Primary health care during the COVID-19 pandemic: A qualitative exploration of the challenges and changes in practice experienced by GPs and GP trainees.

BACKGROUND: The COVID-19 pandemic has rapidly changed general practice in the UK. Research is required to understand how General Practitioners (GPs) and GP trainees adjusted to these changes, so that beneficial changes might be sustained, and Primary Health Care (PHC) can be prepared for future challenges. This study explored the experiences and perspectives of GP and GP trainees during the pandemic. METHODS: Remote, semi-structured interviews (n = 21) were conducted with GPs (n = 11) and GP trainees (n = 10), recruited from across the UK using convenience and purposive sampling. Interviews were audio-recorded and transcribed verbatim. Interview data were analysed with an inductive thematic approach. RESULTS: Five overarching themes were identified: (1) 'Thrown in at the deep end'; (2) Telemedicine: 'it needs to be a happy balance'; (3) Delayed referrals and 'holding' patients; (4) The Covid Cohort-training in Covid; (5) Suggestions and lessons for the future of general practice'. GPs reported a turbulent and uncertain time of major changes to PHC. They described the benefits of technology in general medicine, particularly telemedicine, when used in a balanced manner, highlighting the need for accompanying teaching and guidelines, and the importance of patient preferences. Key tools to help GPs manage patients with delayed referrals to Secondary Care were also identified. CONCLUSION: Several key changes to general practice occurred as a result of the COVID-19 pandemic, including a rapid uptake of telemedicine. The pandemic exposed the strengths and limitations of normal general practice and highlighted the importance of workplace camaraderie. These findings contribute to the evidence base used to adapt PHC infrastructures as we emerge from the pandemic.

Domestic fuel affordability and accessibility in urban Rwanda' policy lessons in a time of crisis?

Background Cooking fuel choice and fuel switching behaviours can be influenced by both social and economic contextual factors;with implications for household air pollution exposure. The Rwandan Government have recently proposed a charcoal sale ban to reduce domestic reliance upon charcoal fuels and reduce associated respiratory health harms. Methods A semi-structured mobile telephone survey administered to 85 participants in an informal settlement in Kigali, Rwanda to identify (i) fuel switching as a result of COVID-19 emergency health protection ‘lockdown’ measures (ii) awareness of proposed charcoal sale restrictions and willingness to pay for alternative domestic cooking fuels. Results Of the 85 interviewed participants, 15 (17.6 %) reported a change in primary cooking fuel since the first national COVID-19 emergency ‘lockdown’ period (March – May), with Liquid Petroleum Gas (LPG) users moving to charcoal (n = 3;20 %), and charcoal users to firewood (n = 7;46.7 %) or LPG (n = 4;26.7 %) and one firewood user to charcoal (n = 1;6.6 %). Awareness of the forthcoming LPG subsidy (81.5 %) and charcoal ban policy proposals was high among all participants (81.5 %), with 90.7 % indicating they would change their cooking fuel as a consequence. LPG was the preferred alternative fuel of choice (89.8 %), with cost, ease of use and cleanliness reported as rationale. Forty-four percent of participants reported a willingness to pay less, 38 % to pay the same and 25 % to pay more than their current cooking fuel expenditure for a cleaner alternative fuel. Conclusion Domestic fuel switching as a result of economic and energy market volatility, was observed in an informal settlement in urban Rwanda as a consequence of COVID-19 emergency measures, most notably by substitution of firewood for charcoal, reflecting a regressive step in the energy ladder. Our findings demonstrate a high level of awareness and engagement with forthcoming domestic fuel policy changes in Kigali, and a large proportion of those interviewed would consider transition to cleaner domestic energy sources. This novel primary research has implications for developing domestic energy resilience to disruptive economic impacts and ensuring effective clean fuel policy implementation in East Africa.

Understanding the invisible workforce: lessons for general practice from a survey of receptionists.

INTRODUCTION: The significance of the role of receptionists during the recent shift to remote triage has been widely recognised and they will have a significant role to play in UK general practice as it continues to cope with a huge increase in demand exacerbated by the COVID-19 pandemic. To maximise their contribution, it is important the social and occupational characteristics of the modern receptionist are understood, alongside their attitudes towards the role and their perceptions of the support and training they receive . METHODS: We used convenience and cross-sectional sampling to survey the demographic characteristics of receptionists and various aspects of their role and responsibilities. This included the training received, specific tasks performed, job satisfaction, the importance of the role, and their interaction with clinical and non-clinical colleagues. We also captured data on the characteristics of their practice including the number of GPs and location. RESULTS: A total of 70 participants completed the survey (16 postal and 54 online responses) of whom the majority were white (97.2%), female (98.6%), and aged 40 and over (56.7%). The majority of the training focussed on customer service (72.9%), telephone (64.3%), and medical administration skills (58.6%). Just over a quarter had received training in basic triage (25.7%). A standard multiple regression model revealed that the strongest predictor of satisfaction was support from practice GPs (ß = .65, p <.001) there were also significant positive correlations between satisfaction and appreciation from GPs, r(68) = .609, p < .001. CONCLUSION: This study has provided a much-needed update on the demographics, duties, and job satisfaction of GP receptionists. The need for diversification of the workforce to reflect the range of primary care patients warrants consideration in light of continuing variation in access along lines of gender andethnicity. Training continues to focus on administrative duties not on the clinically relevant aspects of their role such as triage.

