Being tested but not educated - Patients' perceptions of diabetic dietary advice.

Background Diet is a key component of the management of diabetes. Several studies suggest that patients receive insufficient and inadequate information. As a first step for developing an intervention for improving dietary advice in primary care, we aimed to explore patients’ experience of receiving dietary advice; their attitudes towards that advice; their perceived dietary advice needs, and any barriers faced in adopting a diet that supports the management of their diabetes. Methods A qualitative study with three focus groups (20 purposively sampled participants) was conducted with adult primary care patients with Type 2 diabetes in 2016. A semi-structured topic guide was developed from the literature. The focus groups were audio recorded and transcribed. The data were analysed by emergent themes analysis. Data saturation was achieved in the third focus group. Results The majority of participants were given dietary advice in the form of a generic healthy eating leaflet from a Practice Nurse. Participants had their Haemoglobin A1c (HbA1c) reviewed regularly, but the results seemed not to be linked with review of dietary habits. The test was perceived as being a “pass or fail”, judgmental experience. Participants felt tested but not educated. Conclusion Individuals with type 2 diabetes seem not to receive dietary advice according to their expectations. Information collected as part of the study can be used to inform the development of interventions aimed at improving dietary advice in this population

Towards equity: a qualitative exploration of the implementation and impact of a digital educational intervention for pharmacy professionals in England.

Background: Patients belonging to marginalised (medically under-served) groups experience problems with medicines (i.e. non-adherence, side effects) and poorer health outcomes largely due to inequitable access to healthcare (arising from poor governance, cultural exclusion etc.). In order to promote service equity and outcomes for patients, the focus of this paper is to explore the implementation and impact of a new co-produced digital educational intervention on one National Health Service (NHS) funded community pharmacy medicines management service. Methods: Semi-structured interviews with a total of 32 participants. This included a purposive sample of 22 community pharmacy professionals, (16 pharmacists and 6 pharmacy support staff) all who offered the medicine management service. In order to obtain a fuller picture of the barriers to learning, five professionals who were unable to complete the learning were also included. Ten patients (from a marginalised group) who had received the service (as a result of the digital educational intervention) were also interviewed. Drawing on an interpretative analysis, Normalisation Process Theory (NPT) was used as a theoretical framework. Results: Three themes are explored. The first is how the digital learning intervention was implemented and applied. Despite being well received, pharmacists found it challenging completing and cascading the learning due to organisational constraints (e.g. lack of time, workload). Using the four NPT constructs (coherence, cognitive participation, collective action and reflexive monitoring) the second theme exposes the impact of the learning and the organisational process of ‘normalisation’. Professional reflective accounts revealed instances where inequitable access to health services were evident. Those completing the intervention felt more aware, capable and better equipped to engage with the needs of patients who were from a marginalised group. Operationally there was minimal structural change in service delivery constraining translation of learning to practice. The impact on patients, explored in our final theme, revealed that they experience significant disadvantage and problems with their medicines. The medication review was welcomed and the discussion with the pharmacist was helpful in addressing their medicine-related concerns. Conclusions: The co-produced digital educational intervention increases pharmacy professionals’ awareness and motivation to engage with marginalised groups. However structural barriers often hindered translation into practice. Patients reported significant health and medicine challenges that were going unnoticed. They welcomed the additional support the medication review offered. Policy makers and employers should better enable and facilitate ways for pharmacy professionals to better engage with marginalised groups. The impact of the educational intervention on patients’ health and medicines management could be substantial if supported and promoted effectively

Pharmacy students’ professionalism and perceptions in supporting the care of people living with experience of mental health challenges: A feedback-driven qualitative narrative

Background: Internalised Stigma is considered to be the main barrier to people receiving effective treatment for mental health problems (Knaak et al, 2017). As healthcare students become more professionalised, they learn how to provide optimal quality care to all patients. Experiential models of learning complemented with feedback and debriefing are said to be one of the approaches to preparing healthcare professionals who are work ready (Tavares et al, 2019). Method: We collected feedback data from people living with mental health experiences following an experiential learning activity via interactive learning sessions (ILS) and focus group discussions (FGDs). We manually analysed the data for themes; after which, we used the data as a guide for a series of semi-structured in-depth interviews with MPharm students. Results: Main themes emerged from the FDGs were that people living mental health experiences want to be seen as a person, not a prescription. They also appreciated that there is no “magic bullet” to solve all of the challenges. MPharm students felt that the environment for learning was enriching; however, they felt they needed more time to apply their knowledge and skills. When prompted that people with experiences of mental health would want to be looked at as a person and not a prescription; MPharm students appreciated the feedback. However, they felt they needed to also ensure that they are applying their pharmacotherapy knowledge. Conclusion: ILS with content-based learning improved students’ perceptions of mental health issues. Moreover, the feedback-driven, real-world experiences and experiential learning in the education of pharmacy students, was well-received by MPharm students. Not only does this benefit students’ education, it has also allowed for those with mental health experiences to communicate their concerns in education of future healthcare professionals, as well as enhance their abilities to ‘tell their story’ more effectively, without fear of stigma or judgement

