Background In the United Kingdom, psychology departments are responding to growing calls for curriculum decolonization. However, there remains limited dialogue and sharing of best practice. Objective We aimed to catalyze discussion among key faculty members involved in curriculum decolonization, learn from their experiences, and collaboratively develop recommendations for psychology curriculum decolonization. Method Eleven contributors shared their insights regarding their departments’ decolonization efforts and how they navigated challenges. Findings Reflexive thematic analysis generated five themes. Motivation to decolonize the curriculum highlighted the student-centric, institutional, and ethical reasons driving curriculum decolonization. Approaches to curriculum decolonization described the varied ways in which curriculum decolonization is being envisioned. Efforts towards decolonizing the curriculum included two subthemes: review, revise, and reform discussed the initiatives for decolonizing the content-related aspects of the curriculum, and train, collaborate, and empower highlighted the efforts that complemented these initiatives. Supporting curriculum decolonization explained how decolonization work could be sustained, and creating a conducive ecosystem discussed the need for a supportive environment. Conclusion Our study highlighted the potential of collaborative efforts, institutional support, critical reflection, and inclusive dialogue to reimagine, restructure, and decolonize curricula. Teaching implications: we propose 12 concrete, co-produced, evidence-based recommendations to help initiate and advance psychology curriculum decolonization.

Testing is a cornerstone of epidemic response, underpinning public health and social measures, clinical care, and surveillance. However, testing interventions are inherently complex – not only their implementation but also their effects. The value of testing in epidemics depends on managing this complexity with clear objectives, appropriate technologies, effective implementation, and timely adaptation to changing epidemiological and social contexts. Collectively, these factors determine whether testing delivers its intended benefit. We propose a data-driven framework to guide effective and equitable testing in epidemics. The framework is informed by an interdisciplinary expert consultation that reviewed community testing in response to SARS-CoV-2 in the UK, alongside international experiences. The framework has four components: defining purpose; selecting and evaluating technology; designing engagement and implementation; and enabling monitoring, evaluation, and optimisation. We outline inputs, outputs and required tools to support framework delivery. Preparing this capability in advance of emergencies should be central to pandemic preparedness.

Aims: People with eating disorders can find the experience of social eating difficult, and being able to eat socially can be an important part of recovery. In the context of mental health treatment, experiences of mastery within virtual reality (VR) can be transferred to real life, and previous qualitative research has identified that a VR café environment could be a useful treatment adjunct for people with eating disorders. The aim of this project was to develop a VR café intervention for people with eating disorders who find social eating challenging. Methods: We used the Person-Based Approach to develop the VR café. In Study 1 we conducted qualitative interviews and focus groups with young people with personal experience of a range of different eating disorders (n = 15), parents and carers (n = 4), and clinicians from a variety of professional backgrounds (n = 6), to inform the design of the intervention. In Study 2, the café was further developed through a series of development activities and think aloud interviews with people with experience of eating disorders (n = 12). Results: Study 1 participants described a range of challenges associated with cafés, which were incorporated into the initial build of the VR café by our industry partners, Virtual Bodyworks (Kiin). These included challenges related to social interactions with café staff, the busyness of café settings, and around choosing and ordering food and drink from café menus. Study 2 participants further shaped the intervention, contributing to the scripts for VR café staff; helping to develop food and drink menus; providing feedback on measures for assessing the effectiveness of the intervention; and advising on the ways clinicians could helpfully support people using the VR café, including through the provision of feedback on a written guidance document. During think-aloud interviews, Study 2 participants also identified areas for improvement to the content and experience of the VR café. Conclusion: By placing the perspectives and ideas of people with eating disorders at the heart of the design of the VR café, we have developed a safe space for people with diverse eating disorders to practice relevant challenges related to social eating whilst being supported by a clinician. The intervention aims to reduce anxiety, increase confidence, and improve tolerance of uncertainty around social eating settings, and will be offered to young people accessing eating disorder treatment in two participating NHS trusts, as part of a mixed methods feasibility trial.

