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Background: Numerous pathologies result in multiple-organ failure, which is thought to be a direct consequence of compromised cellular bioenergetic status. Neither the nature of this phenotype nor its relevance to survival are well understood, limiting the efficacy of modern life-support. Methods: To explore the hypothesis that survival from critical illness relates to changes in cellular bioenergetics, we combined assessment of mitochondrial respiration with metabolomic, lipidomic and redox profiling in skeletal muscle and blood, at multiple timepoints, in 21 critically ill patients and 12 reference patients. Results: We demonstrate an end-organ cellular phenotype in critical illness, characterized by preserved total energetic capacity, greater coupling efficiency and selectively lower capacity for complex I and fatty acid oxidation (FAO)-supported respiration in skeletal muscle, compared to health. In survivors, complex I capacity at 48 h was 27% lower than in non-survivors (p = 0.01), but tended to increase by day 7, with no such recovery observed in non-survivors. By day 7, survivors’ FAO enzyme activity was double that of non-survivors (p = 0.048), in whom plasma triacylglycerol accumulated. Increases in both cellular oxidative stress and reductive drive were evident in early critical illness compared to health. Initially, non-survivors demonstrated greater plasma total antioxidant capacity but ultimately higher lipid peroxidation compared to survivors. These alterations were mirrored by greater levels of circulating total free thiol and nitrosated species, consistent with greater reductive stress and vascular inflammation, in non-survivors compared to survivors. In contrast, no clear differences in systemic inflammatory markers were observed between the two groups. Conclusion: Critical illness is associated with rapid, specific and coordinated alterations in the cellular respiratory machinery, intermediary metabolism and redox response, with different trajectories in survivors and non-survivors. Unravelling the cellular and molecular foundation of human resilience may enable the development of more effective life-support strategies.

Abstract Background Deprescribing has been defined as the planned process of reducing or stopping medications that may no longer be beneficial or are causing harm, with the goal of reducing medication burden while improving patient quality of life. At present, little is known about the specific challenges of decision-making to support deprescribing for patients who are accessing palliative care. By exploring the perspectives of healthcare professionals, this qualitative study aimed to address this gap, and explore the challenges of, and potential solutions to, making decisions about deprescribing in a palliative care context. Methods Semi-structured interviews were conducted with healthcare professionals in-person or via video call, between August 2022 – January 2023. Perspectives on approaches to deprescribing in palliative care; when and how they might deprescribe; and the role of carers and family members within this process were discussed. Interviews were audio-recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the NHS Health Research Authority (ref 305394). Results Twenty healthcare professionals were interviewed, including: medical consultants, nurses, specialist pharmacists, and general practitioners (GPs). Participants described the importance of deprescribing decision-making, and that it should be a considered, proactive, and planned process. Three themes were developed from the data, which centred on: (1) professional attitudes, competency and responsibility towards deprescribing; (2) changing the culture of deprescribing; and (3) involving the patient and family/caregivers in deprescribing decision-making. Conclusions This study sought to explore the perspectives of healthcare professionals with responsibility for making deprescribing decisions with people accessing palliative care services. A range of healthcare professionals identified the importance of supporting decision-making in deprescribing, so it becomes a proactive process within a patient’s care journey, rather than a reactive consequence. Future work should explore how healthcare professionals, patients and their family can be supported in the shared decision-making processes of deprescribing. Trial registration Ethical approval was obtained from the NHS Health Research Authority (ref 305394).

Objectives To explore the acceptability and feasibility of detection of atrial fibrillation (AF) by emergency medical services (EMS) and identify potential barriers and facilitators to implementing a formal pathway to facilitate follow-up in primary care, which could reduce the risk of AF-related stroke.Design Qualitative study using focus groups and one-to-one interviews guided by a semistructured topic guide.Setting North East England.Participants Focus groups with 18 members of the public and one-to-one online interviews with 11 healthcare and service providers (six paramedics and five experts representing cardiology, general practice (GP), public health, research, policy and commissioning).Results All participant groups were supportive of a role of EMS in identifying AF as part of routine assessment and formalising the response to AF detection. However, this should not create delays for EMS since rate-controlled AF is non-urgent and alternative community mechanisms exist to manage it. Public participants were concerned about communication of the AF diagnosis and whether this should be ‘on scene’ or in a subsequent GP appointment. Paramedics reported frequent incidental identification of AF, but it is not always clear ‘on scene’ that this is a new diagnosis, and there is variation in practice regarding whether (and how) this is communicated to the GP. Paramedics also focused on ensuring the safety of non-conveyed patients and a perceived need for an ‘active’ reporting process, so that a finding of AF was actioned. Field experts felt that a formal pathway would be useful and favoured a simple intervention without adding to time pressures unnecessarily.Conclusions There is support for the development of a formal pathway to ensure follow-up for people with AF that is incidentally detected by EMS. This has the potential to improve anticoagulation rates and reduce the risk of stroke.

Abstract Background Osteoarthritis is a common, painful and disabling long-term condition. Delivery of high-quality guideline-informed osteoarthritis care that successfully promotes and maintains supported self-management is imperative. However, osteoarthritis care remains inconsistent, including under use of core non-pharmacological approaches of education, exercise and weight loss. Community pharmacies are an accessible healthcare provider. United Kingdom government initiatives are promoting their involvement in a range of long-term conditions, including musculoskeletal conditions. It is not known what an enhanced community pharmacy role for osteoarthritis care should include, what support is needed to deliver such a role, and whether it would be feasible and acceptable to community pharmacy teams. In this (PharmOA) study, we aim to address these gaps, and co-design and test an evidence-based extended community pharmacy model of service delivery for managing osteoarthritis. Methods Informed by the Theoretical Domains Framework, Normalisation Process Theory, and the Medical Research Council (MRC) framework for developing complex interventions, we will undertake a multi-methods study involving five phases: 1. Systematic review to summarise currently available evidence on community pharmacy roles in supporting adults with osteoarthritis and other chronic (non-cancer) pain. 2. Cross-sectional surveys and one-to-one qualitative interviews with patients, healthcare professionals and pharmacy staff to explore experiences of current, and potential extended community pharmacy roles, in delivering osteoarthritis care. 3. Stakeholder co-design to: a) agree on the extended role of community pharmacies in osteoarthritis care; b) develop a model of osteoarthritis care within which the extended roles could be delivered (PharmOA model of service delivery); and c) refine existing tools to support community pharmacies to deliver extended osteoarthritis care roles (PharmOA tools). 4. Feasibility study to explore the acceptability and feasibility of the PharmOA model of service delivery and PharmOA tools to community pharmacy teams. 5. Final stakeholder workshop to: a) finalise the PharmOA model of service delivery and PharmOA tools, and b) if applicable, prioritise recommendations for its wider future implementation. Discussion This novel study paves the way to improving access to and availability of high-quality guideline-informed, consistent care for people with osteoarthritis from within community pharmacies.

