Providing care to marginalised communities: a qualitative study of community pharmacy teams.

BACKGROUND: Health inequalities in the UK are widening, particularly since the COVID-19 pandemic. Community pharmacies are the most visited healthcare provider in England and are ideally placed to provide and facilitate access to care for those most disadvantaged. AIM: To explore the experiences and needs of community pharmacy teams in providing care for marginalised groups and how this has changed since the COVID-19 pandemic. DESIGN AND SETTING: A qualitative study in community pharmacy and across primary care. METHOD: Semi-structured interviews were undertaken with members of community pharmacy teams, primary care network (PCN) pharmacists, GPs, and nurses in the North of England. RESULTS: In total, 31 individuals participated in an interview (26 pharmacy staff, three GPs, and two nurses). Most participants acknowledged that their pharmacy had become busier since COVID-19 because of increased footfall compounded by patient difficulties in navigating remote digital systems. Few participants had received any formal training on working with marginalised communities; however, organisational barriers (such as lack of access to translation facilities) combined with interorganisational barriers (such as lack of integrated care) made it more difficult to provide care for some marginalised groups. Despite this, the continuity of care provided by many pharmacies was viewed as an important factor in enabling marginalised groups to access and receive care. CONCLUSION: There are opportunities to better utilise the skills of community pharmacy teams. Resources, such as access to translation services, and interventions to enable better communication between community pharmacy teams and other primary care services, such as general practice, are essential.

Reflections of patient and public involvement from a commissioned research project evaluating a nationally implemented NHS programme focused on diabetes prevention.

Patient and Public Involvement and Engagement (PPIE) in research is recognised by the National Institute for Health and Care Research as crucial for high quality research with practical benefit for patients and carers. Patient and public contributors can provide both personal knowledge and lived experiences which complement the perspectives of the academic research team. Nevertheless, effective PPIE must be tailored to the nature of the research, such as the size and scope of the research, whether it is researcher-led or independently commissioned, and whether the research aims to design an intervention or evaluate it. For example, commissioned research evaluations have potential limits on how PPIE can feed into the design of the research and the intervention. Such constraints may require re-orientation of PPIE input to other functions, such as supporting wider engagement and dissemination. In this commentary, we use the 'Guidance for Reporting Involvement of Patients and the Public' (GRIPP2) short form to share our own experiences of facilitating PPIE for a large, commissioned research project evaluating the National Health Service Diabetes Prevention Programme; a behavioural intervention for adults in England who are at high risk of developing type 2 diabetes. The programme was already widely implemented in routine practice when the research project and PPIE group were established. This commentary provides us with a unique opportunity to reflect on experiences of being part of a PPIE group in the context of a longer-term evaluation of a national programme, where the scope for involvement in the intervention design was more constrained, compared to PPIE within researcher-led intervention programmes. We reflect on PPIE in the design, analysis and dissemination of the research, including lessons learned for future PPIE work in large-scale commissioned evaluations of national programmes. Important considerations for this type of PPIE work include: ensuring the role of public contributors is clarified from the outset, the complexities of facilitating PPIE over longer project timeframes, and providing adequate support to public contributors and facilitators (including training, resources and flexible timelines) to ensure an inclusive and considerate approach. These findings can inform future PPIE plans for stakeholders involved in commissioned research.

Public Health Interventions Delivered by Pharmacy Professionals in Low- and Middle-Income Countries in Africa: A Systematic Scoping Review.

Pharmacists and their teams play an important role in providing public health services, however little is known about their level of contribution and the strength of evidence in Africa's Low- and Middle-Income Countries (LMICs). The purpose of this scoping review was to explore and map the available evidence on pharmacy professional-delivered public health interventions in Africa's LMICs. Six electronic databases (Medline, Embase, International Pharmaceutical Abstract, PsycInfo, Maternity and Infant Care, and Cochrane database), relevant grey literature sources, key journals focused on African health issues, and libraries of relevant organizations were searched between January 2010 and December 2020. Studies were included if they reported public health interventions delivered by pharmacy professionals (pharmacists or pharmacy technicians) or their teams. The quality of the individual studies was assessed using an adapted grading system. Thirty-nine studies were included in this review. Pharmacy professionals delivered a wide range of public health interventions, with the most common themes being noncommunicable diseases, infectious diseases, sexual and reproductive health, antimicrobial resistance, and other health conditions, e.g., dental health, unused drugs or waste, minor ailments. The majority of the studies were classified as low-quality evidence. They were predominantly feasibility and acceptability studies conducted in a narrow study area, in a small number of LMICs in Africa, resulting in little evidence of service effectiveness, issues of broad generalizability of the findings, and sustainability. The major constraints to service provision were identified as a lack of training, public recognition, and supporting policies. Pharmacy professionals and their teams across LMICs in Africa have attempted to expand their practice in public health. However, the pace of the expansion has been slow and lacks strong evidence for its generalizability and sustainability. Future research is needed to improve the quality of evidence, which will subsequently serve as a foundation for policy reform, allowing pharmacy professionals to make significant contributions to the public health initiatives in the region.

