Service user experiences of using internet-based testing for sexually transmitted infections (STIs): a qualitative study.

OBJECTIVES: Internet-based testing for sexually transmitted infections allows individuals to order a self-sampling kit online, send samples to a central laboratory and receive their results electronically, reducing the need to attend a clinic unless for treatment. Its usage has grown rapidly in many high-income countries, such as England, where it now accounts for 44% of tests within the National Chlamydia Screening Programme. However, there is limited data on the experiences of service users, which may offer insights into low uptake and poor return rates among some high-incidence populations. METHODS: Participants were recruited via sexual health clinics and the website of an internet-based testing service. Purposive sampling was used to ensure a diversity of genders, sexualities and ethnic backgrounds were included. Semistructured interviews were conducted by phone, email and messenger services and explored participants' perceptions and experiences of both internet-based and clinic-based testing. Data underwent thematic analysis. RESULTS: We interviewed 17 participants. Internet-based testing appealed to many due to the privacy and convenience it offered over clinic-based testing. Although most were positive about their experience of internet-based testing, many found the process of finger-prick blood sampling extremely challenging and this contributed to concerns from some participants that test results may be inaccurate. A minority of participants missed the opportunity that clinic-based testing offered to discuss symptoms or concerns with staff. Participants overwhelmingly found the process of receiving test results by short message service (SMS) acceptable and preferable to alternatives. CONCLUSIONS: Internet-based testing is viewed positively by most users but uptake may be improved if providers emphasise the privacy and convenience it offers, as well as the accuracy of self-sampling. Providers should also consider measures to address user concerns around blood sampling and access to specialist advice.

"It's just part of who I am " Living with chronic headache: voices from the CHESS trial, a qualitative study.

BACKGROUND: Between 2015 and 2019 the Chronic Headache Education and Self-management Study (CHESS) developed and tested a supportive self-management approach that aimed to improve outcomes for people with chronic migraine or chronic tension type headache with/without episodic migraine. However, a paucity of qualitative research which explored the lived experiences of people with chronic headache was evidenced. In response, we undertook to explore the experiences of living with chronic headaches of people who participated in the CHESS study. METHODS: We adopted qualitative methodologies, inviting participants in the CHESS study to participate in semi-structured interviews. In phase 1 (feasibility study), a thematic analysis was conducted. In phase 2 (main CHESS trial), interviews were informed by topic guides developed from our learning from the phase 1 interviews. Pen portrait methodology and thematic analysis was employed allowing us to explore the data longitudinally. RESULTS: Phase 1, 15 interviews (10 female) age range 29 to 69 years (median 47 years) revealed the complexities of living with chronic headache. Six overarching themes were identified including the emotional impact and the nature of their headaches. Phase 2, included 66 interviews (26 participants; median age group 50s (range 20s-60s); 20 females. 14 were interviewed at three points in time (baseline, 4 and 12 months) Through an iterative process four overlapping categories of headache impact emerged from the data and were agreed: i) 'I will not let headaches rule my life'; ii) 'Headaches rule my life'; iii) 'Headaches out of control-something needs to change'; and iv) 'Headaches controlled-not ruling my life'. One of these categories was assigned to each pen portrait at each timepoint. The remaining 12 participants were interviewed at two time points during a year; pen portraits were again produced. Analysis revealed that the headache impact categories developed above held true in this sample also providing some validation of the categories. CONCLUSIONS: These data give an insight into the complexities of living with chronic headache. Chronic headache is unpredictable, permeating all aspects of an individual's life; even when an individual feels that their headache is controlled and not interfering, this situation can rapidly change. It shows us that more work needs to be done both medically and societally to help people living with this often-hidden condition. TRIAL REGISTRATION: ISRCTN79708100.

International short-term placements in health professions education-A meta-narrative review.