Factors associated with COVID-19 vaccine intentions during the COVID-19 pandemic; a systematic review and meta-analysis of cross-sectional studies.

BACKGROUND: A high COVID-19 vaccine uptake is essential to achieve herd immunity to combat the current strain of COVID-19 and potential future variants. This review aimed to identify factors associated with public intention to receive COVID-19 vaccines until February 2021 to provide accessible data to policymakers to inform framing and targeting of messages designed to optimise vaccine uptake. METHODS: Medline, Embase, CINAHL, PsycINFO, PsycARTICLES, Sociological Abstracts and Applied Social Sciences Index and Abstracts were searched for cross-sectional studies reporting data regarding COVID-19 vaccine intentions, published between 01/01/2020 and 12/02/2021. Title/abstract and full-text screening were performed independently by two authors. The Appraisal Tool for Cross-sectional Studies (AXIS) was used to assess bias and quality. Both random-effects meta-analysis and narrative synthesis were used to describe vaccine intentions and associated factors. A subgroup analysis assessing the impact of sex, sampling method and time of survey on COVID-19 vaccine intention was performed. RESULTS: Searches identified 4739 studies, and 23 cross-sectional studies were deemed eligible for the review; 22 used online surveys and one used a mixed-methods study design. Eighteen surveys were conducted in the first half of 2020 and five were conducted in the latter half of 2020. Fifteen countries were represented, with the most common being the United States (n = 4) and the United Kingdom (n = 4) sampling 41,403 participants across all surveys. Most studies employed convenience sampling and 11 non-responder rates raised concerns over non-response bias. From the 18 studies included in the meta-analysis, the pooled proportion of survey participants willing to receive the COVID-19 vaccine was 73.3% (n = 18, 95% Confidence Interval 64.2 to 81.5%, I2 = 99.7%). Factors associated with a higher COVID-19 vaccine acceptance included greater perceived risk of COVID-19, lower level of perceived vaccine harm, higher educational attainment and household income, older age, being of White ethnicity and male sex. CONCLUSIONS: There was a high willingness to receive the COVID-19 vaccine which was influenced by sociodemographic factors and risk perceptions. The findings suggest future research should explore reasoning behind vaccine intentions for different sociodemographic groups to allow targeted communication strategies to be formulated by public health agencies. REGISTRATION: PROSPERO Registration Number: CRD42021239134.

EarLy Surveillance for Autoimmune diabetes: protocol for a qualitative study of general population and stakeholder perspectives on screening for type 1 diabetes in the UK (ELSA 1).

OBJECTIVE: Type 1 diabetes (T1D) is the most common form of diabetes in children, accounting for 96% of cases, with 29 000 children affected in the UK. Studies have recently identified immunotherapies that safely delay the development of T1D for at least 3 years, and further therapies are in development. General population screening programs in other countries can now accurately identify children with presymptomatic T1D who can be entered into prevention studies. The UK does not have such a system in place. We aim to explore whether parents and children in the UK would want to be part of such a program of testing for T1D in the general population, how they would want to be informed and participate in such a program, and how any barriers to recruitment and participation can be addressed. Additionally, the views of stakeholders who would be involved in the testing program will be collected and analyzed. RESEARCH DESIGN AND METHODS: We will interview parents/guardians and children aged 3-13 years about their views on screening for T1D. We will recruit purposefully to ensure representation across ethnicities and socioeconomic groups. Interviews will be transcribed, analyzed and used to inform iterative co-design work with additional families to address any issues raised. Similar qualitative work will be undertaken with professional stakeholders who would be involved in implementing any future screening program. Where possible, all aspects of this study will be performed remotely by phone or online to minimize infection risk. CONCLUSIONS: This qualitative study will provide the first insights into acceptability of testing and monitoring for T1D in the general population from the perspective of families and stakeholders in the UK. Co-design work will help establish the barriers and identify strategies to mitigate and overcome these issues, as an important step towards consideration of national testing for T1D.

What can general practice learn from primary care nurses' and healthcare assistants' experiences of the COVID-19 pandemic? A qualitative study.