Supporting underserved patients with their medicines: a study protocol for a patient/professional coproduced education intervention for community pharmacy staff to improve the provision and delivery of Medicine Use Reviews (MURs)

Introduction Community pharmacy increasingly features in global strategies to modernise the delivery of primary healthcare. Medicine Use Reviews (MURs) form part of the English Government's medicines management strategy to improve adherence and reduce medicine waste. MURs provide space for patient–pharmacist dialogue to discuss the well-known problems patients experience with medicine taking. However, ‘underserved’ communities (eg, black and minority ethnic communities, people with mental illness), who may benefit the most, may not receive this support. This study aims to develop, implement and evaluate an e-learning education intervention which is coproduced between patients from underserved communities and pharmacy teams to improve MUR provision. Methods and analysis This mixed-methods evaluative study will involve a 2-stage design. Stage 1 involves coproduction of an e-learning resource through mixed patient–professional development (n=2) and review (n=2) workshops, alongside informative semistructured interviews with patients (n=10) and pharmacy staff (n=10). Stage 2 involves the implementation and evaluation of the intervention with community pharmacy staff within all community pharmacies within the Nottinghamshire geographical area (n=237). Online questionnaires will be completed at baseline and postintervention (3 months) to assess changes in engagement with underserved communities and changes in self-reported attitudes and behaviour. To triangulate findings, 10 pharmacies will record at baseline and postintervention, details of actual numbers of MURs performed and the proportion that are from underserved communities. Descriptive and inferential statistics will be used to analyse the data. The evaluation will also include a thematic analysis of one-to-one interviews with pharmacy teams to explore the impact on clinical practice (n=20). Interviews with patients belonging to underserved communities, and who received an MUR, will also be conducted (n=20). Ethics and dissemination The study has received ethical approval from the NHS Research Ethics Committee (East Midlands–Derby) and governance clearance through the NHS Health Research Authority. Following the evaluation, the educational intervention will be freely accessible online

Supporting the provision of pharmacy medication reviews to marginalised (medically underserved) groups: a before/ after questionnaire study investigating the impact of a patient-professional co-produced digital educational intervention.

Objectives People who are marginalised (medically underserved) experience significant health disparities and their voices are often ‘seldom heard’. Interventions to improve professional awareness and engagement with these groups are urgently needed. This study uses a co-production approach to develop an online digital educational intervention in order to improve pharmacy staffs’ intention to offer a community pharmacy medication review service to medically underserved groups. Design Before/after (3 months) self-completion online questionnaire. Setting Community pharmacies in the Nottinghamshire (England) geographical area. Participants Community pharmacy staff. Intervention Online digital educational intervention. Primary and secondary outcome measures The primary outcome measure was ‘behaviour change intention’ using a validated 12-item survey measure. The secondary outcome measure was pharmacist self-reported recruitment of underserved groups to the medication review service. Results All pharmacies in the Nottinghamshire area (n=237) were approached in June 2017 and responses were received from 149 staff (from 122 pharmacies). At 3 months (after completing the baseline questionnaire), 96 participants (from 80 pharmacies) completed a follow-up questionnaire, of which two-thirds (n=62) reported completing the e-learning. A before/after comparison analysis found an improving trend in all the five constructs of behaviour change intention (intention, social influence, beliefs about capabilities, moral norms and beliefs about consequences), with a significant increase in mean score of participants’ ‘beliefs about capabilities’ (0.44; 95% CI 0.11 to 0.76, p=0.009). In the short-term, no significant change was detected in the number of patients being offered and the patient completing a medication review. Conclusions Although increases in the numbers of patients being offered a medication review was not detected, the intervention has the potential to significantly improve pharmacy professionals’ 'beliefs about capabilities' in the short-term. Wider organisational and policy barriers to engagement with marginasied groups may need to be addressed. Future research should focus on the interplay between digital learning and practice to better identify and understand effective practice change pathways

What are the development priorities for management of type 2 diabetes by general practitioners in Ningbo, China: a qualitative study of patients’ and practitioners’ perspectives

Objectives To explore patients’ and general practitioners’ (GPs’) perspectives on primary care management of patients with type 2 diabetes mellitus (T2DM) in Ningbo, China. We aimed to understand the current benefits and challenges and to identify development priorities. Design Exploratory qualitative descriptive study using face-to-face interviews and analysed by thematic, inductive analysis. Setting 11 primary care facilities spread across the city of Ningbo, China. Participants 23 patients with T2DM and 20 GPs involved in caring for patients with T2DM. Results GPs were considered the first point of contact and providers of information. However, the care varied, and many GPs lacked confidence and felt overworked. The medication was a particularly weak area. The diagnostic screening commenced late, leading to crisis presentations. Patients were variably informed about their condition, contributing to poor adherence. Conclusions Future developments of primary care for T2DM in Ningbo should centre around improving GP confidence and workload and patient education and adherence

