs constituted to meet their defined goals? What factors can be discerned as affecting their ability to deliver benefits to the community, the network as a whole and individual members? What outcomes or outputs are associated with PCNs so far? We draw policy lessons for PCN design and oversight, and consider the utility of the chosen evaluative framework., Design and Setting: Qualitative case studies in seven PCN in England, chosen for maximum variety around geography, rurality and population deprivation. Study took place between May 2019 and December 2022., Participants: PCN members, staff employed in additional roles and local managers. Ninety-one semistructured interviews and approximately 87 hours of observations were undertaken remotely. Interview transcripts and observational field notes were analysed together using a framework approach. Initial codes were derived from our evaluation framework, with inductive coding of new concepts during the analysis., Results: PCNs have been successfully established across England, with considerable variation in structure and operation. Progress is variable, with a number of factors affecting this. Good managerial support was helpful for PCN development. The requirement to work together to meet the specific threat of the global pandemic did, in many cases, generate a virtuous cycle by which the experience of working together built trust and legitimacy. The internal dynamics of networks require attention. Pre-existing strong relationships provided a significant advantage. While policy cannot legislate to create such relationships, awareness of their presence/absence is important., Conclusions: Networked approaches to service delivery are popular in many health systems. Our use of an explicit evaluation framework supports the extrapolation of our findings to networks elsewhere. We found the framework to be useful in structuring our study but suggest some modifications for future use., Competing Interests: Competing interests: The authors have declared that their institutions received grant funding to support this project from the National Institute of Health Research Policy Research Programme., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB., Design: A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements., Participants and Setting: People identified with MDR/RR-TB from 13 high-burden districts within South Africa., Outcome Measures: Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined., Results: Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0-281 days), average patient distance travelled (12-198 km) and number of health facilities involved in care (1-5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district., Conclusions: Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objective: The objective of this study is to characterise the self-reported first contact with the health system and the reasons stated for each choice, testing associations with population characteristics., Design: Cross-sectional survey., Setting: Primary care department of a local health unit in northern Portugal., Participants: Random sample of 4286 persons, retrieved from all registered adults., Outcomes: Participants who stated they usually see the same doctor when a health problem arises were considered to adopt first-contact care and were asked to identify their regular doctor. Participants were asked why they adopt first-contact care or why they choose to do otherwise. Associations between personal characteristics and the adoption of first-contact care were tested using logistic regression., Results: There were 808 valid questionnaires received (19% response rate). The mean age of respondents was 53 years, 58% were women and 60% had a high school or higher degree. Most (71%) stated always seeing the same doctor when facing a health problem. This was a general practitioner (GP) in 84%. The main reasons were previous knowledge and trust in the doctor. When this doctor was not a GP, the main reason was the need to obtain an appointment quickly. Participants who chose first-contact care were less likely to have university degrees than those who did not (OR 0.31; 95% CI 0.13 to 0.76). Being registered with the same GP for over 1 year increased the odds of adopting first-contact care: twice as likely for those registered for 1-4 years with the same GP (2.07; 95% CI 1.04 to 4.11), and three times more likely for those registered for over 10 years (3.21; 95% CI 1.70 to 6.08)., Conclusions: The high adoption of first-contact care and the reasons given for this suggest a strong belief in primary care in this population. The longer patients experience continuity, the more they adopt first-contact care. The preferences of higher-educated patients regarding first-contact care deserve reflection., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The growing incidence of mental ill health in doctors was a major issue in the UK and internationally, even prior to the COVID-19 pandemic. It has significant and far-reaching implications, including poor quality or inconsistent patient care, absenteeism, workforce attrition and retention issues, presenteeism, and increased risk of suicide. Existing approaches to workplace support do not take into account the individual, organisational and social factors contributing to mental ill health in doctors, nor how interventions/programmes might interact with each other within the workplace. The aim of this study is to work collaboratively with eight purposively selected National Health Service (NHS) trusts within England to develop an evidence-based implementation toolkit for all NHS trusts to reduce doctors' mental ill health and its impacts on the workforce., Methods and Analysis: The project will incorporate three phases. Phase 1 develops a typology of interventions to reduce doctors' mental ill health. Phase 