Abstract Introduction Head and neck cancer (HNC) is the eighth most common cancer in the United Kingdom. Survival rates improve when the cancer is diagnosed at an early stage, highlighting a key need to identify at‐risk patients. This study aimed to explore opportunistic HNC identification and referral by community pharmacists (CPs) using a symptom‐based risk assessment calculator, from the perspective of patients with a diagnosis of HNC. Methods Purposive sampling was used to recruit patients from the HNC pathway in three large teaching hospitals in Northern England. Qualitative methodology was used to collect data through an iterative series of semistructured telephone interviews. Framework analysis was utilised to identify key themes. Results Four main themes were constructed through the analytic process: (1) HNC presentation and seeking help; (2) the role of the CP; (3) public perception of HNC and (4) the role of a symptom‐based risk calculator. Participants agreed that CPs could play a role in the identification and referral of suspected HNCs, but there were concerns about access as patients frequently only encounter the medicine counter assistant when they visit the pharmacy. HNC symptoms are frequently attributed to common or minor conditions initially and therefore considered not urgent, leading to delays in seeking help. While there is public promotion for some cancers, there is little known about HNC. Early presentation of HNC can be quite variable, therefore raising awareness would help. The use of a symptom‐based risk calculator was considered beneficial if it enabled earlier referral and diagnosis. Participants suggested that it would also be useful if the public were made aware of it and could self‐assess their symptoms. Conclusion In principle, CPs could play a role in the identification and referral of HNC, but there was uncertainty as to how the intervention would work. Future research is needed to develop an intervention that would facilitate earlier identification and referral of HNC while not disrupting CP work and that would promote HNC and the risk calculator more widely. Patient or Public Contribution Patient and public involvement and engagement (PPIE) was integrated throughout the project. Initially, the proposal was discussed during a Cancer Head and Neck Group Experience (CHANGE) PPIE meeting. CHANGE was set up to support HNC research in 2018. The group is composed of seven members (four female, three male) with an age range of 50–71 years, who were diagnosed at Sunderland Royal Hospital. A patient representative from the University of Sunderland PPIE group and a trustee of the Northern HNC Charity were recruited as co‐applicants. They attended project management group meetings and reviewed patient‐facing documentation.

Abstract Introduction Cultural competence is an important attribute underpinning interactions between healthcare professionals, such as pharmacists, and patients from ethnic minority communities. Health‐ and medicines‐related inequalities affecting people from underrepresented ethnic groups, such as poorer access to healthcare services and poorer overall treatment outcomes in comparison to their White counterparts, have been widely discussed in the literature. Community pharmacies are the first port of call for healthcare services accessed by diverse patient populations; yet, limited research exists which explores the perceptions of culturally competent care within the profession, or the delivery of cultural competence training to community pharmacy staff. This research seeks to gather perspectives of community pharmacy teams relating to cultural competence and identify possible approaches for the adoption of cultural competence training. Methods Semistructured interviews were conducted in‐person, over the telephone or via video call, between October and December 2022. Perspectives on cultural competence and training were discussed. Interviews were audio‐recorded and transcribed verbatim. The reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Ethics Committee (reference: 25680/2022). Results Fourteen participants working in community pharmacies were interviewed, including eight qualified pharmacists, one foundation trainee pharmacist, three pharmacy technicians/dispensers and two counter assistants. Three themes were developed from the data which centred on (1) defining and appreciating cultural competency within pharmacy services; (2) identifying pharmacies as ‘cultural hubs’ for members of the diverse, local community and (3) delivering cultural competence training for the pharmacy profession. Conclusion The results of this study offer new insights and suggestions on the delivery of cultural competence training to community pharmacy staff, students and trainees entering the profession. Collaborative co‐design approaches between patients and pharmacy staff could enable improved design, implementation and delivery of culturally competent pharmacy services. Patient or Public Contribution The Patient and Public Involvement and Engagement group at Newcastle University had input in the study design and conceptualisation. Two patient champions inputted to ensure that the study was conducted, and the findings were reported, with cultural sensitivity.

Abstract Background Training health care providers to administer visual inspection after application of acetic acid (VIA) is paramount in improving cervical cancer screening services for women in low- and middle-income countries. The objective of this systematic review was to create a framework of essential VIA training components and provide illustrating examples of how VIA training programs can be carried out in different clinical settings. Methods A systematic review of PubMed, Embase, and Web of Science (from 2006 to 2021) was undertaken. Our inclusion criteria comprised articles reporting on implemented cervical cancer screening programs using VIA in a screen-and-treat approach. Trained health care providers with any level of health education were included, and the outcome of interest was the reporting of training components. Data were extracted by two reviewers, and a narrative synthesis of the training programs was performed. We developed a framework of seven essential training components and applied it to assess how training courses were conducted in different settings. Results 13 primary studies were eligible for inclusion, including 2,722 trained health care providers and 342,889 screened women. Most training courses lasted 5–7 days and included theoretical education, practical skill development, and competence assessment. It was unclear how visual aids and training in client counselling and quality assessment were integrated in the training courses. After the training course, nearly all the VIA training programs made provisions for on-job training at the providers’ own clinical settings through supervision, feedback, and refresher training. Conclusions This study demonstrates the feasibility of implementing international training recommendations for cervical cancer screening in real-world settings and provides valuable examples of training program implementation across various clinical settings. The diverse reporting practices of quality indicators in different studies hinder the establishment of direct links between these data and training program effectiveness. To enhance future reporting, authors should emphasize specific training components, delivery methods, and contextual factors. Standardized reporting of quality indicators for effective evaluation of VIA training programs is recommended, fostering comparability, facilitating research, and enhancing reporting quality in this field.

Abstract Background Inequalities in cancer incidence and mortality can be partly explained by unequal access to high‐quality health services, including cancer screening. Several interventions have been described to increase access to cancer screening, among them patient navigation (PN), a barrier‐focused intervention. This systematic review aimed to identify the reported components of PN and to assess the effectiveness of PN to promote breast, cervical and colorectal cancer screening. Methods We searched Embase, PubMed and Web of Science Core Collection databases. The components of PN programmes were identified, including the types of barriers addressed by navigators. The percentage change in screening participation was calculated. Results The 44 studies included were mainly on colorectal cancer and were conducted in the USA. All described their goals and community characteristics, and the majority reported the setting (97.7%), monitoring and evaluation (97.7%), navigator background and qualifications (81.4%) and training (79.1%). Supervision was only referred to in 16 studies (36.4%). Programmes addressed mainly barriers at the educational (63.6%) and health system level (61.4%), while only 25.0% reported providing social and emotional support. PN increased cancer screening participation when compared with usual care (0.4% to 250.6% higher) and educational interventions (3.3% to 3558.0% higher). Conclusion Patient navigation programmes are effective at increasing participation to breast, cervical and colorectal cancer screening. A standardized reporting of the components of PN programmes would allow their replication and a better measure of their impact. Understanding the local context and needs is essential to design a successful PN programme.

Abstract Aims This review aims to identify the evidence base for the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population. Method In this systematic review, we searched MEDLINE, Embase, PubMed, CINAHL and the Cochrane Library for studies from January 2001 to 15th August 2022. We included a variety of study types that assessed and reported frailty including patients ≥18 years old. Studies included those that reported the prevalence of over or undertreatment of diabetes mellitus in a frail population and those examining outcomes related to glucose control in frail older people living with diabetes. Data were extracted using a bespoke extraction table using a narrative synthesis approach. Results A total of 4114 articles were identified with 112 meeting inclusion criteria. These included 15,130 participants across the 11 studies with sample sizes ranging from 101 to 11,140. Several areas were identified in the included studies where under or overtreatment of diabetes impacted outcomes for patients. These included hospital admissions, readmissions, length of stay, falls, mortality, cognitive impairment and cardiovascular disease outcomes. Conclusion The results showed that there was a high heterogeneity of outcomes between the studies and that many examined small numbers of participants. In this review, both over and undertreatment were shown to increase adverse outcomes in frail older people. Further research around optimal glycaemic control for frail older people living with diabetes is required with the aim to identify ideal target ranges and produce practical clinical guidelines to promote attainment of these.