Challenges and adaptations to public involvement with marginalised groups during the COVID-19 pandemic: commentary with illustrative case studies in the context of patient safety research.

Patient and public involvement (PPI) is integral to research on patient safety in the NIHR Greater Manchester Patient Safety Translational Research Centre (NIHR GMPSTRC), and is central to our patient safety research within our theme focusing on people in marginalised groups. Due to the impact of COVID-19, researchers had to adapt how they do PPI. For marginalised groups, remote working and digital adaptations (the key adaptations made in accessing and utilising health services in the United Kingdom during COVID-19) can potentially lead to further marginalisation of people already marginalised and provide new barriers to others. This editorial showcases three case examples of PPI with marginalised groups during COVID-19, these are with: (1) adults with vision impairments, (2) adults and carers with lived experience of self-harm and/ or suicide and (3) adults with lived experience of homelessness. In these case examples, we focus on challenges relating to key aspects of PPI during the pandemic. First, setting up a PPI advisory group and secondly maintaining relationships and effective PPI with a pre-existing advisory group. We contrast these examples using more traditional ways of 'doing PPI' i.e. involving public contributors in various stages of the research cycle, with a more fully 'co-produced' approach to research when developing a new patient safety intervention. Important considerations for PPI with marginalised groups during COVID-19 include: how to avoid exacerbating the digital divide when using video conferencing for PPI, the need for enhanced awareness around flexibility and resources, and the value of working closely with specialist charities to enable adaptations that are sensitive to the changed circumstances and needs of PPI contributors.

The National Institute of Health Research (NIHR) Greater Manchester Patient Safety Translational research Centre (GMPSTRC) carries out research to improve patient safety. We work in partnership with patients and members of the public to plan, manage, design, and carry out the research. This is labelled as patient and public involvement. A key area of GMPSTRC research focuses on people who may be marginalised from healthcare and potentially suffer increased patient safety risks relative to the general population. COVID-19 impacted on research in multiple ways, notably how researchers work with members of the public. Remote working via the use of internet enabled technology has now become more commonplace, although this raises concerns about digital exclusion and how to address barriers when face-to-face PPI is not possible. This article showcases three examples of how researchers and public contributors with lived experience have adapted to working together during the COVID-19 pandemic. These case examples are: (1) setting up a public involvement group for developing an intervention to reduce medication errors for adults with vision impairments; (2) working with a pre-existing group of public contributors who are adults and carers with lived experience of self-harm and/or suicide; and (3) working with a charity called Groundswell who train and support researchers with lived experience of homelessness. Challenges during COVID-19 have been making video conferencing meetings accessible to members who have a range of different needs, and addressing the digital divide by allowing members flexibility in how they contribute to research. The article provides examples of how these challenges were addressed.

Remote primary care during the COVID-19 pandemic for people experiencing homelessness: a qualitative study.

BACKGROUND: The COVID-19 pandemic has caused unprecedented disruption and change to the organisation of primary care, including for people experiencing homelessness who may not have access to a phone. Little is known about whether the recent changes required to deliver services to people experiencing homelessness will help to address or compound inequality in accessing care. AIM: To explore the experience and impact of organisational and technology changes in response to COVID-19 on access to health care for people experiencing homelessness. DESIGN AND SETTING: An action-led and participatory research methodology was employed in three case study sites made up of primary care services delivering care for people experiencing homelessness. METHOD: Individual semi-structured interviews were conducted with 21 people experiencing homelessness and 22 clinicians and support workers. Interviews were analysed using a framework approach. RESULTS: The move to remote telephone consultations highlighted the difficulties experienced by participants in accessing health care. These barriers included problems at the practice level associated with remote triage as participants did not always have access to a phone or the means to pay for a phone call. This fostered increased reliance on support workers and clinicians working in the community to provide or facilitate a primary care appointment. CONCLUSION: The findings have emphasised the importance of addressing practical and technology barriers as well as supporting communication and choice for mode of consultation. The authors argue that consultations should not be remote 'by default' and instead take into consideration both the clinical and social factors underpinning health.

