Perceptions towards COVID-19 and adoption of preventive measures among the public in Saudi Arabia: a cross sectional study.

BACKGROUND: Effective management of the spread of a novel infectious disease, such as the COVID-19 virus can be achieved through influencing people's behavior to adopt preventive measures. The public's perceptions and attitudes towards the virus, governmental guidance and preventive measures were unknown in Saudi Arabia. OBJECTIVES: 1) investigate the public perception of COVID-19, anxiety level, the COVID-19 information sources sought, adoption of preventive measures, and ability and willingness to self-isolate during and post-lockdown periods of the COVID-19 pandemic in Saudi Arabia; 2) investigate socio-demographic factors associated with adoption of preventive measures against COVID-19 and self-isolation practices. METHOD: Between April 22nd and June 21st 2020, Saudi adults aged ≥18 years voluntarily completed a self-administered web-based cross-sectional survey, distributed through social media (WhatsApp) and emails to representatives in education, health, business, and social sectors across all Saudi Arabian regions. The survey included questions on anxiety level, COVID-19 risk perceptions and adoption of preventive measures. Weighted percentages, Pearson's chi-square tests, and multiple logistic regression were applied to evaluate associations between these factors and socio-demographic variables. RESULTS: A total of 2393 respondents completed the survey. A majority (74%) were worried about the COVID-19 outbreak and of those, 27% reported that it was likely that they would be infected with COVID-19; 16% believed it would be life-threatening or severe. However, only 11% of respondents reported high anxiety level. Adoption of hygiene practices and social distancing were lower among older (> 65 years) compared to younger (18-24 years) respondents (OR: 0.06; 95% CI: 0.01, 0.28 and OR 0.06; 95% CI: 0.01, 0.27 respectively). High percentages of respondents reported being able to (88%) and were willing to (82%) self-isolate. Those with the lowest gross household income and those with at least one flu symptom were less able and willing to self-isolate. A significant increase in levels of anxiety, perceived effectiveness of social distancing and hygiene practices was reported in the post-lockdown compared to during the lockdown. CONCLUSIONS: The study reported high levels of adoption of preventive measures, willingness and perceived ability to self-isolate during the early phase of the pandemic. Vulnerable groups such as the elderly, and those with low socio-economic status reported lower adoption of preventive measures or ability and willingness to self-isolate. Tailored public health messages and interventions are needed to achieve high adherence to these preventive measures in these groups.

Can health promotion videos 'go viral'? A non-randomised, controlled, before-and-after pilot study to measure the spread and impact of local language mobile videos in Burkina Faso.

BACKGROUND: Mobile phones present a new health communications opportunity but use of mobile videos warrants more exploration. Our study tested a new idea: to produce health promotion videos in languages for which films have never previously been produced to see if they were widely shared. OBJECTIVE: To investigate whether the novelty of films in local languages focusing on health messages would be shared 'virally' among the target population. METHODS: A non-randomised, controlled, before-and-after study was used to evaluate the reach and impact of the intervention. We gave short health promotion videos on memory cards to distributors in eight intervention villages. Ten control villages, where no video distribution took place were randomly selected. We conducted cluster-level difference-in-difference logistic regression to assess self-reported knowledge indicators. We calculated odds ratios for intervention relative to control at baseline and endline and p-values for the change in odds ratios. RESULTS: Seven hundred and eight mothers were interviewed across all villages at baseline and 728 different mothers and 726 men were interviewed in the same villages a year later in October 2015. At endline, 32% of women and 44% of men in the intervention arm had ever seen a film on a mobile phone in Lobiri, compared to 1% of women and 2% of men in the control arm. There was a significant increase in the odds of knowing about giving Orasel to a child with diarrhoea in the intervention area relative to the control area. Awareness of the need to take a child with fever or symptoms of pneumonia to a health centre increased in the intervention area, but not significantly. CONCLUSIONS: Viral sharing of films on mobile phones has the potential to be an effective health promotion tool for communities whose languages are not served by existing mass media channels.