INTRODUCTION: In order to be prepared for professional practice in a globalised world, health professions students need to be equipped with a new set of knowledge, skills and attitudes. Experiential learning gained during an international placement has been considered as a powerful strategy for facilitating the acquisition of global health competencies. The aim of this review was to synthesise the diverse body of empirical research examining the process and outcomes of international short-term placements in health professions education. METHODS: A systematic review was conducted using a meta-narrative methodology. Six electronic databases were searched between September 2016 and June 2022: Medline, Embase, CINAHL, PsycINFO, Education Research Complete and Web of Knowledge. Studies were included if they reported on international placements undertaken by undergraduate health professions students in socio-economically contrasting settings. Included studies were first considered within their research tradition before comparing and contrasting findings between different research traditions. RESULTS: This review included 243 papers from 12 research traditions, which were distinguished by health profession and paradigmatic approach. Empirical findings were considered in four broad themes: learner, educational intervention, institutional context and wider context. Most studies provided evidence on the learner, with findings indicating a positive impact of international placements on personal and professional development. The development of cultural competency has been more focus in research in nursing and allied health than in medicine. Whereas earlier research has focussed on the experience and outcomes for the learner, more recent studies have become more concerned with relationships between various stakeholder groups. Only few studies have looked at strategies to enhance the educational process. CONCLUSION: The consideration of empirical work from different perspectives provides novel understandings of what research has achieved and what needs further investigation. Future studies should pay more attention to the complex nature of the educational process in international placements.

Negotiating grey areas: an interview-based analysis of paramedic uncertainty and decision-making in cardiac arrest events.

BACKGROUND: Paramedics are responsible for critical resuscitation decisions when attending Out of Hospital Cardiac Arrests (OHCA). Existing research indicates that a range of clinical and non-clinical factors moderate their decision-making. Within the United Kingdom (UK), there is little evidence on how and why paramedics make their decisions at actual OHCA events. METHODS: We explored the experiences of UK paramedics using individually recalled OHCA events as catalysts for discussion. Pen portraits developed from semi-structured interviews with 31 paramedics across two UK ambulance services were thematically analysed, enabling cross-participant comparisons whilst retaining depth and context. RESULTS: We identified four themes: uncertainties encountered in resuscitation guidelines, influences on decision-making, holistic perspectives, and indirect moderators. We found that paramedics experienced uncertainty at all stages of the resuscitation process. Uncertainties arose from indeterminate, ambiguous or complex information and were described as having both clinical and ethical dimensions. Whilst guidelines drove paramedics' decisions, non-clinical personal, practical and relational factors moderated their assessments of survivability and decision-making, with attitudes to interactions between patient age, frailty and quality of life playing a substantial role. Coping strategies such as uncertainty reduction, assumption-based reasoning and weighing pros and cons were evident from interviews. CONCLUSIONS: The complexity of interactions between clinical and non-clinical factors points to an element of variability in paramedics' responses to uncertainty. Exploring UK paramedics' uncertainties and decision-making during specific OHCA events can help acknowledge and address uncertainties in resuscitation guidelines and paramedic training, providing paramedics with the tools to manage uncertainty in a consistent and transparent way.

Chronic Headache Education and Self-Management Study (CHESS): a process evaluation.

BACKGROUND: The Chronic Headache Education and Self-Management Study (CHESS) multicentre randomised trial evaluated the impact a group education and self-management support intervention with a best usual care plus relaxation control for people living with chronic headache disorders (tension type headaches or chronic migraine, with or without medication overuse headache). Here we report the process evaluation exploring potential explanations for the lack of positive effects from the CHESS intervention. METHODS: The CHESS trial included 736 (380 intervention: 356 control) people across the Midlands and London UK. We used a mixed methods approach. Our extensive process evaluation looked at context, reach, recruitment, dose delivered, dose received, fidelity and experiences of participating in the trial, and included participants and trial staff. We also looked for evidence in our qualitative data to investigate whether the original causal assumptions underpinning the intervention were realised. RESULTS: The CHESS trial reached out to a large diverse population and recruited a representative sample. Few people with chronic tension type headaches without migraine were identified and recruited. The expected 'dose'of the intervention was delivered to participants and intervention fidelity was high. Attendance ("dose received") fell below expectation, although 261/380 (69%) received at least at least the pre-identified minimum dose. Intervention participants generally enjoyed being in the groups but there was little evidence to support the causal assumptions underpinning the intervention were realised. CONCLUSIONS: From a process evaluation perspective despite our extensive data collection and analysis, we do not have a clear understanding of why the trial outcome was negative as the intervention was delivered as planned. However, the lack of evidence that the intervention causal assumptions brought about the planned behaviour change may provide some insight. Our data suggests only modest changes in managing headache behaviours and some disparity in how participants engaged with components of the intervention within the timeframe of the study. Moving forwards, we need a better understanding of how those who live with chronic headache can be helped to manage this disabling condition more effectively over time. TRIAL REGISTRATION: ISRCTN79708100 .