Effects of acute and chronic temperature changes on the functional responses of the dogfish Scyliorhinus canicula (Linnaeus, 1758) towards amphipod prey Echinogammarus marinus (Leach, 1815)

Predation is a strong driver of population dynamics and community structure and it is essential to reliably quantify and predict predation impacts on prey populations in a changing thermal landscape. Here, we used comparative functional response analyses to assess how predator-prey interactions between dogfish and invertebrate prey change under different warming scenarios. The Functional Response Type, attack rate, handling time and maximum feeding rate estimates were calculated for Scyliorhinus canicula preying upon Echinogammarus marinus under temperatures of 11.3 °C and 16.3 °C, which represent both the potential daily variation and predicted higher summer temperatures within Strangford Lough, N. Ireland. A two x two design of “Predator Acclimated”, “Prey Acclimated”, “Both Acclimated”, and “Both Unacclimated” was implemented to test functional responses to temperature rise. Attack rate was higher at 11.3 °C than at 16.3 °C, but handling time was lower and maximum feeding rates were higher at 16.3 °C. Non-acclimated predators had similar maximum feeding rate towards non-acclimated and acclimated prey, whereas acclimated predators had significantly higher maximum feeding rates towards acclimated prey as compared to non-acclimated prey. Results suggests that the predator attack rate is decreased by increasing temperature but when both predator and prey are acclimated the shorter handling times considerably increase predator impact. The functional response of the fish changed from Type II to Type III with an increase in temperature, except when only the prey were acclimated. This change from population destabilizing Type II to more stabilizing Type III could confer protection to prey at low densities but increase the maximum feeding rate by Scyliorhinus canicula in the future. However, predator movement between different thermal regimes may maintain a Type II response, albeit with a lower maximum feeding rate. This has implications for the way the increasing population Scyliorhinus canicula in the Irish Sea may exploit valuable fisheries stocks in the future

Predicting predatory impact of juvenile invasive lionfish (Pterois volitans) on a crustacean prey using functional response analysis: effects of temperature, habitat complexity and light regimes

The ecological implications of biotic interactions, such as predator-prey relationships, are often context-dependent. Comparative functional responses analysis can be used under different abiotic contexts to improve understanding and prediction of the ecological impact of invasive species. Pterois volitans (Lionfish) [Linnaeus 1758] is an established invasive species in the Caribbean and Gulf of Mexico, with a more recent invasion into the Mediterranean. Lionfish are generalist predators that impact a wide range of commercial and non-commercial species. Functional response analysis was employed to quantify interaction strength between lionfish and a generic prey species, the shrimp (Paleomonetes varians) [Leach 1814], under the contexts of differing temperature, habitat complexity and light wavelength. Lionfish have prey population destabilising Type II functional responses under all contexts examined. Significantly more prey were consumed at 26 °C than at 22 °C. Habitat complexity did not significantly alter the functional response parameters. Significantly more prey were consumed under white light and blue light than under red light. Attack rate was significantly higher under white light than under blue or red light. Light wavelength did not significantly change handling times. The impacts on prey populations through feeding rates may increase with concomitant temperature increase. As attack rates are very high at low habitat complexity this may elucidate the cause of high impact upon degraded reef ecosystems with low-density prey populations, although there was little protection conferred through habitat complexity. Only red light (i.e. dark) afforded any reduction in predation pressure. Management initiatives should account for these environmental factors when planning mitigation and prevention strategies

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

Our lives, our community: The voice of the public on domestic abuse and child safeguarding concerns.

Our lives, our community: The voice of the public on domestic abuse and child safeguarding concerns. J. Solomon and S. Taylor Background Prevention of child and domestic abuse is a public health priority, which requires an integrated approach 1,2. Although it is acknowledged that safeguarding is everybody’s responsibility, this tends to refer to professionals rather than citizens 2. Therefore NHS Primary Care Organizations in the East Midlands commissioned this study to identify the types of scenarios that the public have concerns about, and their thresholds for those concerns. Methods Four qualitative focus groups were conducted with members of the public representing a broad demographic range. Focus groups were recorded, transcribed verbatim, coded thematically and analysed using an interpretive approach. Findings Participants were unsure about whom to refer their concerns to. Furthermore, the emotional distress associated with concerns often acted as a deterrent to reporting. Six categories of types of concern were identified: domestic abuse, neglectful parenting, over-disciplining children, distressed children, suspicious symptoms and inappropriate physical contact. Interpretation There is a need for professionals to listen to the public’s public concerns, offer assistance with signposting and emotional support. The project is continuing to a second stage, in which professional DVD dramatizations have been created of each type of concern. These are being used as a basis of an inter-agency Delphi-style consultation. References 1. Department of Health. Protecting people, Promoting health, 2012. 2. HM Government UK. Working Together to Safeguard Children, 2013