The perceptions of general practice among Central and Eastern Europeans in the United Kingdom: A systematic scoping review.

BACKGROUND: Around 2 million people have migrated from Central and Eastern Europe to the UK since 2004. The UK Central and Eastern European Community (UK-CEE) are disproportionately exposed to the social determinants of poor physical and mental health. Their health and healthcare beliefs remain under-researched, particularly regarding primary care. OBJECTIVE: This review explores UK-CEE community members' use and perceptions of UK general practice. METHODS: A systematic search of nine bibliographic databases identified 2094 publications that fulfilled the search criteria. Grey literature searches identified 16 additional relevant publications. Screening by title and abstract identified 201 publications of relevance, decreasing to 65 after full-text screening. Publications were critically appraised, with data extracted and coded. Thematic analysis using constant comparison allowed generation of higher-order thematic constructs. RESULTS: Full UK-CEE national representation was achieved. Comparatively low levels of GP registration were described, with ability, desire and need to engage with GP services shaped by the interconnected nature of individual community members' cultural and sociodemographic factors. Difficulties overcoming access and in-consultation barriers are common, with health expectations frequently unmet. Distrust and dissatisfaction with general practice often persist, promoting alternative health-seeking approaches including transnational healthcare. Marginalized UK-CEE community subgroups including Roma, trafficked and homeless individuals have particularly poor GP engagement and outcomes. Limited data on the impact of Brexit and COVID-19 could be identified. CONCLUSIONS: Review findings demonstrate the need for codesigned approaches to remove barriers to engagement, culturally adapt and develop trust in GP care for UK-CEE individuals. COMMUNITY INVOLVEMENT: Community members and stakeholders shaped the conceptualisation of the review question and validation of emergent themes.

Exploring the experiences of changes to support access to primary health care services and the impact on the quality and safety of care for homeless people during the COVID-19 pandemic: a study protocol for a qualitative mixed methods approach.

BACKGROUND: Despite high level of health care need amongst people experiencing homelessness, poor access is a major concern. This is sometimes due to organisational and bureaucratic barriers, but also because they often feel stigmatised and treated badly when they do seek health care. The COVID-19 pandemic and the required social distancing measures have caused unprecedented disruption and change for the organisation of primary care, particularly for people experiencing homelessness. Against this backdrop there are many questions to address regarding whether the recent changes required to deliver services to people experiencing homelessness in the context of COVID-19 will help to address or compound problems in accessing care and inequalities in health outcomes. METHODS: An action led and participatory research methodology will be employed to address the study objectives. Interviews with people experiencing homelessness were will be conducted by a researcher with lived experience of homelessness. Researchers with lived experience are able to engage with vulnerable communities in an empathetic, non-judgemental way as their shared experience promotes a sense of trust and integrity, which in turn encourages participation in research and may help people speak more openly about their experience. The experiences of health professionals and stakeholders delivering and facilitating care for people experiencing homelessness during the pandemic will also be explored. DISCUSSION: It is important to explore whether recent changes to the delivery of primary care in response to the COVID-19 pandemic compromise the safety of people experiencing homelessness and exacerbate health inequalities. This could have implications for how primary healthcare is delivered to those experiencing homelessness not only for the duration of the pandemic but in the future.

Patient insights on living with idiopathic inflammatory myopathy and the limitations of disease activity measurement methods - a qualitative study.