OBJECTIVES: UK general practice has radically altered in response to COVID-19. The general practice nursing team has been central to these changes. To help learn from COVID-19 and maintain a sustainable nursing workforce, general practice should reflect on their support needs and perceptions of organisational strategies. This study aimed to explore primary care nurses' and healthcare assistants' experiences and perceptions of general practice, and the changes made to it, during the pandemic. DESIGN: Exploratory qualitative study using semistructured interviews. Interview data were analysed using Braun and Clarke's 'codebook' thematic analysis. SETTING: General practices in the Midlands, South East and South West England. Interviews were conducted in February and March 2021, as England began to unlock from its third national lockdown. PARTICIPANTS: Practice nurses (n=12), healthcare assistants (n=7), advanced nurse practitioners (n=4) and nursing associates (n=1) recruited using convenience and snowball sampling. RESULTS: Three themes were identified. Difficult changes describes dramatic changes made to general practice at the onset of the pandemic, creating confusion and anxiety. Dealing with change characterises how negative emotions were intensified by fear of infection, problematic government guidance, personal protective equipment (PPE) shortages and friction with doctors; but could be mitigated through effective practice communication, peer support and individual coping strategies. An opportunity for improvement highlights certain changes (eg, the increased use of telehealth) that participants believed could be adopted long term to improve efficiency. CONCLUSION: General practice should learn from the COVID-19 pandemic to nurture the clinical role and resilience of nurses and healthcare assistants in the postpandemic 'new normal'. Robust PPE provision could enable them to undertake their patient-facing duties safely and confidently. Judicious implementation of telehealth could help preserve the practical and caring nature of nursing. Improving channels of communication and interprofessional collaboration could help realise their potential within the primary care team.

Women’s Perceptions and Attitudes to Household Air Pollution Exposure and Capability to Change Cooking Behaviours in Urban Rwanda

Household air pollution (HAP) from cooking on biomass fuel presents significant health, environmental and socioeconomic consequences worldwide. However, there is a lack of understanding of the factors influencing cooking behaviours that affect HAP exposure in Rwanda (e.g., cooking location, removing children from the cooking area). Sixteen qualitative in-depth interviews were undertaken with women living in an underprivileged neighbourhood in Kigali, Rwanda. Deductive thematic analysis was carried out using the Behaviour Change Wheel (Capability—ability to engage with chosen activity, Opportunity—factors which are beyond the individual’s control and Motivation—brain processes which direct behaviour: COM-B) to determine the thoughts and perceptions around cooking location and removing children from the cooking area. Facilitators and barriers were subsequently identified within the COM-B framework for the following HAP mitigation interventions: outdoor cooking, removing children from the cooking area and Liquid Petroleum Gas (LPG) use. Of the 16 interviewed, 12 cooked outdoors (75%), two (12.5%) cooked indoors (in the main home) and two (12.5%) in a separate kitchen. Despite the majority cooking outdoors, this was reported not to be a favourable cooking location. Levels of awareness of HAP sources and knowledge of the health effects of air pollution were observed to be limited, reducing women’s capability to change, along with stated barriers of cost, housing constraints and safety. Factors out of the individuals’ control (opportunities) included weather, socio-economic and educational factors. Preconceived beliefs, experiencing smoke reduction and the briefly described short-term health effects, directed motivation. Furthermore, participants identified a need for community-based education as a facilitator to changing their behaviour. Despite a high level of observed motivation towards reducing HAP exposure, many women lacked the capability and opportunity to change their behaviour. There are research and policy implications concerning development of community-based interventions which involved end-users and relevant stakeholders in the development process.

Impact of COVID-19 on the digital divide: a rapid review.

OBJECTIVE: The increased reliance on digital technologies to deliver healthcare as a result of the COVID-19 pandemic has meant pre-existing disparities in digital access and utilisation of healthcare might be exacerbated in disadvantaged patient populations. The aim of this rapid review was to identify how this 'digital divide' was manifest during the first wave of the pandemic and highlight any areas which might be usefully addressed for the remainder of the pandemic and beyond. DESIGN: Rapid review and narrative synthesis. DATA SOURCES: The major medical databases including PubMed and Embase and Google Scholar were searched alongside a hand search of bibliographies. ELIGIBILITY CRITERIA: Original research papers available in English which described studies conducted during wave 1 of the COVID pandemic and reported between 1 March 2020 and 31 July 2021. RESULTS: The search was described using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and identified nine studies. The results are presented within a refined framework describing the three key domains of the digital divide: (1) digital access, within which one study described continuing issues with internet connectivity among vulnerable patients in the UK; (2) digital literacy, where seven studies described how ethnic minorities and the elderly were less likely to use digital technologies in accessing care; (3) digital assimilation, where one study described how video technologies can reduce feelings of isolation and another how elderly black males were the most likely group to share information about COVID-19 on social media platforms. CONCLUSIONS: During the early phase of the pandemic in the developed world, familiar difficulties in utilisation of digital healthcare among the elderly and ethnic minorities continued to be observed. This is a further reminder that the digital divide is a persistent challenge that needs to be urgently addressed when considering the likelihood that in many instances these digital technologies are likely to remain at the centre of healthcare delivery.