Persistent unexplained physical symptoms: a prospective longitudinal cohort study in UK primary care.

BACKGROUND: Unexplained physical symptoms (UPS) are extremely common among primary care attenders, but little is known about their longer-term outcome. AIM: To investigate the persistence of somatic symptoms at 6 months among a cohort with multiple UPS, and identify prognostic factors associated with worsening symptom scores. DESIGN AND SETTING: Prospective longitudinal cohort study involving adults attending UK general practice in North and Central London between January and December 2013. METHOD: Consecutive adults attending nine general practices were screened to identify those with at least three UPS. Eligible participants completed measures of symptom severity (measured using the Patient Health Questionnaire Somatic Symptom Module [PHQ-15]), physical and mental wellbeing, and past health and social history, and were followed up after 6 months. Multivariable linear regression analysis was conducted to identify prognostic factors associated with the primary outcome: somatic symptom severity. RESULTS: Overall, 245/294 (83%) provided 6-month outcome data. Of these, 135/245 (55%) reported still having UPS, 103/245 (42%) had symptoms still under investigation, and only 26/245 (11%) reported complete symptom resolution. Being female, higher baseline somatic symptom severity, poorer physical functioning, experience of childhood physical abuse, and perception of poor financial wellbeing were significantly associated with higher somatic symptom severity scores at 6 months. CONCLUSION: This study has shown that at 6 months few participants had complete resolution of unexplained somatic symptoms. GPs should be made aware of the likelihood of UPS persisting, and the factors that make this more likely, to inform decision making and care planning. There is a need to develop prognostic tools that can predict the risk of poor outcomes.

Guiding practitioners through end of life care for people with dementia: The use of heuristics.

BACKGROUND: End of life care (EOLC) for people with dementia can present a multitude of challenges and difficult decisions for practitioners. These challenges may include assessment and management of difficulties with eating and swallowing, responding to agitation, treating pain, and managing recurrent infections. Practitioners sometimes lack both confidence in making end of life decisions and guidance. This study developed an alternative to lengthy guidelines, in the form of heuristics which were tested in clinical settings. The aim of this study was to test the usability and acceptability of a set of heuristics which could be used by practitioners providing EOLC for people with dementia in a variety of clinical and care settings. METHODS: A three phase co-design process was adopted: 1) Synthesis of evidence and outputs from interviews and focus groups with family carers and practitioners, by a co-design group, to develop heuristics; 2) Testing of the heuristics in five clinical or care settings for six months; 3) Evaluation of the heuristics at three and six months using qualitative individual and group interviews. RESULTS: Four heuristics were developed covering: eating and swallowing difficulties, agitation and restlessness, reviewing treatment and interventions at the end of life, and providing routine care. The five sites reported that the heuristics were simple and easy to use, comprehensive, and made implicit, tacit knowledge explicit. Four themes emerged from the qualitative evaluation: authority and permission; synthesis of best practice; providing a structure and breaking down complexity; and reassurance and instilling confidence. CONCLUSION: Use of heuristics is a novel approach to end of life decision making in dementia which can be useful to both experienced and junior members of staff making decisions. Heuristics are a practical tool which could overcome a lack of care pathways and direct guidance in end of life care for people with dementia.

A qualitative study exploring the difficulties influencing decision making at the end of life for people with dementia.