2 is a realist evaluation of the existing combinations of strategies being used by acute English healthcare trusts to reduce doctors' mental ill health (including preventative promotion of well-being), based on 160 interviews with key stakeholders. Phase 3 synthesises the insights gained through phases 1 and 2, to create an implementation toolkit that all UK healthcare trusts can use to optimise their strategies to reduce doctors' mental ill health and its impact on the workforce and patient care., Ethics and Dissemination: Ethical approval has been granted for phase 2 of the project from the NHS Research Ethics Committee (REC reference number 22/WA/0352). As part of the conditions for our ethics approval, the sites included in our study will remain anonymous. To ensure the relevance of the study's outputs, we have planned a wide range of dissemination strategies: an implementation toolkit for healthcare leaders, service managers and doctors; conventional academic outputs such as journal manuscripts and conference presentations; plain English summaries; cartoons and animations; and a media engagement campaign., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Describe experiences of countries with networks of care's (NOCs') financial arrangements, identifying elements, strategies and patterns., Design: Descriptive using a modified cross-case analysis, focusing on each network's financing functions (collecting resources, pooling and purchasing)., Setting: Health systems in six countries: Argentina, Australia, Canada, Singapore, the United Kingdom and the USA., Participants: Large-scale NOCs., Results: Countries differ in their strategies to implement and finance NOCs. Two broad models were identified in the six cases: top-down (funding centrally designed networks) and bottom-up (financing individual projects) networks. Despite their differences, NOCs share the goal of improving health outcomes, mainly through the coordination of providers in the system; these results are achieved by devoting extra resources to the system, including incentives for network formation and sustainability, providing extra services and setting incentive systems for improving the providers' performance., Conclusions: Results highlight the need to better understand the financial implications and alternatives for designing and implementing NOCs, particularly as a strategy to promote better health in low- and middle-income settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Despite efforts and repeated calls to improve the organisation and quality of healthcare and services, and in view of the many challenges facing health systems, the results and capacity to adapt and integrate innovations and new knowledge remain suboptimal. Learning health systems (LHS) may be an effective model to accelerate the application of research for real quality improvement in healthcare. However, while recognising the enormous potential of LHS, the literature suggests the model remains more of an aspiration than a reality., Methods and Analysis: To reach a fine understanding of the implementation of the concepts involved in LHS, we will use a hybrid method which combines concept analyses with systematic review methodology. We will use a two-step analysis, a content analysis to analyse the definitions, uses and attributes of the concept and a systematic review to analyse the concept's implementation mechanisms. We will search eight databases and grey literature and present a broad synthesis of the available evidence regarding design, implementation and evaluation of LHS in a multilevel perspective. We will follow the latest Preferred Reporting Items for Systematic Review and Meta-Analysis statement for conducting and reporting a systematic review. Two reviewers will independently screen the titles and abstracts against the eligibility criteria followed by full-text screening of potentially relevant articles for final inclusion decision. Conflicts will be resolved with a senior author. We will include published primary studies that use qualitative, quantitative or mixed methods. The assessment of risk of bias will be made using the Mixed-Methods Appraisal Tool., Ethics and Dissemination: This systematic review is exempt from ethics approval. The results formulated will highlight evidence-based interventions that support the implementation of a national LHS. They will be of particular interest to decision makers, researchers, managers, clinicians and patients allowing finally to implement the promising proposal of LHSs at national scale., Prospero Registration Number: CRD42023393565., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: For eligible patient groups, hospital-at-home (HaH) programmes have been shown to deliver equivalent patient outcomes with cost reduction compared with standard care. This study aims to establish a benchmark of inpatient admissions that could potentially be substituted by HaH services., Design: Descriptive retrospective cohort study., Setting: Academic tertiary hospital in Singapore., Participants: 124 253 medical admissions over 20 months (January 2016 to August 2017)., Primary and Secondary Outcome Measures: The primary measure was the proportion of hospitalised patients who may be eligible for HaH, based on eligibility criteria adapted for the Singapore context. The secondary measures were the utilisation patterns and outcomes of these patients., Results: Applying generalised eligibility criteria to the retrospective dataset showed that 53.0% of 124 253 medical admissions fitted the eligibility criteria for HaH based on administrative data. 46.8% of such patients had a length of stay <48 hours ('short-stay') and 53.1% had a length of stay ≥48 hours ('medium-stay'). The mortality rate and the 30-day readmission rate were lower in the 'short-stay' cohort (0.6%, 12.8%) compared with the 'medium-stay' cohort (0.7%, 20.3%). The key services used by both groups were: parenteral drug administration, blood investigations, imaging procedures and consultations with allied health professionals., Conclusions: Up to 53.0% of medical admissions receive care elements that HaH programmes could provide. Applying estimates of functional limitations and patient preferences, we propose a target of ~18% of inpatient medical admissions to be substituted by HaH services. The methodology adopted in this paper is a reproducible approach to characterise potential patients and service utilisation requirements when developing such programmes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