Intravaginal lactic acid gel versus oral metronidazole for treating women with recurrent bacterial vaginosis: the VITA randomised controlled trial.

BACKGROUND: Bacterial vaginosis is a common and distressing condition for women. Short-term antibiotic treatment is usually clinically effective, but recurrence is common. We assessed the effectiveness of intravaginal lactic acid gel versus oral metronidazole for treating recurrent bacterial vaginosis. METHODS: We undertook an open-label, multicentre, parallel group, randomised controlled trial in nineteen UK sexual health clinics and a university health centre. Women aged ≥ 16 years, with current bacterial vaginosis symptoms and a preceding history of bacterial vaginosis, were randomised in a 1:1 ratio using a web-based minimisation algorithm, to 400 mg twice daily oral metronidazole tablets or 5 ml once daily intravaginal lactic acid gel, for 7 days. Masking of participants was not possible. The primary outcome was participant-reported resolution of symptoms within 2 weeks. Secondary outcomes included time to first recurrence of symptoms, number of recurrences and repeat treatments over 6 months and side effects. RESULTS: Five hundred and eighteen participants were randomised before the trial was advised to stop recruiting by the Data Monitoring Committee. Primary outcome data were available for 79% (204/259) allocated to metronidazole and 79% (205/259) allocated to lactic acid gel. Resolution of bacterial vaginosis symptoms within 2 weeks was reported in 70% (143/204) receiving metronidazole versus 47% (97/205) receiving lactic acid gel (adjusted risk difference -23·2%; 95% confidence interval -32.3 to -14·0%). In those participants who had initial resolution and for whom 6 month data were available, 51 of 72 (71%) women in the metronidazole group and 32 of 46 women (70%) in the lactic acid gel group had recurrence of symptoms, with median times to first recurrence of 92 and 126 days, respectively. Reported side effects were more common following metronidazole than lactic acid gel (nausea 32% vs. 8%; taste changes 18% vs. 1%; diarrhoea 20% vs. 6%, respectively). CONCLUSIONS: Metronidazole was more effective than lactic acid gel for short-term resolution of bacterial vaginosis symptoms, but recurrence is common following both treatments. Lactic acid gel was associated with fewer reported side effects. TRIAL REGISTRATION: ISRCTN14161293 , prospectively registered on 18th September 2017.

Evaluating interventions to improve ethical decision making in clinical practice: a review of the literature and reflections on the challenges posed.

Since the 1980s, there has been an increasing acknowledgement of the importance of recognising the ethical dimension of clinical decision-making. Medical professional regulatory authorities in some countries now include ethical knowledge and practice in their required competencies for undergraduate and post graduate medical training. Educational interventions and clinical ethics support services have been developed to support and improve ethical decision making in clinical practice, but research evaluating the effectiveness of these interventions has been limited. We undertook a systematic review of the published literature on measures or models of evaluation used to assess the impact of interventions to improve ethical decision making in clinical care. We identified a range of measures to evaluate educational interventions, and one tool used to evaluate a clinical ethics support intervention. Most measures did not evaluate the key impact of interest, that is the quality of ethical decision making in real-world clinical practice. We describe the results of our review and reflect on the challenges of assessing ethical decision making in clinical practice that face both developers of educational and support interventions and the regulatory organisations that set and assess competency standards.

The effect of a roving nurse mentor on household coverage and quality of care provided by community health worker teams in South Africa: a longitudinal study with a before, after and 6 months post design.

OBJECTIVE: Community health workers (CHW) are undertaking more complex tasks as part of the move towards universal health coverage in many low- and middle-income settings. They are expected to provide promotive and preventative care, make referrals to the local clinic, and follow up on non-attendees for a range of health conditions. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle due to inadequate supervision, low levels of CHW literacy, and the marginalized status of CHW in the health system. In this paper, we assess the effect of a roving nurse mentor on the coverage and quality of care of the CHW service in two vulnerable communities in South Africa. PARTICIPANTS: CHW, their supervisors, household members. INTERVENTION: Roving professional nurse mentor to build skills of supervisors and CHW teams. METHODS: Three household surveys to assess household coverage of the CHW service (baseline, end of the intervention, and 6 months after end of intervention); structured observations of CHW working in households to assess quality of care. RESULTS: The intervention led to a sustained 50% increase in the number of households visited by a CHW in the last year. While the proportion of appropriate health messages given to household members by CHW remained constant at approximately 50%, CHW performed a greater range of more complex tasks. They were more likely to visit new households to assess health needs and register the household in the programme, to provide care to pregnant women, children and people who had withdrawn from care. CHW were more likely to discuss with clients the barriers they were facing in accessing care and take notes during a visit. CONCLUSION: A nurse mentor can have a significant effect both on the quantity and quality of CHW work, allowing them to achieve their potential despite their marginalised status in the health system and their limited prior educational achievement. Supportive supervision is important in enabling the benefit of having a health cadre embedded in marginalised communities to be realised.