Abstract Background In oestrogen‐receptor positive breast cancer, daily oral adjuvant endocrine therapy (ET) for at least 5 years significantly reduces risks of recurrence and breast cancer‐specific mortality. However, many women are poorly adherent to ET. Development of effective adherence support requires comprehensive understanding of influences on adherence. We undertook an umbrella review to identify determinants of ET adherence. Methods We searched PubMed, Embase, CINAHL, PsycINFO, Cochrane and PROSPERO (inception to 08/2022) to identify systematic reviews on factors influencing ET adherence. Abstracted determinants were mapped to the World Health Organization's dimensions of adherence. Reviews were quality appraised and overlap assessed. Results Of 5732 citations screened, 17 reviews were eligible (9 quantitative primary studies; 4 qualitative primary studies; 4 qualitative or quantitative studies) including 215 primary papers. All five WHO dimensions influenced ET non‐adherence: The most consistently identified non‐adherence determinants were patient‐related factors (e.g. lower perceived ET necessity, more treatment concerns, perceptions of ET ‘cons’ vs. ‘pros’). Healthcare system/healthcare professional‐related factors (e.g. perceived lower quality health professional interaction/relationship) were also important and, to a somewhat lesser extent, socio‐economic factors (e.g. lower levels of social/economic/material support). Evidence was more mixed for medication‐related and condition‐related factors, but several may be relevant (e.g. experiencing side‐effects, cost). Potentially modifiable factors are more influential than non‐modifiable/fixed factors (e.g. patient characteristics). Conclusions The evidence‐base on ET adherence determinants is extensive. Future empirical studies should focus on less well‐researched areas and settings. The determinants themselves are numerous and complex in indicating that adherence support should be multifaceted, addressing multiple determinants.

ObjectiveThe growing deprescribing field is challenged by a lack of consensus around evidence and knowledge gaps. The objective of this overview of systematic reviews was to summarize the review evidence for deprescribing interventions in older adults.Methods11 databases were searched from 1st January 2005 to 16th March 2023 to identify systematic reviews. We summarized and synthesized the results in two steps. Step 1 summarized results reported by the included reviews (including meta-analyses). Step 2 involved a narrative synthesis of review results by outcome. Outcomes included medication-related outcomes (e.g., medication reduction, medication appropriateness) or twelve other outcomes (e.g., mortality, adverse events). We summarized outcomes according to subgroups (patient characteristics, intervention type and setting) when direct comparisons were available within the reviews. The quality of included reviews was assessed using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2).ResultsWe retrieved 3,228 unique citations and assessed 135 full-text articles for eligibility. Forty-eight reviews (encompassing 17 meta-analyses) were included. Thirty-one of the 48 reviews had a general deprescribing focus, 16 focused on specific medication classes or therapeutic categories and one included both. Twelve of 17 reviews meta-analyzed medication-related outcomes (33 outcomes: 25 favored the intervention, 7 found no difference, 1 favored the comparison). The narrative synthesis indicated that most interventions resulted in some evidence of medication reduction while for other outcomes we found primarily no evidence of an effect. Results were mixed for adverse events and few reviews reported adverse drug withdrawal events. Limited information was available for people with dementia, frailty and multimorbidity. All but one review scored low or critically low on quality assessment.ConclusionDeprescribing interventions likely resulted in medication reduction but evidence on other outcomes, in particular relating to adverse events, or in vulnerable subgroups or settings was limited. Future research should focus on designing studies powered to examine harms, patient-reported outcomes, and effects on vulnerable subgroups.Systematic review registrationPROSPERO CRD42020178860.

Abstract Background Socioeconomic status (SES) may influence prescribing, concordance and adherence to medication regimens. This review set out to investigate the association between polypharmacy and an individual’s socioeconomic status. Methods A systematic review and meta-analyses of observational studies was conducted across four databases. Older people (≥ 55 years) from any healthcare setting and residing location were included. The search was conducted across four databases: Medline (OVID), Web of Science, Embase (OVID) and CINAHL. Observational studies from 1990 that reported polypharmacy according to SES were included. A random-effects model was undertaken comparing those with polypharmacy (≥ 5 medication usage) with no polypharmacy. Unadjusted odds ratios (ORs), 95% confidence intervals (CIs) and standard errors (SE) were calculated for each study. Results Fifty-four articles from 13,412 hits screened met the inclusion criteria. The measure of SES used were education (50 studies), income (18 studies), wealth (6 studies), occupation (4 studies), employment (7 studies), social class (5 studies), SES categories (2 studies) and deprivation (1 study). Thirteen studies were excluded from the meta-analysis. Lower SES was associated with higher polypharmacy usage: individuals of lower educational backgrounds displayed 21% higher odds to be in receipt of polypharmacy when compared to those of higher education backgrounds. Similar findings were shown for occupation, income, social class, and socioeconomic categories. Conclusions There are socioeconomic inequalities in polypharmacy among older people, with people of lower SES significantly having higher odds of polypharmacy. Future work could examine the reasons for these inequalities and explore the interplay between polypharmacy and multimorbidity.

Abstract Introduction Medicines‐centred consultations are vital to support medicine effectiveness and optimize health outcomes for patients. However, inequalities negatively impact ethnic minority populations when accessing medicines advice. It is important to identify opportunities to improve access for these communities however, knowledge of how best to achieve this is lacking; this study will generate recommendations to improve access to medicines advice from community pharmacies for people from ethnic minority communities. Methods A series of codesign workshops, with four groups of patient‐stakeholders, were conducted between September–November 2021; they took place in‐person or via video call (adhering to COVID‐19 restrictions). Existing evidence‐based perceptions affecting access to medicines advice were critiqued and recommendations were generated, by use of reflexive thematic analysis, to improve access for ethnic minority patients. The workshops were audio‐recorded and transcribed verbatim. QSR NVivo (Version 12) facilitated data analysis. Results Twelve participants were recruited using purposive sampling; including eight UK citizens, two asylum seekers and two participants in receipt of residency visas. In total, four different ethnic minority groups were represented. Each participant took part in a first and second workshop to share and cocreate recommendations to improve access to medicines advice in community pharmacies. Three recommendations were developed and centred on: (i) delivering and providing culturally competent medicines advice; (ii) building awareness of accessing medicines advice from community pharmacies; and (iii) enabling better discussions with patients from ethnic minority communities. Conclusions These recommendations have the potential to support community pharmacy services to overcome ethnic inequalities affecting medicines advice; service commissioners should consider these findings to best meet the needs of ethnic minority patients. Cultural competence training for community pharmacy staff could support the creation of pharmacies as inclusive healthcare settings. Collaborative working with ethnic minority communities could enable specific tailoring of medicines‐centred services to best meet their needs. Patient or Public Contribution The National Institute for Health Research (NIHR) and Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualization. Seven patient champions were appointed to the steering group to ensure that the research was conducted, and findings were reported, with cultural competence. Trial Registration Not applicable.