As healthcare systems grow increasingly complex, greater demands are placed on patients' abilities to find, understand, appraise, and use health information - often termed their 'health literacy'. Most health literacy research does not focus on information appraisal. When it does, there is a tendency to equate it with patients' assessment of credibility. This reproduces a healthcare-centric understanding of information appraisal where patient agency is omitted. This study explores how participants in a health information intervention practiced information appraisal. The intervention aimed to increase information uptake for people with low back pain by delivering health information to them through animations. This study draws on ethnographic participant observation of the encounters between the intervention and its participants, including 49 rapid interviews and semi-structured telephone interviews with 23 participants carried out in the spring of 2021. Inspired by a social practice approach, the study thoroughly grounds the health literacy subcategory of 'appraisal' in practice. It illustrates that participants appraised the information provided in the intervention according to several factors. These include relating the information to their personal health needs, interpreting the intended audience of the health animations, and prioritising their attention situationally between the animations and other immediate concerns. We suggest that information appraisal is a fundamental component of health literacy and should be considered key in research, policy and practice. To accommodate current healthcare ideals of patient centeredness, empowerment and informed choice, the complex and dynamic ways in which people appraise health information need be considered legitimate practices of health literacy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To explore the views of professional stakeholders on the future of community pharmacy services in England. Specific objectives related to expectations of how community pharmacy services will be provided by 2030 and factors that will influence this., Design: Qualitative, using semistructured interviews in person or via telephone/Skype. The topic guide was informed by a recent policy review that used the Walt and Gilson policy framework. Transcripts were analysed using inductive thematic analysis., Setting: England., Participants: External stakeholders were representatives of non-pharmacy organisations, including policy-makers, commissioners and representatives of healthcare professions. Internal stakeholders were community pharmacists or pharmacy organisation representatives. Interviewees were identified using stakeholder mapping RESULTS: In total, 25 interviews were completed (7 external stakeholders and 18 internal stakeholders, of which 10 were community pharmacists). Community pharmacy was recognised as having a key role in expanding health system capacity (' …pharmacy is the obvious person to take on those roles… '), particularly for long-term condition management (eg, adherence, reducing polypharmacy, monitoring), urgent care (eg, minor illnesses) and public health (including mental health). For these contributions to be developed and optimised, greater integration and collaboration with general practices will be needed (' …there is no room for isolationism in pharmacy anymore… '), as well as use of technology in a patient-centred way and full access to health records. These changes will require workforce development together with appropriate commissioning and contractual arrangements. Community pharmacy is currently undervalued (' …the complete misunderstanding by senior Government officials is very scary ') and recent investment in general practice pharmacists rather than community pharmacy was seen as a missed opportunity., Conclusions: Community pharmacy as a sector could and should be developed to increase health service capacity to address its current challenges. Numerous modifications are required from a range of stakeholders to create the environment in which these changes can occur., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Population ageing and the prevalence of multimorbidity represent major challenges for healthcare systems. People who need long-term care have complex conditions requiring both health and social services. Informal caregivers are emerging as an important part of the long-term care ecosystem. This paper aims to explore the position and capacities of informal caregivers in Croatia., Design: Health and social care legislative documents were analysed using a structured set of keywords. In addition, focus groups were conducted with informal caregivers who cared for a family member. The qualitative method of thematic analysis was used., Setting and Participants: Two focus groups were conducted with 15 caregivers (13 women and 2 men). Geographically, participants came from all four NUTS2 Croatian regions. All participants cared for a close family member. The length of care provision ranged from 3 to 35 years. Focus groups were conducted using the Zoom platform., Results: The analysis of the documents indicates the fragmentation