BACKGROUND: Dementia is a progressive neurodegenerative condition characterized by declining functional and cognitive abilities. The quality of end of life care for people with dementia in the UK can be poor. Several difficult decisions may arise at the end of life, relating to the care of the person with dementia, for example management of comorbidities. OBJECTIVE: To explore difficulties in decision making for practitioners and family carers at the end of life for people with dementia. DESIGN: Qualitative methodology using focus groups and semi-structured interviews and thematic analysis methods. SETTINGS AND PARTICIPANTS: Former (n=4) and current (n=6) family carers of people with experience of end of life care for a person with dementia were recruited from an English dementia voluntary group in 2015. A further 24 health and care professionals were purposively sampled to include a broad range of expertise and experience in dementia end of life care. RESULTS: Four key themes were identified as follows: challenges of delivering coherent care in dynamic systems; uncertainty amongst decision makers; internal and external conflict amongst decision makers; and a lack of preparedness for the end of life. Overarching difficulties such as poor communication, uncertainty and conflict about the needs of the person with dementia as well as the decision maker's own role can characterize decision making at the end of life. CONCLUSIONS: This study suggests that decision making at the end of life for people with dementia has the potential to be improved. More planning earlier in the course of dementia with an on-going approach to conversation may increase preparedness and family carers' expectations of end of life.

Improving teaching about medically unexplained symptoms for newly qualified doctors in the UK: findings from a questionnaire survey and expert workshop.

OBJECTIVES: Medically unexplained symptoms (MUS) present frequently in healthcare, can be complex and frustrating for clinicians and patients and are often associated with overinvestigation and significant costs. Doctors need to be aware of appropriate management strategies for such patients early in their training. A previous qualitative study with foundation year doctors (junior doctors in their first 2 years postqualification) indicated significant lack of knowledge about this topic and appropriate management strategies. This study reviewed whether, and in what format, UK foundation training programmes for newly qualified doctors include any teaching about MUS and sought recommendations for further development of such training. DESIGN: Mixed-methods design comprising a web-based questionnaire survey and an expert consultation workshop. SETTING: Nineteen foundation schools in England, Wales and Northern Ireland PARTICIPANTS: Questionnaire administered via email to 155 foundation training programme directors (FTPDs) attached to the 19 foundation schools, followed by an expert consultation workshop attended by 13 medical educationalists, FTPDs and junior doctors. RESULTS: The 53/155 (34.2%) FTPDs responding to the questionnaire represented 15 of the 19 foundation schools, but only 6/53 (11%) reported any current formal teaching about MUS within their programmes. However, most recognised the importance of providing such teaching, suggesting 2-3 hours per year. All those attending the expert consultation workshop recommended case-based discussions, role-play and the use of videos to illustrate positive and negative examples of doctor-patient interactions as educational methods of choice. Educational sessions should cover the skills needed to provide appropriate explanations for patients' symptoms as well as avoid unnecessary investigations, and providing information about suitable treatment options. CONCLUSIONS: There is an urgent need to improve foundation level training about MUS, as current provision is very limited. An interactive approach covering a range of topics is recommended, but must be delivered within a realistic time frame for the curriculum.

How do hospital doctors manage patients with medically unexplained symptoms: a qualitative study of physicians.

Objective Medically unexplained symptoms are a common presentation in medical practice and are associated with significant morbidity and high levels of service use. Most research exploring the attitudes and training of doctors in treating patients with unexplained symptoms has been conducted in primary care. This study aims to explore the ways in which doctors working in secondary care approach and manage patients with medically unexplained symptoms. Design A qualitative study using in-depth interviews and thematic analysis. Setting Three hospitals in the North Thames area. Participants Twenty consultant and training-grade physicians working in cardiology, gastroenterology, rheumatology and neurology. Main outcome measure Physicians' approach to patients with medically unexplained symptoms and their views on managing these patients. Results There was considerable variation in how the physicians approached patients who presented with medically unexplained symptoms. Investigations were often ordered without a clear rationale and the explanations given to patients when results of investigations were normal were highly variable, both within and across specialties. The doctor's level of experience appeared to be a more important factor in their investigation and management strategies than their medical specialty. Physicians reported little or no formal training in how to manage such presentations, with no apparent consistency in how they had developed their approach. Doctors described learning from their own experience and from senior role models. Organisational barriers were identified to the effective management of these patients, particularly in terms of continuity of care. Conclusions Given the importance of this topic, there is a need for serious consideration as to how the management of patients with medically unexplained symptoms is included in medical training and in the planning and delivery of services.