BACKGROUND:For many women who experience hypertension in pregnancy, raised blood pressure continues into the postpartum period, usually settling over the first 6-12 weeks. Blood pressure control during this time appears to be important for long-term cardiovascular health but care appears to be haphazard. This study aimed to understand UK National Health Service usual postpartum care for such women. METHODS:A cross-sectional online survey was designed and piloted by a multidisciplinary team of midwives, obstetricians, primary care researchers, patient representatives, and a general practitioner, to capture current practice including blood pressure monitoring, antihypertensive prescribing, and use of self-monitoring; there were 38 questions. The survey was delivered via the Doctors.net (for obstetricians and general practitioners) and Joint Information Systems Committee (JISC) online platforms (for Midwives) from May to November 2023. RESULTS:A total of 253 clinicians responded to the survey, including 101 General Practitioners, 100 doctors working in maternity care, trained in obstetrics (obstetricians) or with specialist expertise in medical disorders in pregnancy (obstetric physicians), 50 midwives, and 2 maternity support workers. Women's care generally transferred from secondary to primary care at around two weeks postpartum, although this was not consistent, and there were differences in practice, awareness, and expectations between professions around the management of hypertension and responsibility. Communication barriers between professional groups and a need for better guidance and co-ordination were highlighted, and most professionals agreed that self-measured blood pressure readings could support postpartum care for those with hypertension. CONCLUSIONS:The survey highlighted variations in the practice and expectations of different healthcare professionals involved in postpartum care. The time when care was transferred from hospital to primary care was not consistent, with potential for women's care to fall through gaps. The transfer of information and women's ability to access care at this time were highlighted as problematic.

Interventions are increasingly being co-produced in partnership with people from the communities who will use them. This can help to ensure interventions are appropriate for and valued by these communities. This article describes how our research team has implemented the methods and tools of the widely used Person-Based Approach to integrate co-production into the heart of our intervention development. We describe a series of case studies and consider how traditional engagement approaches may be complemented with approaches that better suit the needs and preferences of those from underserved communities. We consider the benefits and limitations of each co-production approach and propose a range of tools (e.g. table of changes, planning table, guiding principles) to support co-production. We conclude by highlighting that collaborating with intervention users requires flexibility in engagement efforts to facilitate meaningful partnerships at all stages of intervention development. We also advocate working with community partners to agree on an approach that supports both research requirements and reflects their needs and preferences.

Background/Objectives: In England, gay, bisexual, and other men who have sex with men (GBMSM) are eligible for vaccination at NHS sexual health services, including human papillomavirus (HPV), hepatitis A virus (HAV), and hepatitis B virus (HBV) vaccines. However, current research shows limited understanding of the factors influencing vaccination uptake among GBMSM. This study aimed to examine the barriers and facilitators affecting the offer and uptake of these vaccination programmes. Methods: A qualitative interview study following the Person-Based Approach (a systematic method for developing and optimising health interventions) involving GBMSM and sexual health service staff from two regions of England. Purposive sampling aimed to include GBMSM with diverse backgrounds and engagement with sexual health services. Patient and public involvement shaped the study design and interview topic guides. The interviews were recorded, transcribed, and thematically analysed to identify barriers and facilitators which were interpreted using the COM-B model of behaviour change. Results: Twenty GBMSM and eleven staff took part. The findings showed that opportunistic delivery of HPV, HAV, and HBV vaccination within sexual health services is mostly acceptable and feasible for GBMSM and staff, while also highlighting areas for optimization. Despite low knowledge of these viruses and their associated risks, willingness to be vaccinated was high, with healthcare provider recommendations and the convenience of vaccine delivery during routine clinic visits acting as important facilitators. However, the reach of opportunistic models was limited, particularly for individuals underserved by sexual health services or disengaged from GBMSM social networks. System-level barriers such as complex vaccine schedules (particularly when multiple schedules are combined), inconsistent access to vaccination histories, and limited system-level follow-up processes (e.g., automated invites and reminders) were also found to act as obstacles to vaccination uptake and delivery. Conclusions: To improve equitable uptake, sexual health services should explore the feasibility of addressing both individual and structural barriers through additional strategies, including targeted and persuasive communication to increase knowledge, leveraging regular contact with GBMSM to promote uptake, and implementing enhanced approaches to support vaccination completion (e.g., automated prompts or reminders).