BACKGROUND: The idiopathic inflammatory myopathies (IIMs) are chronic autoimmune conditions, typically resulting in proximal muscle weakness and impacting upon quality of life. Accurate measurement of IIM disease activity is imperative for appropriate medical management and carrying out valid clinical trials. The International Myositis Assessment and Clinical Studies Group (IMACS) "Disease Activity Core Set Measures" are the current gold-standard of IIM disease activity assessment. Anecdotally, patients with an IIM report that the IMACS Core Set Measures and other available methods do not necessarily capture their perceived disease activity. Investigating the patient experiences of living with an IIM and their views on the accuracy of the IMACS Core Set Measures will provide valuable insights for both clinical and research purposes. METHODS: Eighteen interviews with patients with an IIM were carried out and analysed thematically, using a grounded theory approach. Experiences on living with an IIM and perceptions on the accuracy of disease activity measurement methods were explored. RESULTS: Interview analysis revealed four themes: 1) fatigue, 2) pain, 3) day-to-day symptom variation, 4) limitations of creatine kinase levels and manual muscle testing. CONCLUSIONS: This study has provided valuable insights into patient experiences of living with an IIM. Aspects of IIM disease activity perceived not to be wholly measured by the IMACS Core Set Measures have also been identified. These findings have implications for future IIM clinical care and research, in particular providing justification for research into pain, fatigue and symptom variation.

Engagement and Participant Experiences With Consumer Smartwatches for Health Research: Longitudinal, Observational Feasibility Study.

BACKGROUND: Wearables provide opportunities for frequent health data collection and symptom monitoring. The feasibility of using consumer cellular smartwatches to provide information both on symptoms and contemporary sensor data has not yet been investigated. OBJECTIVE: This study aimed to investigate the feasibility and acceptability of using cellular smartwatches to capture multiple patient-reported outcomes per day alongside continuous physical activity data over a 3-month period in people living with knee osteoarthritis (OA). METHODS: For the KOALAP (Knee OsteoArthritis: Linking Activity and Pain) study, a novel cellular smartwatch app for health data collection was developed. Participants (age ≥50 years; self-diagnosed knee OA) received a smartwatch (Huawei Watch 2) with the KOALAP app. When worn, the watch collected sensor data and prompted participants to self-report outcomes multiple times per day. Participants were invited for a baseline and follow-up interview to discuss their motivations and experiences. Engagement with the watch was measured using daily watch wear time and the percentage completion of watch questions. Interview transcripts were analyzed using grounded thematic analysis. RESULTS: A total of 26 people participated in the study. Good use and engagement were observed over 3 months: most participants wore the watch on 75% (68/90) of days or more, for a median of 11 hours. The number of active participants declined over the study duration, especially in the final week. Among participants who remained active, neither watch time nor question completion percentage declined over time. Participants were mainly motivated to learn about their symptoms and enjoyed the self-tracking aspects of the watch. Barriers to full engagement were battery life limitations, technical problems, and unfulfilled expectations of the watch. Participants reported that they would have liked to report symptoms more than 4 or 5 times per day. CONCLUSIONS: This study shows that capture of patient-reported outcomes multiple times per day with linked sensor data from a smartwatch is feasible over at least a 3-month period. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/10238.

Does health coaching improve health-related quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease? A systematic review and meta-analysis.

PURPOSE: To systematically review the evidence for health coaching as an intervention to improve health-related quality of life (HRQoL) and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD). METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, and CINAHL from database inception to August 2018 to identify all randomized controlled trials (RCTs) of health coaching for people with COPD. Eligible health coaching interventions had to include three components: goal setting, motivational interviewing, and COPD-related health education. Data were extracted on study characteristics and the effects of the intervention on HRQoL, hospital admissions, physical activity, self-care behaviour, and mood. Study quality was appraised by two authors using the Cochrane tool for assessing the risk of bias in RCTs. Effect sizes (standardized mean differences [SMD] or odds ratios [OR]) with 95% confidence intervals (CIs) were calculated and pooled using random effects meta-analyses. RESULTS: Of 1578 articles, 10 RCTs were included. Meta-analysis showed that health coaching has a significant positive effect on HRQoL (SMD = -0.69, 95% CI: -1.28, -0.09, p = .02, from k = 4) and leads to a significant reduction in COPD-related hospital admissions (OR = 0.46, 95% CI: 0.31, 0.69, p = .0001, from k = 5), but not in all-cause hospital admissions (OR = 0.70, 95% CI: 0.41-1.12, p = .20, from k = 3). Three of four studies reported significant improvements to self-care behaviours such as medication adherence and exercise compliance. CONCLUSIONS: This is the first systematic review to show that health coaching may be a candidate intervention to improve HRQoL and reduce costly hospital admissions in people with COPD. Statement of contribution What is already known on this subject? COPD is a leading cause of death worldwide and considerably reduces HRQoL. In turn, HRQoL is associated with a range of adverse health outcomes in COPD. Health coaching is a self-management intervention for people with long-term conditions such as COPD. Studies have examined whether health coaching improves HRQOL and other health outcomes in people with COPD, but no systematic review has been conducted. What does this study add? The first systematic review and meta-analysis of RCTs of health coaching for people with COPD. Health coaching may be a candidate intervention for improving HRQoL and reducing COPD-related hospital admissions in people with COPD. The need to establish the most effective health coaching components, delivery modality, and economic impact.