Abstract Introduction Regular reviews of medications, including prescription reviews and adherence reviews, are vital to support pharmacological effectiveness and optimize health outcomes for patients. Despite being more likely to report a long‐term illness that requires medication when compared to their white counterparts, individuals from ethnic minority communities are less likely to engage with regular medication reviews, with inequalities negatively affecting their access. It is important to understand what barriers may exist that impact the access of those from ethnic minority communities and to identify measures that may act to facilitate improved service accessibility for these groups. Methods Semi‐structured interviews were conducted between June and August 2021 using the following formats as permitted by governmental COVID‐19 restrictions: in person, over the telephone or via video call. Perspectives on service accessibility and any associated barriers and facilitators were discussed. Interviews were audio‐recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Health Research Authority (ref: 21/HRA/1426). Results In total 20 participants from ethnic minority communities were interviewed; these participants included 16 UK citizens, 2 refugees and 2 asylum seekers, and represented a total of 5 different ethnic groups. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medication reviews and identified approaches to improve the accessibility of such services for ethnic minority patients. These centred on (1) building knowledge and understanding about medication reviews; (2) delivering medication review services; and (3) appreciating the lived experience of patients. Conclusion The results of this study have important implications for addressing inequalities that affect ethnic minority communities. Involving patients and practitioners to work collaboratively in coproduction approaches could enable better design, implementation and delivery of accessible medication review services that are culturally competent. Patient or Public Contribution The National Institute for Health Research Applied Research Collaboration and Patient and Public Involvement and Engagement group at Newcastle University supported the study design and conceptualization. Seven patient champions inputted to ensure that the research was conducted, and the findings were reported, with cultural sensitivity.

Introduction Biological and precision therapies are increasingly used in cancer treatment. Although they may improve survival, they are also associated with various—and unique—adverse effects, which can be long lasting. Little is known about the experiences of people treated with these therapies. Moreover, their supportive care needs have not been fully explored. Consequently, it is unclear whether existing instruments adequately capture the unmet needs of these patients. The TARGET study seeks to address these evidence gaps by exploring the needs of people treated with these therapies with the aim of developing an unmet needs assessment instrument for patients on biological and precision therapies.Methods and analysis The TARGET study will adopt a multi-methods design involving four Workstreams (1) a systematic review to identify, describe and assess existing unmet needs instruments in advanced cancer; (2) qualitative interviews with patients on biological and precision therapies, and their healthcare professionals, to explore experiences and care needs; (3) development and piloting of a new (or adapted) unmet needs questionnaire (based on the findings of Workstream 1 and Workstream 2) designed to capture the supportive care needs of these patients; and finally, (4) a large-scale patient survey using the new (or modified) questionnaire to determine (a) the psychometric properties of the questionnaire, and (b) the prevalence of unmet needs in these patients. Based on the broad activity of biological and precision therapies, the following cancers will be included: breast, lung, ovarian, colorectal, renal and malignant melanoma.Ethics and dissemination This study was approved by National Health Service (NHS) Heath Research Authority Northeast Tyne and Wear South Research Ethics Committee (REC ref: 21/NE/0028). Dissemination of the research findings will take several formats to reach different audiences, including patients, healthcare professionals and researchers.

Abstract Introduction Healthcare inequalities and ethnicity are closely related. Evidence has demonstrated that patients from ethnic minority groups are more likely to report a long‐term illness than their white counterparts; yet, in some cases, minority groups have reported poorer adherence to prescribed medicines and may be less likely to access medicine services. Knowledge of the barriers and facilitators that impact ethnic minority access to medicine services is required to ensure that services are fit for purpose to meet and support the needs of all. Methods Semistructured interviews with healthcare professionals were conducted between October and December 2020, using telephone and video call‐based software. Perspectives on barriers and facilitators were discussed. Interviews were audio‐recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Faculty of Medical Sciences Ethics Committee. Results Eighteen healthcare professionals were interviewed across primary, secondary and tertiary care settings; their roles spanned medicine, pharmacy and dentistry. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medicine services for ethnic minority patients. These centred around patient expectations of health services; appreciating cultural stigma and acceptance of certain health conditions; and individually addressing communication and language needs. Conclusion This study provides much‐needed evidence relating to the barriers and facilitators impacting minority ethnic communities when seeking medicine support. The results of this study have important implications for the delivery of person‐centred care. Involving patients and practitioners in coproduction approaches could enable the design and delivery of culturally sensitive and accessible medicine services. Patient or Public Contribution The Patient and Public Involvement and Engagement (PPIE) group at Newcastle University had extensive input in the design and concept of this study before the research was undertaken. Throughout the work, a patient champion (Harpreet Guraya) had input in the project by ensuring that the study was conducted, and the findings were reported, with cultural sensitivity.

Abstract Background Adults with long-term health conditions (LTCs) are more likely to experience depressive symptoms which can worsen health outcomes and quality of life, and increase healthcare costs. Subthreshold depression may go undetected and/or untreated. The Community Pharmacies Mood Intervention Study (CHEMIST) explored whether community pharmacies represent a suitable setting to offer brief psychological support to people with LTCs and comorbid subthreshold depression. Methods A feasibility intervention study with a nested mixed methods evaluation was employed. Adults with subthreshold depression and a minimum of one LTC were recruited from community pharmacies/local general practices and offered a brief psychological support intervention (‘Enhanced Support Intervention’ (ESI)), based on behavioural activation within a Collaborative Care framework. The intervention included up to six sessions supported by pharmacy staff (‘ESI facilitators’) trained to deliver the ESI within the community pharmacy setting. Recruitment, retention rates and engagement with the ESI were assessed. Semi-structured, one-to-one interviews with pharmacy staff and study participants, and a focus group with pharmacy staff, explored experiences and acceptability of the study and the ESI. Themes were mapped onto constructs of the Theoretical Framework of Acceptability. Results Recruitment of ESI participants was challenging and slower than anticipated despite the varied methods of recruitment employed; although, this was useful in identifying barriers and enabling factors for participation. Engagament with the ESI was good with n=17 (71%) recruited participants commencing the ESI. The ESI was found to be acceptable to participants and ESI facilitators. Retention rate at 4 months was good n=20 (87.0%). The main barriers to identifying potential participants for pharmacy staff were lack of time, resources and limited experience in research. The ESI training and support manual were acceptable to ESI facilitators. The ESI and supporting patient workbook were acceptable to people with LTCs and subthreshold depression. Conclusions Community pharmacies were viewed as an acceptable setting in which to deliver preventative brief psychological support to people with LTCs at risk of depression. This feasibility study provided important data to inform the design of a pilot randomised controlled trial in this setting and highlighted important considerations for future pharmacy-based research. Trial registration ISRCTN11290592

Abstract Background There is increasing interest in the role of community pharmacy in the early diagnosis and prevention of cancer. This study set out to examine how often community pharmacists (CPs) encourage patients to spot or respond to potential signs and symptoms of cancer, and how often they help people to make an informed decision about taking part in bowel cancer screening. Methods Data from 400 UK CPs, who completed the 2018 Cancer Research UK Healthcare Professional Tracker survey, were analysed. The primary outcomes were: ‘how often CPs encourage patients to spot or respond to potential signs and symptoms of cancer’ and ‘how often CPs encourage eligible people to make an informed decision to participate in bowel cancer screening’. Associations between behaviours and demographic and psychological variables (Capability, Opportunity and Motivation) were assessed using multivariate logistic regression. Results Most (n = 331, 82.8%) CPs reported occasionally, frequently or always encouraging patients to spot or respond to potential signs and symptoms of cancer, while only half (n = 203, 50.8%) reported occasionally, frequently or always helping people make an informed decision to participate in bowel cancer screening. Female sex (aOR: 3.20, 95%CI: 1.51, 6.81; p