Invasive group A streptococcal (iGAS) disease is a rare but serious bacterial infection affecting a broad cross-section of people. Public health advice is routinely provided to close contacts of iGAS cases to encourage early presentation to medical facilities, given the elevated risk of secondary transmission. Despite being at heightened risk, people experiencing homelessness (PEH) and people who inject drugs (PWID) have not been involved in developing the pre-existing public health materials, and therefore they may not be accessible, understandable, or actionable for these groups. Coproduction is an approach in which people with lived experience work in partnership with researchers, in this case, to design and evaluate interventions intended for their use. This project (1) explored the experiences and communication needs of PEH and PWID; (2) coproduced iGAS factsheets with PEH and PWID; and (3) evaluated whether the coproduced materials were accessible, understandable, non-stigmatising, and actionable. We used the Agile Co-production and Evaluation (ACE) framework to embed coproduction throughout the development and evaluation of iGAS public health materials, recognising the need for approaches tailored to the contexts and constraints faced by PEH and PWID. A multidisciplinary steering group including public health professionals, service providers, and researchers guided the study. The protocol was pre-registered (OSF: z4268) and the study is reported in accordance with GRIPP2 long-form guidelines for public involvement. Coproduction activities informed factsheet modifications incorporating simplified language, visual cues, and content relevant to PEH and PWID. Coproducers described the new factsheet as eye-catching, easy to read, and person-centred whereas the original version was viewed as having limited relevance. In the evaluation survey, 32/39 responders preferred the coproduced factsheet, which was rated higher for readability and clarity. Symptoms of iGAS were correctly identified and responders reported they would follow the advice. Coproduction can improve the design and evaluation of public health advice for underserved groups. Using the ACE framework, coproduced materials were clearer, more actionable, and better aligned with the needs of PEH and PWID. The process also identified practical considerations for health protection teams and future incident settings.

Aims To develop, assess the feasibility and test the effectiveness and cost-effectiveness of a multifaceted ePrescribing-based Antimicrobial Stewardship intervention to safely reduce inappropriate antibiotic use in adult medical inpatient settings. Methods We undertook a mixed-methods programme of work organised into four interlinked work packages: Work package 1: (a) planning, developing and optimising all elements of ePrescribing-based Antimicrobial Stewardship; and (b) carrying out qualitative, feasibility and process studies of ePrescribing-based Antimicrobial Stewardship implementation. Work package 2: agreeing secondary outcome measures through an expert consensus building workshop, developing the methods to collect outcome data and establishing the feasibility of evaluating ePrescribing-based Antimicrobial Stewardship through a hybrid cluster-randomised stepped-wedge trial. Work package 3: evaluating the effectiveness of ePrescribing-based Antimicrobial Stewardship in achieving our coprimary outcomes of reducing antibiotic consumption without any adverse impact on 30-day mortality through piloting and undertaking a formal evaluation. Work package 4: estimating the cost-effectiveness of ePrescribing-based Antimicrobial Stewardship, including cost-minimisation and sensitivity analyses through evidence synthesis and expert engagement. Our research (which started on 1 January 2019) was majorly disrupted by the COVID-19 pandemic, with members of the team being redeployed to clinical and government advisory roles, and limited opportunities to undertake hospital fieldwork compounded by strikes. These delays resulted in our trial plans being pushed back by ≈ 3 years, by which time it was no longer possible to recruit sufficient numbers of hospitals into the planned definitive trial. Following discussion with the funders, we aborted plans to run the pilot and definitive trials, replacing this with qualitative scoping work to understand the ways in which trusts had innovated in the intervening period to promote antimicrobial stewardship (work package 5). Results We developed the ePrescribing-based Antimicrobial Stewardship intervention, comprising technical, educational and behavioural components and were able to agree secondary outcome measures and the cost-effectiveness model. The feasibility trial was undertaken in two hospitals in one trust, studying 24,884 antibiotic orders on 1958 admissions. This demonstrated that several aspects of the intervention were deliverable and that we were able to extract data on 20/43 outcome measures. Modelling of the coprimary outcomes, total antibiotic defined daily dose per admission, was feasible and enabled its variability to be estimated to support further research planning. There was, however, limited engagement of clinical staff with the training element of the intervention, which was initially only voluntary. Given the severe delays, many trusts had begun implementing their own approaches to deal with growing challenge of antimicrobial stewardship. As such, we