A co-design process developing heuristics for practitioners providing end of life care for people with dementia.

BACKGROUND: The end of life for someone with dementia can present many challenges for practitioners; such as, providing care if there are swallowing difficulties. This study aimed to develop a toolkit of heuristics (rules-of-thumb) to aid practitioners making end-of-life care decisions for people with dementia. METHODS: An iterative co-design approach was adopted using a literature review and qualitative methods, including; 1) qualitative interviews and focus groups with family carers and 2) focus groups with health and care professionals. Family carers were recruited from a national charity, purposively sampling those with experience of end-of-life care for a person with dementia. Health and care professionals were purposively sampled to include a broad range of expertise including; general practitioners, palliative care specialists, and geriatricians. A co-design group was established consisting of health and social care experts and family carers, to synthesise the findings from the qualitative work and produce a toolkit of heuristics to be tested in practice. RESULTS: Four broad areas were identified as requiring complex decisions at the end of life; 1) eating/swallowing difficulties, 2) agitation/restlessness, 3) ending life-sustaining treatment, and 4) providing "routine care" at the end of life. Each topic became a heuristic consisting of rules arranged into flowcharts. Eating/swallowing difficulties have three rules; ensuring eating/swallowing difficulties do not come as a surprise, considering if the situation is an emergency, and considering 'comfort feeding' only versus time-trialled artificial feeding. Agitation/restlessness encourages a holistic approach, considering the environment, physical causes, and the carer's wellbeing. Ending life-sustaining treatment supports practitioners through a process of considering the benefits of treatment versus quality-of-life and comfort. Finally, a heuristic on providing routine care such as bathing, prompts practitioners to consider adapting the delivery of care, in order to promote comfort and dignity at the end of life. CONCLUSIONS: The heuristics are easy to use and remember, offering a novel approach to decision making for dementia end-of-life care. They have the potential to be used alongside existing end-of-life care recommendations, adding more readily available practical assistance. This is the first study to synthesise experience and existing evidence into easy-to-use heuristics for dementia end-of-life care.

Junior doctors' experiences of managing patients with medically unexplained symptoms: a qualitative study.

OBJECTIVES: To explore junior doctors' knowledge about and experiences of managing patients with medically unexplained symptoms (MUS) and to seek their recommendations for improved future training on this important topic about which they currently receive little education. DESIGN: Qualitative study using in-depth interviews analysed using the framework method. SETTING: Participants were recruited from three North Thames London hospitals within the UK. PARTICIPANTS: Twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2). RESULTS: The junior doctors interviewed identified a significant gap in their training on the topic of MUS, particularly in relation to their awareness of the topic, the appropriate level of investigations, possible psychological comorbidities, the formulation of suitable explanations for patients' symptoms and longer term management strategies. Many junior doctors expressed feelings of anxiety, frustration and a self-perceived lack of competency in this area, and spoke of over-investigating patients or avoiding patient contact altogether due to the challenging nature of MUS and a difficulty in managing the accompanying uncertainty. They also identified the negative attitudes of some senior clinicians and potential role models towards patients with MUS as a factor contributing to their own attitudes and management choices. Most reported a need for more training during the foundation years, and recommended interactive case-based group discussions with a focus on providing meaningful explanations to patients for their symptoms. CONCLUSIONS: There is an urgent need to improve postgraduate training about the topics of MUS and avoiding over-investigation, as current training does not equip junior doctors with the necessary knowledge and skills to effectively and confidently manage patients in these areas. Training needs to focus on practical skill development to increase clinical knowledge in areas such as delivering suitable explanations, and to incorporate individual management strategies to help junior doctors tolerate the uncertainty associated with MUS.