Collecting Symptoms and Sensor Data With Consumer Smartwatches (the Knee OsteoArthritis, Linking Activity and Pain Study): Protocol for a Longitudinal, Observational Feasibility Study.

BACKGROUND: The Knee OsteoArthritis, Linking Activity and Pain (KOALAP) study is the first to test the feasibility of using consumer-grade cellular smartwatches for health care research. OBJECTIVE: The overall aim was to investigate the feasibility of using consumer-grade cellular smartwatches as a novel tool to capture data on pain (multiple times a day) and physical activity (continuously) in patients with knee osteoarthritis. Additionally, KOALAP aimed to investigate smartwatch sensor data quality and assess whether engagement, acceptability, and user experience are sufficient for future large-scale observational and interventional studies. METHODS: A total of 26 participants with self-diagnosed knee osteoarthritis were recruited in September 2017. All participants were aged 50 years or over and either lived in or were willing to travel to the Greater Manchester area. Participants received a smartwatch (Huawei Watch 2) with a bespoke app that collected patient-reported outcomes via questionnaires and continuous watch sensor data. All data were collected daily for 90 days. Additional data were collected through interviews (at baseline and follow-up) and baseline and end-of-study questionnaires. This study underwent full review by the University of Manchester Research Ethics Committee (#0165) and University Information Governance (#IGRR000060). For qualitative data analysis, a system-level security policy was developed in collaboration with the University Information Governance Office. Additionally, the project underwent an internal review process at Google, including separate reviews of accessibility, product engineering, privacy, security, legal, and protection regulation compliance. RESULTS: Participants were recruited in September 2017. Data collection via the watches was completed in January 2018. Collection of qualitative data through patient interviews is still ongoing. Data analysis will commence when all data are collected; results are expected in 2019. CONCLUSIONS: KOALAP is the first health study to use consumer cellular smartwatches to collect self-reported symptoms alongside sensor data for musculoskeletal disorders. The results of this study will be used to inform the design of future mobile health studies. Results for feasibility and participant motivations will inform future researchers whether or under which conditions cellular smartwatches are a useful tool to collect patient-reported outcomes alongside passively measured patient behavior. The exploration of associations between self-reported symptoms at different moments will contribute to our understanding of whether it may be valuable to collect symptom data more frequently. Sensor data-quality measurements will indicate whether cellular smartwatch usage is feasible for obtaining sensor data. Methods for data-quality assessment and data-processing methods may be reusable, although generalizability to other clinical areas should be further investigated. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/10238.

Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity? An evaluation of reach, effectiveness and cost-effectiveness using a 'trial within a cohort'.

BACKGROUND: Innovative ways of delivering care are needed to improve outcomes for older people with multimorbidity. Health coaching involves 'a regular series of phone calls between patient and health professional to provide support and encouragement to promote healthy behaviours'. This intervention is promising, but evidence is insufficient to support a wider role in multimorbidity care. We evaluated health coaching in older people with multimorbidity. METHODS: We used the innovative 'Trials within Cohorts' design. A cohort was recruited, and a trial was conducted using a 'patient-centred' consent model. A randomly selected group within the cohort were offered the intervention and were analysed as the intervention group whether they accepted the offer or not. The intervention sought to improve the skills of patients with multimorbidity to deal with a range of long-term conditions, through health coaching, social prescribing and low-intensity support for low mood. RESULTS: We recruited 4377 older people, and 1306 met the eligibility criteria (two or more long-term conditions and moderate 'patient activation'). We selected 504 for health coaching, and 41% consented. More than 80% of consenters received the defined 'dose' of 4+ sessions. In an intention-to-treat analysis, those selected for health coaching did not improve on any outcome (patient activation, quality of life, depression or self-care) compared to usual care. We examined health care utilisation using hospital administrative and self-report data. Patients selected for health coaching demonstrated lower levels of emergency care use, but an increase in the use of planned services and higher overall costs, as well as a quality-adjusted life year (QALY) gain. The incremental cost per QALY was £8049, with a 70-79% probability of being cost-effective at conventional levels of willingness to pay. CONCLUSIONS: Health coaching did not lead to significant benefits on the primary measures of patient-reported outcome. This is likely related to relatively low levels of uptake amongst those selected for the intervention. Demonstrating effectiveness in this design is challenging, as it estimates the effect of being selected for treatment, regardless of whether treatment is adopted. We argue that the treatment effect estimated is appropriate for health coaching, a proactive model relevant to many patients in the community, not just those seeking care. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ( ISRCTN12286422 ).