Spontaneously generated online patient experience data - how and why is it being used in health research: an umbrella scoping review.

PURPOSE: Social media has led to fundamental changes in the way that people look for and share health related information. There is increasing interest in using this spontaneously generated patient experience data as a data source for health research. The aim was to summarise the state of the art regarding how and why SGOPE data has been used in health research. We determined the sites and platforms used as data sources, the purposes of the studies, the tools and methods being used, and any identified research gaps. METHODS: A scoping umbrella review was conducted looking at review papers from 2015 to Jan 2021 that studied the use of SGOPE data for health research. Using keyword searches we identified 1759 papers from which we included 58 relevant studies in our review. RESULTS: Data was used from many individual general or health specific platforms, although Twitter was the most widely used data source. The most frequent purposes were surveillance based, tracking infectious disease, adverse event identification and mental health triaging. Despite the developments in machine learning the reviews included lots of small qualitative studies. Most NLP used supervised methods for sentiment analysis and classification. Very early days, methods need development. Methods not being explained. Disciplinary differences - accuracy tweaks vs application. There is little evidence of any work that either compares the results in both methods on the same data set or brings the ideas together. CONCLUSION: Tools, methods, and techniques are still at an early stage of development, but strong consensus exists that this data source will become very important to patient centred health research.

Supportive supervision from a roving nurse mentor in a community health worker programme: a process evaluation in South Africa.

BACKGROUND: Many low and middle- income countries (LMICs) are repositioning community health worker (CHW) programmes to provide a more comprehensive range of promotive and preventive services and referrals to the formal health service. However, insufficient supervision, fragmented programmes, and the low literacy levels of CHWs often result in the under-performance of the programmes. We evaluate the impact of a roving nurse mentor working with CHW teams proving supportive supervision in a semi-rural area of South Africa. METHODS: We conducted a longitudinal process evaluation, using in-depth interviews, focus groups and observations prior to the intervention, during the intervention, and 6 months post-intervention to assess how the effects of the intervention were generated and sustained. Our participants were CHWs, their supervisors, clients and facility staff members and community representatives. RESULTS: The nurse mentor operated in an environment of resource shortages, conflicts between CHWs and facility staff, and an active CHW labour union. Over 15 months, the mentor was able to (1) support and train CHWs and their supervisors to gain and practice new skills, (2) address their fears of failing and (3) establish operational systems to address inefficiencies in the CHWs' activities, resulting in improved service provision. Towards the end of the intervention the direct employment of the CHWs by the Department of Health and an increase in their stipend added to their motivation and integration into the local primary care clinic team. However, given the communities' focus on accessing government housing, rather than better healthcare, and volatile nature of the communities, the nurse mentor was not able to establish a collaboration with local structures. CONCLUSIONS: A roving nurse mentor overseeing several CHW teams within a district healthcare system is a feasible option, particularly in a context where there is a shortage of qualified supervisors to support CHWs activities. A roving nurse mentor can contribute to the knowledge and skills development of the CHWs and enhance the capacity of junior supervisors. However, the long-term sustainability of the effects of intervention is dependent on CHWs' formal employment by the Department of Health.

Evidence generated from a realist synthesis of trials on educational weight loss interventions in type 2 diabetes mellitus.

BACKGROUND: Obesity and diabetes are major public health problems. Current approaches to weight loss show varying success. Complex community-based interventions work through several interconnected stages. An individual's actions in response to an intervention depend on many known and unknown factors, which vary among individuals. AIM: To conduct a realist synthesis to identify in which context, for whom, in what circumstances, and how weight loss interventions work in obese or overweight individuals with type 2 diabetes. METHODS: A total of 49 trials identified during a systematic review were subsequently analysed using realist methodology. This iterative process involved hypothesis generation about how participants within a particular context respond to an intervention's resources producing the outcomes. We used established behaviour change theory to look for repeating themes. Theory and 'mechanisms' were tested against the literature on what is shown to be effective. Where established theory was lacking, we discussed issues during discussion groups with individuals living with the condition to generate our own programme theories. RESULTS: Mechanisms that were repeatedly identified included high-frequency contact with those delivering the intervention, social support, education increasing awareness of diabetes-related modifiable risk factors, motivational interviewing and counselling, goal-setting, self-monitoring and feedback and meal replacements. The central theme underlying successful mechanisms was personalising each intervention component to the participants' gender, culture and family setting. CONCLUSION: This is the first comprehensive realist synthesis in this field. Our findings suggest that, for weight loss interventions to be successful in those with diabetes, they must be personalized to the individual and their specific context.

