To develop a questionnaire to measure quantitatively barriers and facilitators to women’s disclosure of perinatal mental health problems in UK primary care. To pilot and evaluate the questionnaire for content validity and internal consistency.

Around 15% of women develop a mental illness in the perinatal period, such as depression, anxiety or post-traumatic stress disorder. In the United Kingdom, 90% of these women will be cared for in primary care, yet currently in as many as 50% of cases, no discussion of this issue takes place. One reason for this is that women experience barriers to disclosing symptoms of perinatal mental illness in primary care. These have previously been explored qualitatively, but no tool currently exists with which to measure these barriers quantitatively.

Questionnaire items, drawn from qualitative literature and accounts of women’s experiences, were identified, refined iteratively and arranged in themes. The questionnaire was piloted using cognitive debriefing interviews to establish content validity. Women completed a refined version online. Responses were analysed using descriptive statistics. Internal consistency of subscales was calculated using Cronbach’s alpha.

Cognitive debriefing interviews with five women showed the majority of questionnaire items were relevant, appropriate and easy to understand. The final questionnaire was completed by 71 women, and the majority of subscales had good internal consistency. The barrier scoring most highly was fear and stigma, followed by willingness to seek help and logistics of attending an appointment. Family/partner support and general practitioners’ (GPs) reaction were the lowest scoring barriers. Factors facilitating disclosure were GPs being empathetic and non-judgemental and listening during discussions. In the future, this questionnaire can be used to examine which barriers are most important for particular groups of women. This may enable the development of strategies to improve acknowledgement and discussion, and prevent under-recognition and under-treatment, of perinatal mental health problems in primary care.

This service aimed to improve patient access to treatment for urinary tract infections (UTI), impetigo and exacerbation of chronic obstructive pulmonary disease (COPD) and relieve pressure on general practice and out of hours services.

In 2016, a service (Pharmacy First) was introduced in Forth Valley for the management of UTI, impetigo and exacerbation of COPD using patient group directions in community pharmacies. Trained pharmacists supplied a limited range of prescription medicines. Pathways for GP referral were defined. After 5 months of implementation, the service was evaluated.

A quantitative evaluation was undertaken. Feedback was sought from patients, GPs, pharmacists and GP reception staff, using structured questionnaires. Pharmacy records were used to assess referrals and pharmacy data summarised the number and type of consultations. Basic cost data was obtained from the Health Board.

In all, 75 pharmacies (of 76), and all 55 GP practices in the area, participated in the service. Over a 5-month period, 1189 cases were managed, the majority being for UTI (75.4%) followed by impetigo (15.2%), then COPD (9.3%). Of all cases, 77.9% were prescribed medication by the pharmacist, 9.1% were given advice only and 16.7% were referred to the GP. Independent clinical assessment of a random sample of 30 GP referrals considered all to be ‘appropriate’. Feedback was received from 69 pharmacists, 34 GPs, 54 reception staff and 73 patients. Patients were very satisfied with the service, most frequently citing the ‘quick and efficient’ access to treatment, and a ‘professional service’. Two thirds of GPs (67%) and 59% of reception staff found the service useful, mainly because it reduced pressure on GP appointments. A further cost benefit evaluation would allow objective assessment of the value of this service.

To understand enablers and barriers influencing postpartum screening for type 2 diabetes following gestational diabetes in Australian Indigenous women and how screening might be improved.

Australian Indigenous women with gestational diabetes mellitus (GDM) are less likely than other Australian women to receive postpartum diabetes screening. This is despite a fourfold higher risk of developing type 2 diabetes within eight years postpartum.

We conducted interviews with seven Indigenous women with previous GDM, focus groups with 20 Indigenous health workers and workshops with 24 other health professionals. Data collection included brainstorming, visualisation, sorting and prioritising activities. Data were analysed thematically using the Theoretical Domains Framework. Barriers are presented under the headings of ‘capability’, ‘motivation’ and ‘opportunity’. Enabling strategies are presented under ‘intervention’ and ‘policy’ headings.

Participants generated 28 enabling environmental, educational and incentive interventions, and service provision, communication, guideline, persuasive and fiscal policies to address barriers to screening and improve postpartum support for women. The highest priorities included providing holistic social support, culturally appropriate resources, improving Indigenous workforce involvement and establishing structured follow-up systems. Understanding Indigenous women’s perspectives, developing strategies with health workers and action planning with other health professionals can generate context-relevant feasible strategies to improve postpartum care after GDM. Importantly, we need evidence which can demonstrate whether the strategies are effective.

To investigate public health nurses’ perceptions and experiences of mental health and of the prevention of mental ill health among women postpartum, within paediatric healthcare services.