Objective To explore pharmacists’ perceptions of, and attitudes towards, the early identification and referral of patients with signs and symptoms indicating potential diagnosis of head and neck cancer (HNC) in community pharmacy settings.Design Qualitative methodology, using constant comparative analysis to undertake an iterative series of semistructured interviews. Framework analysis facilitated the identification of salient themes.Setting Community pharmacies in Northern England.Participants 17 community pharmacists.Results Four salient and inter-related categories emerged: (1) Opportunity and access, indicating frequent consultations with patients presenting with potential HNC symptoms and the accessible nature of community pharmacists; (2) Knowledge gap, indicating knowledge of key referral criteria, but limited experience and expertise in undertaking more holistic patient assessments to inform clinical decision making; (3) Referral pathways and workloads; indicating good working relationships with general medical practices, but limited collaboration with dental services, and a desire to engage with formal referral pathways, but current practices based entirely on signposting resulting in a potential lack of safety-netting, no auditable trail, feedback mechanism or integration into the multidisciplinary team; (4) Utilisation of clinical decision support tools; indicating that no participants were aware the Head and Neck Cancer Risk Calculator (HaNC-RC V2) for HNC but were positive towards the use of such tools to improve decision making. HaNC-RC V2 was seen as a potential tool to facilitate a more holistic approach to assessing patient’s symptoms, acting as a prompt to further explore a patient’s presentation, requiring further investigation in this context.Conclusions Community pharmacies offer access to patients and high-risk populations that could support HNC awareness initiatives, earlier identification and referral. However, further work to develop a sustainable and cost-effective approach to integrating pharmacists into cancer referral pathways is needed, alongside appropriate training for pharmacists to successfully deliver optimum patient care.

This global umbrella review aimed to synthesise evidence of socioeconomic inequalities in the uptake of routine vaccinations and identify the mechanisms that may contribute to the association. To our knowledge, no attempt has been made to synthesise the global body of systematic reviews across a variety of vaccines, geographical locations, and measures of SES. The inclusion criteria were as follows: studies assessing vaccination uptake according to education, income, occupation/employment, and/or area-level deprivation; any country or universally recommended routine vaccination (according to the WHO); qualitative or quantitative reviews, published 2011-present. The searches were performed in eight databases. The screening process followed PRISMA-E guidelines, each stage was performed by one reviewer, and a 10% sample checked by a second for consistency. Included reviews underwent data extraction, quality appraisal (AMSTAR-2), and narrative synthesis according to country-context. After deduplication, 9,163 reports underwent title and abstract screening, leaving 119 full texts to be assessed for eligibility. Overall, 26 studies were included in the umbrella review. Evidence for lower uptake amongst disadvantaged SES individuals was found in all 26 reviews. However, 17 reviews showed mixed results, as inverse associations were also identified (lower uptake for advantaged SES, and/or higher uptake for disadvantaged SES). Those that explored high-income countries had a greater prevalence of mixed findings than those focusing on low/middle-income countries. The two most frequently cited mechanisms were vaccination knowledge, and confidence in vaccination or vaccination providers. These mechanisms were often understood by review authors as varying by level of education. We find socioeconomic differences in routine vaccination uptake, but the association did not always follow a gradient. Whilst education may be associated with uptake globally, our study indicates that its role varies by country-context. A limitation is the overlap of some primary studies across the included systematic reviews.

IntroductionA high prevalence of diabetes and diabetes-related complications in people from minority ethnic communities in high income countries is of significant concern. Several studies have indicated low adherence rates to antidiabetic medication in ethnic minority groups. Poor adherence to antidiabetic medication leads to a higher risk of complications and potential mortality. This review aims to qualitatively explore the barriers to and facilitators of adherence to antidiabetic medication among ethnic minority groups in high-income countries.MethodsA comprehensive search of MEDLINE, Embase, CINAHL, PsycINFO, and Global Health databases for qualitative studies exploring the barriers to or facilitators of adherence to antidiabetic medication in minority ethnic groups was conducted from database inception to March 2023 (PROSPERO CRD42022320681). A quality assessment of the included studies was conducted using the Critical Appraisal Skills Programme (CASP) tool. Key concepts and themes from relevant studies were synthesised using a meta-ethnographic approach. The Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach was used to assess the Confidence in the review findings.ResultOf 13,994 citations screened, 21 studies that included primary qualitative studies were selected, each of which involved people from minority ethnic communities from eight high income countries. This qualitative evidence synthesis has identified three overarching themes around the barriers to and facilitators of adherence to antidiabetic medication among ethnic minority groups.: 1) cultural underpinnings, 2) communication and building relationships, and 3) managing diabetes during visiting home countries. Based on the GRADE-CERQual assessment, we had mainly moderate- and high-confidence findings.ConclusionMultiple barriers and facilitators of adherence to antidiabetic medication among people from minority ethnic communities in high-income countries have been identified. A medication adherence intervention focusing on identified barriers to adherence to antidiabetic medication in these communities may help in improving diabetes outcomes in these groups.

Objectives Adherence to prescribed medication is an essential component of diabetes management to obtain optimal outcomes. Understanding the relationship between medication adherence and ethnicity is key to optimising treatment for all people with different chronic illnesses, including those with diabetes. The aim of this review is to examine whether the adherence to antidiabetic medications differed by ethnicity among people with diabetes. Methods A systematic review was conducted of studies reporting adherence to antidiabetic medication amongst people from different ethnic groups. MEDLINE, Embase, CINAHL, and PsycINFO were searched from their inception to June 2022 for quantitative studies with a specific focus on studies assessing adherence to antidiabetic medications (PROSPERO: CRD42021278392). The Joanna Briggs Institute critical appraisal checklist and a second checklist designed for studies using retrospective databases were used to assess study quality. A narrative synthesis approach was used to summarize the results based on the medication adherence measures. Results Of 17,410 citations screened, 41 studies that included observational retrospective database research and cross-sectional studies were selected, each of which involved diverse ethnic groups from different settings. This review identified a difference in the adherence to antidiabetic medications by ethnicity in 38 studies, despite adjustment for several confounding variables that may otherwise explain these differences. Conclusion This review revealed that adherence to antidiabetic medication differed by ethnicity. Further research is needed to explore the ethnicity-related factors that may provide an explanation for these disparities.

Abstract Background Novel biological and precision therapies and their associated predictive biomarker tests offer opportunities for increased tumor response, reduced adverse effects, and improved survival. This systematic review determined if there are socio-economic inequalities in utilization of predictive biomarker tests and/or biological and precision cancer therapies. Methods MEDLINE, Embase, Scopus, CINAHL, Web of Science, PubMed, and PsycINFO were searched for peer-reviewed studies, published in English between January 1998 and December 2019. Observational studies reporting utilization data for predictive biomarker tests and/or cancer biological and precision therapies by a measure of socio-economic status (SES) were eligible. Data was extracted from eligible studies. A modified ISPOR checklist for retrospective database studies was used to assess study quality. Meta-analyses were undertaken using a random-effects model, with sub-group analyses by cancer site and drug class. Unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) were computed for each study. Pooled utilization ORs for low versus high socio-economic groups were calculated for test and therapy receipt. Results Among 10,722 citations screened, 62 papers (58 studies; 8 test utilization studies, 37 therapy utilization studies, 3 studies on testing and therapy, 10 studies without denominator populations or which only reported mean socio-economic status) met the inclusion criteria. Studies reported on 7 cancers, 5 predictive biomarkers tests, and 11 biological and precision therapies. Thirty-eight studies (including 1,036,125 patients) were eligible for inclusion in meta-analyses. Low socio-economic status was associated with modestly lower predictive biomarker test utilization (OR 0.86, 95% CI 0.71–1.05; 10 studies) and significantly lower biological and precision therapy utilization (OR 0.83, 95% CI 0.75–0.91; 30 studies). Associations with therapy utilization were stronger in lung cancer (OR 0.71, 95% CI 0.51–1.00; 6 studies), than breast cancer (OR 0.93, 95% CI 0.78–1.10; 8 studies). The mean study quality score was 6.9/10. Conclusions These novel results indicate that there are socio-economic inequalities in predictive biomarker tests and biological and precision therapy utilization. This requires further investigation to prevent differences in outcomes due to inequalities in treatment with biological and precision therapies.