Measuring health-related quality of life in chronic headache: A comparative evaluation of the Chronic Headache Quality of Life Questionnaire and Headache Impact Test (HIT-6).

OBJECTIVE: To compare the quality and acceptability of a new headache-specific patient-reported measure, the Chronic Headache Quality of Life Questionnaire (CHQLQ) with the six-item Headache Impact Test (HIT-6), in people meeting an epidemiological definition of chronic headaches. METHODS: Participants in the feasibility stage of the Chronic Headache Education and Self-management Study (CHESS) (n = 130) completed measures three times during a 12-week prospective cohort study. Data quality, measurement acceptability, reliability, validity, responsiveness to change, and score interpretation were determined. Semi-structured cognitive interviews explored measurement relevance, acceptability, clarity, and comprehensiveness. RESULTS: Both measures were well completed with few missing items. The CHQLQ's inclusion of emotional wellbeing items increased its relevance to participant's experience of chronic headache. End effects were present at item level only for both measures. Structural assessment supported the three and one-factor solutions of the CHQLQ and HIT-6, respectively. Both the CHQLQ (range 0.87 to 0.94) and HIT-6 (0.90) were internally consistent, with acceptable temporal stability over 2 weeks (CHQLQ range 0.74 to 0.80; HIT-6 0.86). Both measures responded to change in headache-specific health at 12 weeks (CHQLQ smallest detectable change (improvement) range 3 to 5; HIT-6 2.1). CONCLUSIONS: While both measures are structurally valid, internally consistent, temporally stable, and responsive to change, the CHQLQ has greater relevance to the patient experience of chronic headache.Trial registration number: ISRCTN79708100. Registered 16th December 2015, http://www.isrctn.com/ISRCTN79708100.

Ethical conflicts during the process of deciding about ICU admission: an empirically driven ethical analysis.

BACKGROUND: Besides balancing burdens and benefits of intensive care, ethical conflicts in the process of decision-making should also be recognised. This calls for an ethical analysis relevant to clinicians. The aim was to analyse ethically difficult situations in the process of deciding whether a patient is admitted to intensive care unit (ICU). METHODS: Analysis using the 'Dilemma method' and 'wide reflective equilibrium', on ethnographic data of 45 patient cases and 96 stakeholder interviews in six UK hospitals. ETHICAL ANALYSIS: Four moral questions and associated value conflicts were identified. (1) Who should have the right to decide whether a patient needs to be reviewed? Conflicting perspectives on safety/security. (2) Does the benefit to the patient of getting the decision right justify the cost to the patient of a delay in making the decision? Preventing longer-term suffering and understanding patient's values conflicted with preventing short-term suffering and provision of security. (3) To what extent should the intensivist gain others' input? Professional independence versus a holistic approach to decision-making. (4) Should the intensivist have an ongoing duty of care to patients not admitted to ICU? Short-term versus longer-term duty to protect patient safety. Safety and security (experienced in a holistic sense of physical and emotional security for patients) were key values at stake in the ethical conflicts identified. The life-threatening nature of the situation meant that the principle of autonomy was overshadowed by the duty to protect patients from harm. The need to fairly balance obligations to the referred patient and to other patients was also recognised. CONCLUSION: Proactive decision-making including advance care planning and escalation of treatment decisions may support the inclusion of patient autonomy. However, our analysis invites binary choices, which may not sufficiently reflect reality. This calls for a complementary relational ethics analysis.

Bayesian belief network modelling of household food security in rural South Africa.