Although maternal health following childbirth should be a priority within primary care, it is known that women postpartum do not always receive the support they need to adapt to and cope with motherhood. Research implies that postnatal problems lack recognition and are not always acknowledged in routine practice. Few studies have been presented on this topic or from the perspective of nurses.

For this study, eight semi-structured interviews were conducted with public health nurses, and the transcribed texts were analysed through a process inspired by Burnard’s description of the four-step qualitative content analysis.

Three categories – external influences on postpartum mental health, screening for and preventing postpartum mental ill health and paediatric healthcare services as a platform for support – were interpreted to reflect the nurses’ perceptions and experiences of mental health among women postpartum and of the prevention of mental ill health among women postpartum.

We found that public health nurses can have an important role in supporting mothers’ mental health postpartum. Although caution is warranted in interpreting our results, the findings concur with those of other studies, highlighting that an equal care emphasis on both the mother and child can be an important aspect of successful support. Implementing person-centred care might be one strategy to create such an emphasis, while also promoting the mental health of new mothers. Public health nurses have a unique opportunity to support mothers’ transition into healthy motherhood, especially because they are likely to meet both mothers and children on a regular basis during the first year after birth.

Majority of the individuals with hepatitis C virus (HCV) infection in England are people who inject drugs, a vulnerable and disenfranchised cohort with poor engagement with secondary care. Our aim is to describe our experiences in setting up a successful nurse led HCV service at a substance misuse service (SMS).

We justify the need for a community HCV service and review the different community based models. Our experiences in engaging with stakeholders, obtaining funding, service set up, challenges faced and key recommendations are discussed. Finally, a summary of interim clinical outcomes is presented.

A successful community based “one-stop” nurse led HCV service was set up in Dec 2013 at a large SMS. It provides all aspects of care (blood borne virus screening, non-invasive assessment of hepatic fibrosis, Hepatology input, HCV treatment, peer mentor, social and psychiatrist support, and opiod substitution) at one site. Interim clinical data indicate high service uptake with HCV treatment outcomes comparable to secondary care.

The advent of direct acting antivirals provides a unique opportunity for HCV elimination in England by 2030. Our “one-stop” integrated and multidisciplinary community HCV model suggests that HCV care can be successfully delivered outside of a hospital setting and warrants national adoption.

To examine how patient perspectives and person-centred care values have been represented in documents on medicines optimisation policy in England.

There has been growing support in England for a policy of medicines optimisation as a response to the rise of problematic polypharmacy. Conceptually, medicines optimisation differs from the medicines management model of prescribing in being based around the patient rather than processes and systems. This critical examination of current official and independent policy documents questions how central the patient is in them and whether relevant evidence has been utilised in their development.

A documentary analysis of reports on medicines optimisation published by the Royal Pharmaceutical Society (RPS), The King’s Fund and National Institute for Health and Social Care Excellence since 2013. The analysis draws on a non-systematic review of research on patient experiences of using medicines.

The reports varied in their inclusion of patient perspectives and person-centred care values, and in the extent to which they drew on evidence from research on patients’ experiences of polypharmacy and medicines use. In the RPS report, medicines optimisation is represented as being a ‘step change’ from medicines management, in contrast to the other documents which suggest that it is facilitated by the systems and processes that comprise the latter model. Only The King’s Fund report considered evidence from qualitative studies of people’s use of medicines. However, these studies are not without their limitations.

We suggest five ways in which researchers could improve this evidence base and so inform the development of future policy: by facilitating reviews of existing research; conducting studies of patient experiences of polypharmacy and multimorbidity; evaluating medicines optimisation interventions; making better use of relevant theories, concepts and tools; and improving patient and public involvement in research and in guideline development.

To describe community representation in Nepal’s Health Facility Operation and Management Committees (HFMCs) and the degree of influence of community representatives in the HFMC decision-making processes.

Community participation has been recognised as one of the key components for the successful implementation of primary health care (PHC) strategies, following the 1978 Declaration of Alma-Ata. In low- and middle-income countries (LMICs), HFMCs are now widely considered as a mechanism to increase community participation in health through community representation. There is some research examining the implementation process, impact and factors affecting the effectiveness of HFMCs. Despite the documented evidence of the importance of factors such as adequate representation, links with wider community, and decision-making power, there is limited evidence about the nature of community representation and degree of decision making within HFMCs in the PHC setting, particularly in LMICs.

Qualitative interviews with 39 key informants were held to explore different aspects of community representation in HFMCs, and the influence of the HFMC on health facility decision-making processes. In addition, a facility audit at 22 facilities and review of HFMC meeting minutes at six health facilities were conducted.