of national policy into health and social policy. Long-term care as a term is recognised only in health policy. However, some components related to long-term care are part of social policy. Caregivers are recognised in social policy, although not in healthcare. In focus groups, three main themes were identified as follows: (1) position and role of the caregivers in the system and society; (2) types of care based on the recipient's need and (3) support for the caregivers., Conclusion: The research showed that the process of exercising certain rights and services for caregivers is not sufficiently clear and feasible in practice. There is a lack of a clearly defined role of caregivers and relationships towards professional care providers in the system. The key to improving long-term care is connecting community services, including health and social services, both formal and informal, with the process of providing care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To explore the characteristics of the General Practice Patient Survey (GPPS) respondents using the different functionalities of the online services in the context of England's National Health Service General Practices. We hypothesised that respondents who are older, with lower socioeconomic status and non-white ethnicity would be less likely to use online services, while long-term conditions might increase their usage., Design: Cross-sectional study using respondent-level data from the GPPS in England of the years 2018, 2019 and 2020. We assessed the association between online services use and respondent characteristics using two-level mixed-effects logistic regression., Participants: Survey respondents of the GPPS 2018-2020., Primary Outcome Measures: Online appointment booking and online repeat prescription ordering., Results: 1 807 049 survey respondents were included in this study. 15% (n=263 938) used online appointment booking in the previous 12 months, and 19% (n=339 449) had ordered a repeat prescription in the previous 12 months. Respondents with a long-term condition, on regular multiple medications, who have deafness or hearing loss and who are from the lowest deprivation quintile were more likely to have used online services. Male respondents (compared with females) and respondents with black and other ethnicity compared with white ethnicity were less likely to use online services. Respondents over 85 years old were less likely to use online appointment booking and online repeat prescription ordering compared with the younger age groups., Conclusions: Specific groups of respondents were more likely to use online services such as patients with long-term conditions or those with deafness or hearing loss. While online services could provide efficiency to patients and practices it is essential that alternatives continue to be provided to those that cannot use or choose not to use online services. Understanding the different patients' needs could inform solutions to increase the uptake and use of the services., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Association of Southeast Asian Nations (ASEAN) is among the hardest hit low-income and middle-income countries by diabetes. Innovative Care for Chronic Conditions (ICCC) framework has been adopted by the WHO for health system transformation towards better care for chronic conditions including diabetes. We conducted an umbrella review of systematic reviews on diabetes care components effectively implemented in the ASEAN health systems and map those effective care components into the ICCC framework., Design: An umbrella review of systematic reviews and/or meta-analyses following JBI (Joanna Briggs Institute) guidelines., Data Sources: Health System Evidence, Health Evidence, PubMed and Ovid MEDLINE., Eligibility Criteria: We included systematic reviews and/or meta-analyses which focused on management of type 2 diabetes, reported improvements in measured outcomes and had at least one ASEAN member state in the study setting., Data Extraction and Synthesis: Two reviewers independently extracted the data and mapped the included studies into the ICCC framework. A narrative synthesis method was used to summarise the findings. The included studies were assessed for methodological quality based on the JBI critical appraisal checklist for systematic reviews and research syntheses., Results: 479 records were found of which 36 studies were included for the analysis. A multidisciplinary healthcare team including pharmacists and nurses has been reported to effectively support patients in self-management of their conditions. This can be supported by effective use of digital health interventions. Community health workers either peers or lay people with necessary software (knowledge and skills) and hardware (medical equipment and supplies) can provide complementary care to that of the healthcare staff., Conclusion: To meet challenges of the increased burden of chronic conditions including diabetes, health policy-makers in the ASEAN member states can consider a paradigm shift in human resources for health towards the multidisciplinary, inclusive, collaborative and complementary team., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The rate of outpatient therapeutic curettage is lower in Germany than in other countries, although there are no differences in patient safety between outpatient and inpatient management. In this context, outpatient surgery is economically advantageous and efficient. This study aims to identify organisational and regional factors that determine the rate of outpatient curettage in German hospitals., Methods: We analysed the hospital quality reports for 2013-2019, which include data from all German hospitals with gynaecology departments (n=709). These organisational data (teaching status, size, ownership, department type and hospital group) are