Effect of health literacy on the quality of life of older patients with long-term conditions: a large cohort study in UK general practice.

PURPOSE: The levels of health literacy in patients with long-term conditions (LTCs) are critical for better disease management and quality of life (QoL). However, the impact of health literacy on QoL in older adults with LTCs is unclear. This study examined the association between health literacy and domains of QoL in older people with LTCs, investigating key socio-demographic and clinical variables, as confounders. METHODS: A prospective cohort study was conducted on older adults (n = 4278; aged 65 years and over) with at least one LTC, registered in general practices in Salford, UK. Participants completed measures of health literacy, QoL, multi-morbidity, depression, social support, and socio-demographic characteristics. Multivariate linear regressions were performed to examine the effects of health literacy on four QoL domains at baseline, and then changes in QoL over 12 months. RESULTS: At baseline, poor health literacy was associated with lower scores in all four QoL domains (physical, psychological, social relationships and environment), after adjusting for the effects of multi-morbidity, depression, social support and socio-demographic factors. At 12-month follow-up, low health literacy significantly predicted declines in the physical, psychological and environment domains of QoL, but not in social relationships QoL. CONCLUSIONS: This is the largest, most complete assessment of the effects of health literacy on QoL in older adults with LTCs. Low health literacy is an independent indicator of poor QoL older patients with LTCs. Interventions to improve health literacy in older people with LTCs are encouraged by these findings.

The cohort multiple randomized controlled trial design was found to be highly susceptible to low statistical power and internal validity biases.

OBJECTIVES: The "cohort multiple randomized controlled trial" (cmRCT) is a recent innovation by which novel interventions are trialed within large longitudinal cohorts of patients to gain efficiencies and align trials more closely to standard clinical practice. The use of cmRCTs is outpacing its methodological understanding, and more appropriate methods for designing and analyzing such trials are urgently needed. STUDY DESIGN AND SETTING: We established the UK Comprehensive Longitudinal Assessment of Salford Integrated Care cohort of 4,377 patients with long-term conditions within which we are conducting a cmRCT ("Proactive Telephone Coaching and Tailored Support") of telephone-based health coaching. RESULTS: We identify some key methodological challenges to the use of the cmRCT in actual practice. Principal are issues around statistical power, sample size, and treatment effect estimation, for which we provide appropriate methods. Sampling procedures commonly applied in conventional RCTs can result in unintentional selection bias. The fixed data collection points that feature in cmRCTs can also threaten validity. CONCLUSION: The cmRCT may offer advantages over conventional trial designs. However, a cmRCT requires appropriate power calculation, sampling, and analysis procedures; else, studies may be underpowered or subject to validity biases. We offer solutions to some of the key issues, but further methodological investigations are needed. Cohort multiple RCT-specific Consolidated Standards of Reporting Trials guidance may be indicated.

Exploring the career choices of White and Black, Asian and Minority Ethnic women pharmacists: a qualitative study.

OBJECTIVE: In the UK, a growing number of females entering pharmacy are women from Black, Asian and minority ethnic groups (BAME). Research shows that BAME women are more likely to work in the community sector and be self-employed locums than white women, and Asian women overrepresented in part-time, lower status roles. This study aims to explore the employment choices of white and BAME women pharmacists to see whether their diverse work patterns are the product of individual choices or other organisational factors. METHODS: This study analyses 28 qualitative interviews conducted with 18 BAME and 10 white women pharmacists. The interview schedule was designed to explore early career choices, future career aspirations and key stages in making their career decisions. KEY FINDINGS: The findings show that white and BAME women are influenced by different factors in their early career choices. Cultural preferences for self-employment and business opportunities discourage BAME women from hospital sector jobs early in their careers. Resonating with other studies, the findings show that white and BAME women face similar barriers to career progression if they work part-time. CONCLUSIONS: Women working part-time are more likely to face workforce barriers, irrespective of ethnic origin. Cultural preferences may be preventing BAME women from entering the hospital sector. This research is important in the light of current debates about the future shape of pharmacy practice, as well as wider government policy objectives that seek to improve the working lives of health care professionals and promote racial diversity and equality in the workplace.