BACKGROUND: Achieving food security remains a key challenge for public policy throughout the world. As such, understanding the determinants of food insecurity and the causal relationships between them is an important scientific question. We aim to construct a Bayesian belief network model of food security in rural South Africa to act as a tool for decision support in the design of interventions. METHODS: Here, we use data from the Agincourt Health and Socio-demographic Surveillance System (HDSS) study area, which is close to the Mozambique border in a low-income region of South Africa, together with Bayesian belief network (BBN) methodology to address this question. RESULTS: We find that a combination of expert elicitation and learning from data produces the most credible set of causal relationships, as well as the greatest predictive performance with 10-fold cross validation resulting in a Briers score 0.0846, information reward of 0.5590, and Bayesian information reward of 0.0057. We report the resulting model as a directed acyclic graph (DAG) that can be used to model the expected effects of complex interventions to improve food security. Applications to sensitivity analyses and interventional simulations show ways the model can be applied as tool for decision support for human experts in deciding on interventions. CONCLUSIONS: The resulting models can form the basis of the iterative generation of a robust causal model of household food security in the Agincourt HDSS study area and in other similar populations.

Evaluation of a self-help intervention to promote the health and wellbeing of marginalised people including those living with leprosy in Nepal: a prospective, observational, cluster-based, cohort study with controls.

BACKGROUND: People affected by leprosy are at increased risk of ulcers from peripheral nerve damage. This in turn can lead to visible impairments, stigmatisation and economic marginalisation. Health care providers suggest that patients should be empowered to self-manage their condition to improve outcomes and reduce reliance on services. Self-care involves carrying out personal care tasks with the aim of preventing disabilities or preventing further deterioration. Self-help, on the other hand, addresses the wider psychological, social and economic implications of leprosy and incorporates, for example, skills training and microfinance schemes. The aim of this study, known as SHERPA (Self-Help Evaluation for lepRosy and other conditions in NePAl) is to evaluate a service intervention called Integrated Mobilization of People for Active Community Transformation (IMPACT) designed to encourage both self-care and self-help in marginalised people including those affected by leprosy. METHODS: A mixed-method evaluation study in Province 5, Nepal comprising two parts. First, a prospective, cluster-based, non-randomised controlled study to evaluate the effectiveness of self-help groups on ulcer metrics (people affected by leprosy only) and on four generic outcome measures (all participants) - generic health status, wellbeing, social integration and household economic performance. Second, a qualitative study to examine the implementation and fidelity of the intervention. IMPACT: This research will provide information on the effectiveness of combined self-help and self-care groups, on quality of life, social integration and economic wellbeing for people living with leprosy, disability or who are socially and economically marginalised in low- and middle- income countries.

General practitioners' experiences of emergency care and treatment planning in England: a focus group study.

BACKGROUND: Emergency Care and Treatment Plans are recommended for all primary care patients in the United Kingdom who are expected to experience deterioration of their health. The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was developed to integrate resuscitation decisions with discussions about wider goals of care. It summarises treatment recommendations discussed and agreed between patients and their clinicians for a future emergency situation and was designed to meet the needs of different care settings. Our aim is to explore GPs' experiences of using ReSPECT and how it transfers across the primary care and secondary care interface. METHODS: We conducted five focus groups with GPs in areas being served by hospitals in England that have implemented ReSPECT. Participants were asked about their experience of ReSPECT, how they initiate ReSPECT-type conversations, and their experiences of ReSPECT-type recommendations being communicated across primary and secondary care. Focus groups were transcribed and analysed using Thematic Analysis. RESULTS: GPs conceptualise ReSPECT as an end of life planning document, which is best completed in primary care. As an end of life care document, completing ReSPECT is an emotional process and conversations are shaped by what a 'good death' is thought to be. ReSPECT recommendations are not always communicated or transferable across care settings. A focus on the patient's preferences around death, and GPs' lack of specialist knowledge, could be a barrier to completion of ReSPECT that is transferable to acute settings. CONCLUSION: Conceptualising ReSPECT as an end of life care document suggests a difference in how general practitioners understand ReSPECT from its designers. This impacts on the transferability of ReSPECT recommendations to the hospital setting.

Custodians of Information: Patient and Physician Views on Sharing Medical Records in the Acute Care Setting.