were unable to find sufficient naive sites to progress the trial. Our additional qualitative scoping work identified the myriad ways in which trusts were attempting to respond to antimicrobial stewardship. These included order sets and order protocols, default durations, alerts for review, incorporation of guidelines, and audit and feedback functionality. Limitations We identify five key limitations: (1) the COVID-19 pandemic caused major delays, and non-COVID research activities had a lower priority than front-line clinical work and COVID-related research. The timescale for the development work is, therefore, unlikely to be representative of the time it should take to develop an intervention of this scope outside of pandemic contexts. (2) Although there was considerable stakeholder input into the development of ePrescribing-based Antimicrobial Stewardship, this did not include the entire potential user population. Nurses were under-represented. Although not directly involved in prescribing, more engagement with nurses would have been useful because they were involved in medication management workflows. (3) Undertaking the work in one trust limits generalisability, although inclusion of several ward types should help ensure that our findings related to a breadth of clinical contexts. (4) Implementation of ePrescribing-based Antimicrobial Stewardship within Cerner Millennium (North Kansas City, Missouri, USA) means feasibility in other systems still needs to be established. (5) The add-on study of antimicrobial stewardship practices included views of antimicrobial stewardship pharmacists and consultant microbiologists but did not include all hospitals nor ward prescribers. Nonetheless, this study provided many valuable insights into approaches, including the need for development of evidence for different practices. Conclusions We developed ePrescribing-based Antimicrobial Stewardship and conducted a feasibility trial of this in inpatient settings. This development and feasibility work was, however, undertaken during challenging circumstances resulting from a combination of the COVID-19 pandemic and National Health Service pressures, making it difficult for clinicians to fully engage. Delays with our work resulted in provisionally recruited trusts innovating in relation to antimicrobial stewardship such that it was no longer possible to deliver the planned follow-on pilot and definitive trials. In summary, ePrescribing-based Antimicrobial Stewardship is, in its present format, not suitable for use in National Health Service hospitals. Future work Hospitals are currently pursuing a range of approaches in an attempt to promote antimicrobial stewardship. There is a need to develop a typology of these approaches and establish the strength of the underpinning evidence using naturalistic designs. Trial registration This trial is registered as ISRCTN13429325. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0617-20009) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 12. See the NIHR Funding and Awards website for further award information. Plain language summary Increasingly, bacteria (germs) no longer respond to antibiotics. This can result in patients experiencing more severe or longer infections and may lead to an increased risk of dying from infections. This is due to too much – inappropriate – use of antibiotics. The reasons for overuse of antibiotics include doctors not having relevant information when prescribing, concerns about missing possibly serious infections, and limited opportunities to review diagnoses and stop antibiotics if no longer needed. From our previous research, we found that hospital electronic prescribing (ePrescribing) systems can support new ways of working to safely reduce unnecessary antibiotic prescribing. We built on our previous work to see if ePrescribing systems can safely reduce antibiotic prescribing. We conducted interviews with clinicians and undertook observations in hospitals, and used these insights to develop new tools to support prescribers, training of prescribers and organisational changes. The development and go-live date of this complex intervention, which we called ePrescribing-based Antimicrobial Stewardship, were delayed due to COVID-19. Once pandemic restrictions were lifted, we were able to progress a trial of ePrescribing-based Antimicrobial Stewardship across two hospitals, showing it was possible to implement ePrescribing-based Antimicrobial Stewardship and to extract the information we needed to see if it was reducing inappropriate antibiotic usage. We found little appetite from clinicians to engage with the training and use ePrescribing-based Antimicrobial Stewardship as hospitals were under pressure from pandemic backlogs and National Health Service strikes. The delays to our main trial resulted in other already recruited hospitals having to innovate locally to address antibiotic over-usage. These innovations overlapped with ePrescribing-based Antimicrobial Stewardship such that it was no longer possible to progress the main trial as planned. We decided not to progress the trial, as we would have struggled to recruit enough hospitals to generate a clear answer. Finally, we interviewed National Health Service staff to understand new ways hospitals were attempting to reduce inappropriate antibiotic use. Scientific summary Background Antibiotic-resistant infections are responsible for considerable morbidity and