The effect of using social pressure in cover letters to improve retention in a longitudinal health study: an embedded randomised controlled retention trial.

BACKGROUND: Retention of participants in cohort studies is important for validity. One way to promote retention is by sending a persuasive cover letter with surveys. The study aimed to compare the effectiveness of a covering letter containing social pressure with a standard covering letter on retention in a health cohort study. Social pressure involves persuading people to behave in a certain way by the promise that their actions will be made know to others. We implemented a mild form of social pressure, where the recipient was told that information about whether they responded to the current survey would be noted by the research team and printed on future correspondence from the research team to the recipient. METHODS: The design was an embedded randomised controlled retention trial, conducted between July 2015 and April 2016 in Salford, UK. Participants in the host health cohort study were eligible. They received either: (1) a covering letter with two consecutive surveys (sent six and twelve months after recruitment), containing a social pressure intervention; or (2) a matching letter without the social pressure text. The primary outcome was retention in the host study, defined as return of both surveys. Randomisation was computer-generated, with stratification by household size. Participants were blinded to group assignment. Researchers were blinded for outcome ascertainment. RESULTS: Adults (n = 4447) aged over 65 years, with a long-term condition and enrolled in the host study, were randomly allocated to receive a social pressure covering letter (n = 2223) or control (n = 2224). All 4447 participants were included in the analysis. Both questionnaires were returned by 1577 participants (71%) sent the social pressure letters and 1511 (68%) sent control letters, a risk difference of 3 percentage points (adjusted odds ratio = 1.16 (95% confidence interval = 1.02-1.33)). CONCLUSION: A mild form of social pressure made a small but significant improvement in retention of older adults in a health cohort study. Investigation of social pressure across other research contexts and stronger social pressure messages is warranted. TRIAL REGISTRATION: The host cohort study, the Comprehensive Longitudinal Assessment of Salford Integrated Care (CLASSIC) study is associated with the CLASSIC PROTECTs trial, which is registered on the ISRCTN registry. TRIAL REGISTRATION NUMBER: ISRCTN12286422 . Date of registration 19 June 2014.

Patient activation in older people with long-term conditions and multimorbidity: correlates and change in a cohort study in the United Kingdom.

BACKGROUND: Patient Activation is defined as the knowledge, skill, and confidence a patient has in managing their health. Higher levels of patient activation are associated with better self-management, better health outcomes, and lower healthcare costs. Understanding the drivers of patient activation can allow better tailoring of patient support and interventions. There are few data on patient activation in UK patients with long-term conditions. METHODS: A prospective cohort design was used. Questionnaires were mailed to 12,989 patients over the age of 65 years with at least one long-term condition in Salford, UK. They completed the Patient Activation Measure and self-report measures of: depression, health literacy, social support, health-related quality of life, and impact of multimorbidity. We report descriptive data on baseline activation and change over time, and use multivariate regression to model associations with patient activation at baseline and predictors of change in Activation over 6 months. RESULTS: The cohort included 4377 (33.6 %) older people, of whom 4225 were mailed a further questionnaire at 6 months; 3390 returned it complete (80.2 %). At baseline, 15 % self-reported PAM level 1, 16 % level 2, 45 % level 3, and 25 % level 4. Across all patients, depression had the strongest association with patient activation. Other important factors were: older age, being retired, poor health literacy, health-related quality of life, and social support. Total number of self-reported comorbidities and the perceived impact of comorbidities were also important for patients with more than one long-term condition. Patient activation scores were reasonably enduring over time (r = 0.43 between baseline and at six months), although nearly half changed 'levels' of activation over that time. Few variables predicted change in activation over 6 months. CONCLUSIONS: This is the first large scale assessment of patient activation in the UK. Our data may be useful in identifying patients who need support with patient activation, and allow interventions (such as health coaching) to be tailored to better support older patients with long-term conditions who have symptoms of depression, poor social support and impaired health literacy. Further analyses of longitudinal studies will be necessary to better understand the causal relationships between patient activation and variables such as depression.