Abstract Background Internationally, there are growing concerns about antimicrobial resistance. This has resulted in increased scrutiny of antibiotic prescribing trends – particularly in primary care where the majority of prescribing occurs. In England, antibiotic prescribing targets are set nationally but little is known about the local context of antibiotic prescribing. This study aimed to examine trends in antibiotic prescribing (including broad-spectrum), and the association with area-level deprivation and region in England. Methods Antibiotic prescribing data by GP surgery in England were obtained from NHS Business Service Authority for the years 2014–2018. These data were matched with the Index of Multiple Deprivation (IMD) 2015 at the Lower Layer Super Output Area level Lower Layer Super Output Area (LSOA) level. Linear regression methods were employed to explore the relationship between antibiotic use and area-level deprivation as well as region, after controlling for a range of other confounding variables, including health need, rurality, and ethnicity. Results Over time, the amount of antibiotic prescribing significantly reduced from 1.11 items per STAR-PU to 0.96 items per STAR-PU – a reduction of 13.6%. The adjusted models found that, at LSOA level, the most deprived areas of England had the highest levels of antibiotic prescribing (0.03 items per STAR-PU higher). However, broad spectrum antibiotic prescribing exceeding 10% of all antibiotic prescribing within a GP practice was higher in more affluent areas. There were also significant regional differences – with the North East and the East of England having the highest levels of antibiotic prescribing (by 0.16 items per STAR-PU). Conclusion Although antibiotic prescribing has reduced over time, there remains significant variation in by area-level deprivation and region in England – with higher antibiotic prescribing in more deprived areas. Future prescribing targets should account for local factors to ensure the most deprived communities are not inappropriately penalised.

Background: Depression is common in people with long-term health conditions, and this combination can lead to worsened health outcomes and increased health-care costs. Subthreshold depression, a risk factor for major depression, is prevalent in this population, but many people remain untreated due to the demand on services. The community pharmacy may be an alternative setting to offer mental health support; however, insufficient evidence exists to support implementation. Objectives: To conduct a feasibility study and pilot randomised controlled trial of a community pharmacy-delivered psychological intervention aimed at preventing depression in adults with long-term health conditions. Design: A feasibility study with nested qualitative evaluation and an external pilot, two-arm, 1 : 1 individually randomised controlled trial with nested process and economic evaluations. Setting: Community pharmacies in the north of England. Participants: Adults aged ≥ 18 years with subthreshold depression and at least one long-term health condition. Intervention: A bespoke enhanced support intervention (behavioural activation within a collaborative care framework) involving up to six sessions delivered by trained community pharmacy staff (intervention facilitators) compared with usual care. Main outcome measures: Recruitment and retention rates, completeness of outcome measures and intervention engagement. The intended primary outcome was depression severity at 4 months, assessed by the Patient Health Questionnaire-9. Results: In the feasibility study, 24 participants were recruited. Outcome measure completeness was 95–100%. Retention at 4 months was 83%. Seventeen participants (71%) commenced intervention sessions and all completed two or more sessions. Depression symptoms reduced slightly at 4 months. The process evaluation suggested that the intervention was acceptable to participants and intervention facilitators. In the pilot randomised controlled trial, 44 participants (target of 100 participants) were randomised (intervention, n = 24; usual care, n = 20). Outcome measure completeness was 100%. Retention at 4 months was 93%. Eighteen participants (75%) commenced intervention sessions and 16 completed two or more sessions. Depression symptoms reduced slightly at 4 months, with a slightly larger reduction in the usual-care arm, although the small sample size limits any conclusions. The process evaluation reported good acceptability of the intervention and identified barriers associated with study implementation and its impact on core pharmacy functions. The economic analysis revealed some indication of reduced resource use/costs associated with the intervention, but this is limited by the small sample size. Intervention costs were low. Limitations: The main limitation is the small sample size due to difficulties with recruitment and barriers to implementing the study within existing pharmacy practices. Conclusions: The community pharmacy represents a new setting to deliver a depression prevention intervention. Recruitment was a challenge and pharmacy staff encountered barriers to effective implementation of the study within busy pharmacy practice. Despite these challenges, good retention rates and intervention engagement were demonstrated, and process evaluation suggested that the intervention was acceptable in this setting. To the best of our knowledge, this is the first study to demonstrate that community pharmacy staff can be trained to deliver a depression prevention intervention. Future work: Further work is needed to address barriers to recruitment, intervention delivery and implementation of psychological interventions in the community pharmacy setting. Trial registration: This trial is registered as ISRCTN11290592. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.

Abstract Feasibility study Objectives:(a)Refine a bespoke enhanced support intervention (ESI) (including self-help materials, intervention manual and training) for implementation by community pharmacy (CP) staff to people with sub-threshold depression and long-term conditions (LTCs) based upon evidence-supported interventions in primary care(b)Develop and refine study procedures (recruitment strategies and set up, screening, participant recruitment, assessment, suitability of outcome measures and data collection procedures) for testing in the pilot study phase Design: A case series/qualitative study Setting: UK community pharmacy Population: Adults with long-term health conditions who screen-positive for depression but who do not reach the threshold for DSM IV Moderate Depressive disorder Intervention: Enhanced support intervention (ESI) delivered by an appropriately trained community pharmacy team member involving four to six sessions over four months. ESI is a modified form of an intervention within the collaborative care framework for sub-threshold depression validated in previous studies in UK primary care which appears suitable for implementation in community settings. Sample size: 20–30 participants Outcomes: Study implementation (recruitment and attrition rates), quality of data collection at baseline and 4 months and ESI adherence (number of contacts, DNA and drop out) as per objectives 1a/b Qualitative evaluation: Semi-structured interviews with up to 10 participants and ESI facilitators and focus group(s) (range of pharmacy staff n = 8–10) will be conducted to explore the acceptability of the intervention and feasibility of the study, training and study procedures. External pilot study Objectives:(a)Quantify the flow of participants (eligibility, recruitment and follow-up rate)(b)Evaluate proposed recruitment, assessment and outcome measure collection methods(c)Examine the delivery of the enhanced support intervention in a community pharmacy setting (intervention uptake, retention and dose) to inform process evaluation(d)Process evaluation, using semi-structured interviews with participants across a range of socio-economic settings, and pharmacy staff to explore the acceptability of the ESI within community pharmacy, elements of the intervention that were considered useful (or not) and appropriateness of study procedures Design: Pilot randomised controlled trial, including a prospective economic and qualitative evaluation Setting: As above Population: As above Intervention: As above with adaptations post feasibility study Comparator: Usual care Sample size: 100 participants Outcomes: Data will be used to estimate recruitment, intervention delivery and study completion rates as per objectives 2a–d. Definitive estimates of the effectiveness of ESI will not be made. Primary outcome: Depression severity (Patient Health Questionnaire 9) at four months. Secondary outcomes: Patient acceptance, uptake and attrition. ICD10 depression status, anxiety (GAD 7), health-related quality of life (SF-12v2) and health-state utility (EQ5D 3L) will be measured at four months. Economic evaluation: The incremental cost per QALY will be calculated from both the NHS and societal perspective. Process evaluation: Using mixed methods, potential mediators/moderators of the intervention, the acceptability (to participants and pharmacy staff), barriers and facilitators to the use of ESI in community pharmacy, and impact on usual practice will be examined. Semi-structured interviews with approximately 30 study participants, 20 pharmacy staff and eight GPs near participating pharmacies will be conducted. Trial registration ISRCTN: ISRCTN11290592 Protocol version number: Version 4.1 (dated 16th January 2018) Study Sponsor Tees Esk and Wear Valleys NHS Foundation Trust