There were Dalit (a marginalised caste) and Janajati (an ethnic group) representations in 77% and 100% of the committees, respectively. Likewise, there were at least two female members in each committee. However, the HFMC member selection process and decision making within the committees were influenced by powerful elites. The degree of participation through HFMCs appeared to be at the ‘Manipulation’ and ‘Informing’ stage of Arnstein’s ladder of participation. In conclusion, despite representation of the community on HFMCs, the depth of participation seems low. There is a need to ensure a democratic selection process of committee members; and to expand the depth of participation.

To develop a diabetes education model based on individual beliefs, knowledge and risk awareness, aimed at migrants with type 2 diabetes, living in Sweden.

Type 2 diabetes is rapidly increasing globally, particularly affecting migrants living in developed countries. There is ongoing debate about what kind of teaching method gives the best result, but few studies have evaluated different methods for teaching migrants. Previous studies lack a theoretical base and do not proceed from the individuals’ own beliefs about health and illness, underpinned by their knowledge, guiding their health-related behaviour.

A diabetes education model was developed to increase knowledge about diabetes and to influence self-care among migrants with type 2 diabetes. The model was based on literature review, on results from a previous study investigating knowledge about diabetes, on experience from studies of beliefs about health and illness, and on collaboration between researchers in diabetes care and migration and health and staff working in a multi-professional diabetes team.

This is a culturally appropriate diabetes education model proceeding from individual beliefs about health and illness and knowledge, conducted in focus-group discussions in five sessions, led by a diabetes specialist nurse in collaboration with a multi-professional team, and completed within three months. The focus groups should include 4–5 persons and last for about 90 min, in the presence of an interpreter. A thematic interview guide should be used, with broad open-ended questions and descriptions of critical situations/health problems. Discussions of individual beliefs based on knowledge are encouraged. When needed, healthcare staff present at the session answer questions, add information and ensure that basic principles for diabetes care are covered. The diabetes education model is tailored to both individual and cultural aspects and can improve knowledge about type 2 diabetes, among migrants and thus increase self-care behaviour and improve health.

To evaluate the organizational processes that influence the quality of care for patients with multimorbidity at nurse practitioner-led clinics (NPLCs).

People are living longer, most with one or more chronic diseases (mulitmorbidity) and primary healthcare for these patients has become increasingly complex. One response was the establishment of new models of primary healthcare. NPLCs are an example of a model developed in Ontario, Canada, which feature nurse practitioners as the primary care providers practicing within an interprofessional team. Evaluation of the extent to which the processes within NPLC model addressed the needs of patients with multimorbidity is warranted.

Eight nurse practitioners were interviewed to determine their perception of the quality of care provided to patients with multimorbidity at NPLCs. Interpretive description guided the analysis and themes were identified.

Three themes arose from the analysis, each of which has an impact on the quality of care. The level of patient vulnerability at the NPLCs was high resulting in the need to address social and financial issues before the care of chronic conditions. Dynamics within the interprofessional team impacted the quality of patient care, including NP recruitment and retention, leaves of absence and turnover in staff at the NPLCs had an effect on interprofessional team functioning and patient care. Finally, coordination of care at the NPLCs, such as length of appointments, determined the extent to which attention was given to individual clinical issues was a factor. Strategies to address social determinants of health and for recruitment and retention of NPs is essential for improved quality of care. Comprehensive orientation to the interprofessional team as well as flexibility in care processes may also have positive effects on the quality of care of patients with complex clinical issues.

Patient and Public involvement (PPI) in health care occupies a central place in Western democracies. In England, this theme has been continuously prominent since the introduction of market reforms in the early 1990s. The health care reforms implemented by the current Coalition Government are making primary care practitioners the main commissioners of health care services in the National Health Service, and a duty is placed on them to involve the public in commissioning decisions and strategies. Since implementation of PPI initiatives in primary care commissioning is not new, we asked how likely it is that the new reforms will make a difference. We scanned the main literature related to primary care-led commissioning and found little evidence of effective PPI thus far. We suggest that unless the scope and intended objectives of PPI are clarified and appropriate resources are devoted to it, PPI will continue to remain empty rhetoric and box ticking.

To examine the effect of previous PPI initiatives on health care commissioning and draw lessons for future development.

We scanned the literature reporting on previous PPI initiatives in primary care-led commissioning since the introduction of the internal market in 1991. In particular, we looked for specific contexts, methods and outcomes of such initiatives.

1. PPI in commissioning has been constantly encouraged by policy makers in England. 2. Research shows limited evidence of effective methods and outcomes so far. 3. Constant reconfiguration of health care structures has had a negative impact on PPI. 4. The new structures look hardly better poised to bring about effective public and patient involvement.