In the UK, in the acute in-patient setting, the only information that a patient receives about their medical care is verbal; there is no routine patient access to any part of the medical record. It has been suggested that this should change, so that patients can have real-time access to their notes, but no one has previously explored patient or clinician views on the impact this might have. Semi-structured interviews were conducted with 12 patients and 13 doctors about their experience of information sharing in the context of the acute care setting, and their views on sharing all of the medical records, or a summary note. Interviews were transcribed verbatim, double coded and analyzed using the constant comparative method. Patients were not given written information and did not ask questions even when they wanted to know things. Patients and doctors supported increased sharing of written information, but the purpose of the medical record - and the risks and benefits of sharing it - were disputed. Concerns included disclosing uncertainty, changing what was written, and causing patient anxiety. Benefits included increased transparency. Use of a summary record was welcomed as a way to empower patients, while doctors felt they had a responsibility to curate what information was given and when. A clinical summary for patients would be of benefit to doctors, nurses, patients and their relatives. It should be designed to reflect the needs of all users, and evaluated to consider patient-relevant outcomes and resource implications.

Health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis.

BACKGROUND: Mobile health (mHealth), refers to healthcare practices supported by mobile devices, such as mobile phones and tablets. Within primary care, health workers often use mobile devices to register clients, track their health, and make decisions about care, as well as to communicate with clients and other health workers. An understanding of how health workers relate to, and experience mHealth, can help in its implementation. OBJECTIVES: To synthesise qualitative research evidence on health workers' perceptions and experiences of using mHealth technologies to deliver primary healthcare services, and to develop hypotheses about why some technologies are more effective than others. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL, Science Citation Index and Social Sciences Citation Index in January 2018. We searched Global Health in December 2015. We screened the reference lists of included studies and key references and searched seven sources for grey literature (16 February to 5 March 2018). We re-ran the search strategies in February 2020. We screened these records and any studies that we identified as potentially relevant are awaiting classification. SELECTION CRITERIA: We included studies that used qualitative data collection and analysis methods. We included studies of mHealth programmes that were part of primary healthcare services. These services could be implemented in public or private primary healthcare facilities, community and workplace, or the homes of clients. We included all categories of health workers, as well as those persons who supported the delivery and management of the mHealth programmes. We excluded participants identified as technical staff who developed and maintained the mHealth technology, without otherwise being involved in the programme delivery. We included studies conducted in any country. DATA COLLECTION AND ANALYSIS: We assessed abstracts, titles and full-text papers according to the inclusion criteria. We found 53 studies that met the inclusion criteria and sampled 43 of these for our analysis. For the 43 sampled studies, we extracted information, such as country, health worker category, and the mHealth technology. We used a thematic analysis process. We used GRADE-CERQual to assess our confidence in the findings. MAIN RESULTS: Most of the 43 included sample studies were from low- or middle-income countries. In many of the studies, the mobile devices had decision support software loaded onto them, which showed the steps the health workers had to follow when they provided health care. Other uses included in-person and/or text message communication, and recording clients' health information. Almost half of the studies looked at health workers' use of mobile devices for mother, child, and newborn health. We have moderate or high confidence in the following findings. mHealth changed how health workers worked with each other: health workers appreciated being more connected to colleagues, and thought that this improved co-ordination and quality of care. However, some described problems when senior colleagues did not respond or responded in anger. Some preferred face-to-face connection with colleagues. Some believed that mHealth improved their reporting, while others compared it to "big brother watching". mHealth changed how health workers delivered care: health workers appreciated how mHealth let them take on new tasks, work flexibly, and reach clients in difficult-to-reach areas. They appreciated mHealth when it improved feedback, speed and workflow, but not when it was slow or time consuming. Some health workers found decision support software useful; others thought it threatened their clinical skills. Most health workers saw mHealth as better than paper, but some preferred paper. Some health workers saw mHealth as creating more work. mHealth led to new forms of engagement and relationships with clients and communities: health workers felt that communicating with clients by mobile phone improved care and their relationships with clients, but felt that some clients needed face-to-face contact. Health workers were aware of the importance of protecting confidential client information when using mobile devices. Some health workers did not mind being contacted by clients outside working hours, while others wanted boundaries. Health workers described how some community members trusted health workers that used mHealth while others were sceptical. Health workers pointed to problems when clients needed to own their own phones. Health workers' use and perceptions of mHealth could be influenced by factors tied to costs, the health worker, the technology, the health system and society, poor network access, and poor access to electricity: some health workers did not mind covering extra costs. Others complained that phone credit was not delivered on time. Health workers who were accustomed to using mobile phones were sometimes more positive towards mHealth. Others with less experience, were sometimes embarrassed about making mistakes in front of clients or worried about job security. Health workers wanted training, technical support, user-friendly devices, and systems that were integrated into existing electronic health systems. The main challenges health workers experienced were poor network connections, access to electricity, and the cost of recharging phones. Other problems included damaged phones. Factors outside the health system also influenced how health workers experienced mHealth, including language, gender, and poverty issues. Health workers felt that their commitment to clients helped them cope with these challenges. AUTHORS' CONCLUSIONS: Our findings propose a nuanced view about mHealth programmes. The complexities of healthcare delivery and human interactions defy simplistic conclusions on how health workers will perceive and experience their use of mHealth. Perceptions reflect the interplay between the technology, contexts, and human attributes. Detailed descriptions of the programme, implementation processes and contexts, alongside effectiveness studies, will help to unravel this interplay to formulate hypotheses regarding the effectiveness of mHealth.