Despite significant progress in the last few decades, infectious diseases remain a major threat to child health in low- and middle-income countries (LMICs)—particularly amongst more disadvantaged groups. It is imperative to understand the best available evidence concerning which public health interventions reduce morbidity, mortality and health inequalities in children aged under five years. To address this gap, we carried out an umbrella review (a systematic reviews of reviews) to identify evidence on the effects of public health interventions (promotion, protection, prevention) on morbidity, mortality and/or health inequalities due to infectious diseases amongst children in LMICs. Ten databases were searched for records published between 2014–2021 alongside a manual search of gray literature. Articles were quality-assessed using the Assessment of Multiple Systematic Reviews tool (AMSTAR 2). A narrative synthesis was conducted. We identified 60 systematic reviews synthesizing 453 individual primary studies. A majority of the reviews reported on preventive interventions (n = 48), with a minority on promotion (n = 17) and almost no reviews covering health protection interventions (n = 2). Effective interventions for improving child health across the whole population, as well as the most disadvantaged included communication, education and social mobilization for specific preventive services or tools, such as immunization or bed nets. For all other interventions, the effects were either unclear, unknown or detrimental, either at the overall population level or regarding health inequalities. We found few reviews reporting health inequalities information and the quality of the evidence base was generally low. Our umbrella review identified some prevention interventions that might be useful in reducing under five mortality from infectious diseases in LMICs, particularly amongst the most disadvantaged groups.

BackgroundPolypharmacy is potentially harmful and under-researched amongst the fastest growing subpopulation, the very old (aged ≥85). We aimed to characterise polypharmacy using data from the Newcastle 85+ Study-a prospective cohort of people born in 1921 who turned 85 in 2006 (n = 845).MethodsThe prevalence of polypharmacy at baseline (mean age 85.5) was examined using cut-points of 0, 1, 2-4, 5-9 and ≥10 medicines-so-called 'no polypharmacy', 'monotherapy', 'minor polypharmacy', 'polypharmacy' and 'hyperpolypharmacy.' Cross-tabulations and upset plots identified the most frequently prescribed medicines and medication combinations within these categories. Mixed-effects models assessed whether gender and socioeconomic position were associated with prescribing changes over time (mean age 85.5-90.5). Participant characteristics were examined through descriptive statistics.ResultsComplex multimorbidity (44.4%, 344/775) was widespread but hyperpolypharmacy was not (16.0%, 135/845). The median medication count was six (interquartile range 4-8). Preventative medicines were common to all polypharmacy categories, and prescribing regimens were diverse. Nitrates and oral anticoagulants were more frequently prescribed for men, whereas bisphosphonates, non-opioid analgesics and antidepressants were more common in women. Cardiovascular medicines, including loop diuretics, tended to be more frequently prescribed for socioeconomically disadvantaged people (ConclusionConsidering their complex medical conditions, prescribing is relatively conservative amongst 85-year-olds living in North East England. Prescribing shows significant gender and selected socioeconomic differences. More support for managing preventative medicines, of uncertain benefit, might be helpful in this population.

INTRODUCTION:The management of minor conditions represents a significant burden for urgent and emergency care services and reduces the capacity to provide specialist care for higher acuity healthcare need. A pilot Digital Minor Illness Service (DMIRS) was commenced in the North East of England in December 2017 to feasibility test the NHS 111 referral to community pharmacy for patients presenting with minor conditions. OBJECTIVES:A formative evaluation of the service activity data and qualitative investigation of stakeholders involved in the service design, management, delivery and use, aims to present and investigate the service outcomes. METHOD:Routine service activity data was evaluated during Jan-Dec 2018 to investigate the demographics of patients included in the service; the presenting conditions; and how those referrals were managed by community pharmacies. Semi-structured interviews with NHS 111 call handlers, project team members, community pharmacists and patients were undertaken to investigate the design, management, implementation and delivery of the service. RESULTS:13,246 NHS 111 patient calls were referred to community pharmacy during the evaluative period. The most common presenting conditions were acute pain (n = 1144, 8.6%) and cough (n = 887, 6.7%). A large volume of complaints (47.1%, 6233) were resolved in community pharmacy. Stakeholders explained the structured approach to service design, organisation and implementation facilitated successful delivery and management. Patients reported positive experiences with accessing care via DMIRS. CONCLUSIONS:DMIRS demonstrated that patients could be referred to community pharmacy for the management of minor conditions, shifting a burden away from urgent and emergency care. The service data provides key information for further optimisation of service design, and stakeholder training and awareness. The service was acceptable and valued by patients. Evidence from the DMIRS pilot has been utilised to inform recent national healthcare policy and practice around the management of minor conditions within the urgent and emergency care setting.

Introduction Despite evidence of possible patient harm and substantial costs, medication overuse is persistent. Patient reaction is one potential barrier to deprescribing, but little research has assessed this in specific instances of medication discontinuation. We sought to understand Veteran and provider experience when de-implementing guideline-discordant use of inhaled corticosteroids (ICS) in those with mild-to-moderate chronic obstructive pulmonary disease (COPD). Methods We conducted a mixed-methods analysis in a provider-randomized quality improvement project testing a proactive electronic-consultation from pulmonologists recommending ICS discontinuation when appropriate. PCPs at two Veterans Health Administration healthcare systems were included. We completed interviews with 16 unexposed providers and 6 intervention-exposed providers. We interviewed 9 patients within 3 months after their PCP proposed ICS discontinuation. We conducted inductive and deductive content analysis of qualitative data to explore an emergent theme of patient reaction. Forty-eight PCPs returned surveys (24 exposed and 24 unexposed, response rate: 35%). Results The unexposed providers anticipated their patients might resist ICS discontinuation because it seems counterintuitive to stop something that is working, patient’s fear of worsening symptoms, or if the prescription was initiated by another provider. Intervention-exposed providers reported similar experiences in post-intervention interviews. Unexposed providers anticipated that patients may accept ICS discontinuation, citing tactical use of patient-centered care strategies. This was echoed by intervention-exposed providers who had successfully discontinued an ICS. Veterans reported acceding to their providers out of trust or deference to their advanced training, even after describing an ICS as a ‘security blanket’. Our survey findings supported the subthemes from our interviews. Among providers who proposed discontinuation of an ICS, 76% reported that they were able to discontinue it or switch to another more appropriate medication. Conclusions While PCPs anticipated that patients would resist discontinuing an ICS, interviews with patient and intervention-exposed PCPs along with surveys suggest that patients were receptive to this change.

Abstract The area of “deprescribing” has rapidly expanded in recent years as a positive intervention to reduce inappropriate polypharmacy and improve health outcomes for (older) people with multimorbidity. While our understanding of deprescribing as a process has greatly improved and existing approaches all have patient-centered elements, there is still limited literature exploring the importance of the individual patient context in deprescribing decision-making. This is clearly an important consideration to ensure that any deprescribing approach is ethical, respectful, and successful. To address this gap in the literature, we have developed a conceptual framework in the form of a rainbow – with five different deprescribing determinants – and place the person at the center of the deprescribing process. This framework is informed by literature on patient-centered care for older people and people with multimorbidity. We illustrate the potential application of this framework to a complex patient case to highlight the importance of the different clinical, psychological, social, financial and physical deprescribing determinants, and how this approach could be adopted by those working in clinical practice.