enhanced by contextual data (degree of urbanisation, market concentration and population income). We calculated a zero-one inflated beta regression model to identify factors that influence the rate of outpatient curettages in 2019., Results: Increasing numbers of curettages are provided on an outpatient basis; accordingly, the number of inpatient curettages declined during the analysis period. In 2019, 69.6% of in-hospital curettages were performed as outpatient surgery. Hospital size is significantly negative and outpatient physician department type is significantly positively associated with outpatient curettage rates. We found no effects of hospital ownership type, degree of urbanisation or market concentration. A high income in the surgical district's population is also associated with a higher rate of outpatient curettages., Conclusions: The analyses demonstrate that organisational factors are associated with the outpatient curettage rate. This indicates that external elements, such as reimbursements and regulations, influence outpatient surgical events in Germany, and current regulations do not incentivise hospitals to significantly increase their rate of outpatient curettages., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Same day emergency care (SDEC) is a new model of care, which has emerged over the past 5 years, building on prior ambulatory care services. The National Health Service (NHS) England National Strategy for SDEC suggests SDEC can meet local health needs by providing alternatives to emergency department attendance or hospital admission, for people with an urgent healthcare need, beyond the limited scope of an urgent treatment centre. This review focuses on acute medical SDEC, as medical patients represent a significant proportion of emergency admissions. The planned scoping review aims to map the existing evidence base., Methods and Analysis: This is a protocol for a scoping review to be conducted in accordance with the format of the Joanna Briggs Institute (JBI) methodology for scoping reviews. The databases to be searched will include EMBASE, MEDLINE and CINAHL, via EBSCOhost. Sources of unpublished studies, policies and grey literature will include Google Scholar, the Cochrane Library, TRIP database, ProQuest Dissertations and Theses Open, and the Health Management Information Consortium. Papers relating to acute medicine adult patients attending NHS SDEC services in the UK will be included. International papers will be excluded, as will those over 5 years old, and those where full text is not available. The results of the search and study inclusion/exclusion process will be reported and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram. Data will be extracted from papers included in the scoping review by two reviewers, using a JBI data extraction tool. Any differences of opinion will be discussed until consensus is reached. If needed, a third reviewer will be asked to join the review team to achieve consensus. Data and themes extracted will be summarised and presented in tables. A narrative thematic summary will accompany the presented results, describing how the results relate to the review objective. Literature gaps will be identified and recommendations for future research made., Ethics and Dissemination: There is no requirement for ethical approval for this scoping review. On completion, it will be published in a peer-reviewed academic journal and presented at a conference., Competing Interests: Competing interests: SD: The Midlands Faculty for Advancing Practice of Health Education England is prospectively funding the BMJ Open article processing charge for this paper. Predoctoral clinical academic fellowship—funding provided to my employer (United Lincolnshire Hospitals NHS Trust) to release time for the fellowship. JB: Employed by Health Education England (now NHS England Workforce, Training and Education from April 2023 onward) as the Lead for the Centre for Advancing Practice and Regional Faculty Lead for Advancing Practice. The Midlands Faculty for Advancing Practice of NHS England Workforce, Training and Education is prospectively funding the BMJ Open article processing charge for this paper., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Sexual harassment (SH) at work can have an impact on the general health and well-being and on the productivity of the employee. To date, the Belgian Armed Forces do not have any accurate data about SH. Therefore, this study assessed the prevalence of SH within Belgian Defence., Methods: The prevalence of SH and staff mental well-being was investigated in a sample of 399 female soldiers. Using quantitative analysis, we measured the impact on mental well-being and the relation to demographic characteristics. Using a qualitative analysis in a subsample of eight female soldiers, we investigated barriers to reporting SH and the impact on professional performance and psychosocial well-being., Results: The prevalence of non-physical SH is 36.1% over the last 12 months and 64.4% over the course of a career. Physical SH has a prevalence of 16.1% and 43.4%, respectively. Rape prevalence was reported to be 1.4% over the past 12 months, 9% over the course of their career.One in three female soldiers suffer from reduced mental well-being, which was significantly associated with SH. In the interviews, female employees report an impact of SH on professional and personal performance. The willingness to report is low due to misunderstanding, disinformation and psychosocial insecurity., Conclusion: High prevalence numbers were found suggesting an important impact on the professional performance and mental well-being of female military personnel. Organisational changes may create more willingness among victims to report incidents to the designated services., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)