A qualitative exploration of the experiences of community health animation on malaria control in rural Malawi.

BACKGROUND: While great strides have been achieved in fighting malaria through the Roll Back Malaria (RBM) strategy, the recent world malaria report shows an increase in malaria-related deaths compared to previous years. Malaria control tools are efficacious and effective in preventing the disease; however, the human behaviour aspect of the intervention strategies is weak due to heavy reliance on positive human health behaviour. The challenge lies in adoption of control interventions by the target population which, to an extent, may include access to prevention and treatment tools. We present a qualitative assessment of the use of the Health Animator (HA) model for Information, Education and Communication (IEC) to improve adoption and use of malaria control by promoting positive health behaviours. RESULTS: We conducted 3 Focus Group Discussions (FGDs) and 23 individual in-depth interviews (IDIs) with HAs. Each FGD consisted of 8 participants. Data was analysed using QSR International NVivo 10 software. There are four main themes emerging regarding HA experiences. The perceptions include; collaborative work experience, personal motivation and growth, community participation with health animation and challenges with implementation. Results suggest that HAs were pleased with the training as they gained new information regarding malaria, which affected their use of malaria control interventions within their families. Knowledge was well assimilated from the trainings and influenced personal growth in becoming a community leader. Support from the leadership within the village and the health system was important in legitimising the main messages. The community responded positively to the workshops valued the information imparted. The voluntary nature of the work in a poverty-stricken community affected sustainability. CONCLUSIONS: There is need to empower communities with strategies within their reach. Functioning traditional social support structures are a crucial element in sustainability. Voluntarism is also key for sustainability, especially for rural and remote communities with limited sources of income.

Perceptions and Experiences of Internet-Based Testing for Sexually Transmitted Infections: Systematic Review and Synthesis of Qualitative Research.

BACKGROUND: Internet-based testing for sexually transmitted infections (STIs) allows asymptomatic individuals to order a self-sampling kit online and receive their results electronically, reducing the need to attend a clinic unless for treatment. This approach has become increasingly common; however, there is evidence that barriers exist to accessing it, particularly among some high-risk populations. We review the qualitative evidence on this topic, as qualitative research is well-placed to identify the complex influences that relate to accessing testing. OBJECTIVE: This paper aims to explore perceptions and experiences of internet-based testing for STIs among users and potential users. METHODS: Searches were run through 5 electronic databases (CINAHL, EMBASE, MEDLINE, PsycINFO, and Web of Science) to identify peer-reviewed studies published between 2005 and 2018. Search terms were drawn from 4 categories: STIs, testing or screening, digital health, and qualitative methods. Included studies were conducted in high-income countries and explored patient perceptions or experiences of internet-based testing, and data underwent thematic synthesis. RESULTS: A total of 11 studies from the 1735 studies identified in the initial search were included in the review. The synthesis identified that internet-based testing is viewed widely as being acceptable and is preferred over clinic testing by many individuals due to perceived convenience and anonymity. However, a number of studies identified concerns relating to test accuracy and lack of communication with practitioners, particularly when receiving results. There was a lack of consensus on preferred media for results delivery, although convenience and confidentiality were again strong influencing factors. The majority of included studies were limited by the fact that they researched hypothetical services. CONCLUSIONS: Internet-based testing providers may benefit from emphasizing this testing's comparative convenience and privacy compared with face-to-face testing in order to improve uptake, as well as alleviating concerns about the self-sampling process. There is a clear need for further research exploring in depth the perceptions and experiences of people who have accessed internet-based testing and for research on internet-based testing that explicitly gathers the views of populations that are at high risk of STIs. TRIAL REGISTRATION: PROSPERO CRD42019146938; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=146938.