Abstract Background Socio-economic inequalities are associated with unequal exposure to social, economic and environmental risk factors, which in turn contribute to health inequalities. Understanding the impact of specific public health policy interventions will help to establish causality in terms of the effects on health inequalities. Methods Systematic review methodology was used to identify systematic reviews from high-income countries that describe the health equity effects of upstream public health interventions. Twenty databases were searched from their start date until May 2017. The quality of the included articles was determined using the Assessment of Multiple Systematic Reviews tool (AMSTAR). Results Twenty-nine systematic reviews were identified reporting 150 unique relevant primary studies. The reviews summarised evidence of all types of primary and secondary prevention policies (fiscal, regulation, education, preventative treatment and screening) across seven public health domains (tobacco, alcohol, food and nutrition, reproductive health services, the control of infectious diseases, the environment and workplace regulations). There were no systematic reviews of interventions targeting mental health. Results were mixed across the public health domains; some policy interventions were shown to reduce health inequalities (e.g. food subsidy programmes, immunisations), others have no effect and some interventions appear to increase inequalities (e.g. 20 mph and low emission zones). The quality of the included reviews (and their primary studies) were generally poor and clear gaps in the evidence base have been highlighted. Conclusions The review does tentatively suggest interventions that policy makers might use to reduce health inequalities, although whether the programmes are transferable between high-income countries remains unclear. Trial registration PROSPERO registration number: CRD42016025283

Abstract Background Community pharmacies have great potential to deliver services aimed at promoting health and preventing disease, and are embedded within communities. In the light of a rapid increase in community pharmacy-delivered public health services and an accompanying increase in the evidence base, this systematic review of reviews will synthesise systematic reviews of public health community pharmacy interventions and assess their effects on public health and health inequalities. Methods/design Systematic review methodology will be used to identify all systematic reviews that describe the health and health equity effects of community pharmacy public health interventions. Twenty databases will be searched using a pre-determined search strategy to evaluate community pharmacy-delivered public health interventions. Findings from the included reviews will be pooled, and a narrative synthesis executed to identify overarching patterns and results. Discussion Findings will support future decision-making around how community pharmacy public health services can be used alongside other strategies to promote health, prevent disease and reduce health inequalities. Systematic review registration PROSPERO registration number: CRD42017056264 .

Introduction Despite significant progress in the last few decades, infectious diseases remain a significant threat to children’s health in low-income and middle-income countries. Effective means of prevention and control for these diseases exist, making any differences in the burden of these diseases between population groups or countries inequitable. Yet, gaps remain in our knowledge of the effect these public health interventions have on health inequalities in children, especially in low-income and middle-income countries. This umbrella review aims to address some of these gaps by exploring which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases among children in low-income and middle-income countries.Methods and analysis An umbrella review will be conducted to identify systematic reviews or evidence synthesis of public health interventions that reduce morbidity, mortality and/or health inequalities due to infectious diseases among children (aged under 5 years) in low-income and middle-income countries. The interventions of interest are public health interventions targeting infectious diseases or associated risk factors in children. We will search for reviews reporting health and health inequalities outcomes in and between populations. The literature search will be undertaken using the Cochrane Library, Medline, EMBASE, the CAB Global Health database, Health Evidence, the Campbell Collaboration Library of Systematic Reviews, International Initiative for Impact Evaluation Systematic review repository, Scopus, the Social Sciences Citation Index and PROSPERO. Additionally, a manual search will be performed in Google Scholar and three international organisations websites (UNICEF Office of Research—Innocenti, UNICEF, WHO) to capture grey literature. Data from the records meeting our inclusion/exclusion criteria will be collated using a narrative synthesis approach.Ethics and dissemination This review will exclusively work with anonymous group-level information available from published reviews. No ethical approval was required.The results of the review will be submitted for publication in academic journals and presented at international public health conferences. Additionally, key findings will be summarised for dissemination to a wider policy and general public audience as part of the Centre for Global Health Inequalities Research’s policy work.PROSPERO registration number CRD42019141673

Background: The Department of Health has identified interventions to manage alcohol misuse, smoking and overweight, delivered by community pharmacists, as public health priorities. Objectives: To systematically review the effectiveness of community pharmacy interventions to manage alcohol misuse, smoking cessation and weight loss; to explore if and how age, sex, ethnicity and socioeconomic status moderate effectiveness; and to describe how the interventions have been organised, implemented and delivered. Data sources: Ten electronic databases were searched: Applied Social Sciences Index and Abstracts; Cumulative Index to Nursing and Allied Health Literature; EMBASE; International Bibliography of the Social Sciences; MEDLINE; NHS Economic Evaluation Database; PsycINFO; Social Science Citation Index; Scopus; and the Sociological Abstracts from inception to May 2014. There was no restriction on language or country. Supplementary searches included website, grey literature, study registers, bibliographies and contacting experts. Review methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Any type of intervention of any duration based in any country and in people of any age was included. The review included interventions set in a community pharmacy and delivered by the pharmacist or the wider pharmacy team. Randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies were included. Data extraction and quality assessment were conducted independently for each study by two reviewers. Meta-analysis and narrative synthesis were also conducted. Results: The searches identified over 14,000 records, of which 24 studies were included. There were two alcohol, 12 smoking cessation, five weight loss and five multicomponent interventions that included pharmacotherapy and lifestyle changes in participants with diabetes mellitus, dyslipidaemia or hypertension. Nine of the studies were UK based; seven of the studies were rated ‘strong’ for quality. All studies were of adults. Pharmacy-based smoking cessation interventions including behavioural support and/or nicotine replacement therapy are effective and cost-effective in helping adults to stop smoking, particularly when compared with usual care. The pooled odds ratio of the intervention effects for smoking cessation was 1.85 (95% confidence interval 1.25 to 2.75). It is currently unknown which specific types of smoking cessation interventions are the most effective. There was insufficient evidence for the effectiveness of community pharmacy-based brief alcohol interventions. Evidence suggests that pharmacy-based weight-loss interventions are as effective as similar interventions in other primary care settings, but not as effective or cost-effective as commercially provided weight management services based in community settings. None of the five multicomponent studies demonstrated an improvement compared with control for anthropometric outcomes in participants with comorbidities, but they did show improvement in measures associated with the comorbidities. Very few studies explored if and how sociodemographic or socioeconomic variables moderated the effect of interventions. In two studies based in areas of high deprivation, where participants chose the intervention, the sociodemographic characteristics of participants differed between intervention settings. There were also differences in recruitment, attendance and retention of participants by type of setting. The evidence suggests that a distinct group of people might access pharmacies compared with other settings for alcohol management, smoking cessation and weight loss. There is insufficient evidence to examine the relationship between behaviour change strategies and effectiveness; or evidence of consistent implementation factors or training components that underpin effective interventions. Limitations: The information reported in the publications of included studies did not allow us to assess in detail if and how age, sex, ethnicity and socioeconomic status moderate effectiveness, or to describe how the interventions had been organised, implemented and delivered. Conclusions: Community pharmacy interventions are effective for smoking cessation. Evaluations of interventions to manage alcohol misuse and obesity, set within the community pharmacy, are needed. The effect of community pharmacy interventions on health inequalities is unclear. Future research in this area is warranted, and trials should include the assessment of age, sex, ethnicity, socioeconomic status and contextual factors, and present analysis of how these factors moderate effectiveness. Study registration: This study is registered as PROSPERO CRD42013005943. Funding: The National Institute for Health Research Public Health Research programme.