mortality globally. In response to the growing problem of antimicrobial resistance (AMR), there are global efforts afoot to minimise the inappropriate, excessive use of antibiotics, particularly in healthcare settings. Aims We sought to develop, assess the feasibility of and test the effectiveness and cost-effectiveness of a multifaceted ePrescribing-based Antimicrobial Stewardship (ePAMS+) intervention to safely reduce inappropriate antibiotic use in adult medical inpatient settings. Research questions We sought to answer the following research questions that were pursued through five interlinked work packages (WPs): What were the main challenges to and facilitators for reducing inappropriate antibiotic use? (WP1 phase 1 and phase 2a) In what ways could ePAMS+ promote antimicrobial stewardship (AMS)? (WP1 phase 1 and phase 2b) How should ePAMS+ best conceptualised/delivered? [WP1 (phase 1 and phases 2a and b) and WP2] What are suitable secondary outcomes and process measures? [WPs1 (phase 1 and phase 2a and b) and WP2] Was ePAMS+ acceptable/feasible to implement? (WP2) Were our trial procedures acceptable/feasible? (WP2) How much patient-level variability was there in the coprimary outcomes? (WP2) Was ePAMS+ effective in safely reducing inappropriate antibiotic use? (WP3) What were the mechanisms of action/unintended consequences of ePAMS+? [WP1 (phase 2b), WP2 and WP3] Was ePAMS+ cost-effective? (WP4) What approaches were being pursued by hospitals in the pandemic era to promote AMS? (WP5) Methods We undertook a mixed-methods programme of work that comprised of in-depth qualitative work, consensus building approaches, a feasibility trial and evidence synthesis. This work was originally organised into four interlinked WPs, but not all WPs were able to proceed as planned because of the emergence of the COVID-19 pandemic, with associated major impacts on the NHS. A fifth WP was added towards the end of the work to help contextualise our work within the changed AMS landscape in the aftermath of the pandemic. The methods employed in our WPs are summarised below: Work packages 1–5 Work package 1 phase 1 Some text in this section has been reproduced with permission from Mureyi D, Cresswell K, Sivyer K, Heed A, Weir CJ, Adamestam I, et al. The development of a complex digital and behavioural Antimicrobial Stewardship intervention for hospitals in England. BMC Med Inform Decis Mak 2024. https://doi.org/10.21203/rs.3.rs-3715230/v1 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text. ePrescribing-based Antimicrobial Stewardship’s development was informed by a qualitative person-based approach. This involved literature reviews, structured stakeholder workshops and interviews with policy-makers, practitioner and patient representatives, vendors and international experts. Engagements and interviews focused on identifying key barriers to and facilitators of appropriate prescribing and post-prescription reviewing of antimicrobial therapy by users of ePrescribing systems in hospitals. Qualitative data were thematically analysed and, where feasible, used to inform the design ePAMS+ features. Work package 1 phase 2a We conducted 18 semistructured interviews with medical prescribers and pharmacists with varying levels of seniority exploring current AMS practices and investigating potential areas for improvement before ePAMS+ was implemented. Participants were recruited with the help of local gatekeepers. Topic guides sought to explore both formal and informal practices surrounding AMS, and challenges and opportunities for ePrescribing-based intervention. Work package1 phase 2b Some text in this section has been reproduced from Cresswell K, Hinder S, Sheikh A, Pontefract S, Watson NW, Price D, et al. ePrescribing-based antimicrobial stewardship practices in an English National Health Service Hospital: qualitative interview study among medical prescribers and pharmacists. JMIR Form Res 2023;7:e37863. https://doi.org/10.2196/37863 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text. Two and 7 weeks after intervention initiation, we interviewed 25 users of the intervention, including senior and junior prescribers, a senior nurse, a pharmacist and a microbiologist. Topics discussed included perceived impacts of different elements of the intervention, and facilitators and barriers to effective use. Interviews were supplemented by two observations of ward rounds to gain insights into AMS practices. Work package 2a A scoping review of the literature was conducted to identify AMS interventions and outcomes measures for the hospital setting. The review was published in the Journal of Antimicrobial Chemotherapy – AMR (AMS using electronic prescribing systems in hospital settings: scoping review of interventions and outcome measures). This identified 33 indicators that have been used to measure AMS in hospitals, which, together with an additional 3 indicators from other scoping work, was used to inform an eDelphi to gain consensus on 36 potential study outcome measures: 20 quality indicators (relating to the appropriateness of antibiotic use) 11 quantity indicators (relating to the cost or volume of antibiotic use) 5 indicators relating to clinical decision support. Additional measures from expert review at eDelphi identified an additional 43 outcome measures to a total of 79 outcome measures that were taken forward to assess for appropriateness, reliability and feasibility. Work package 2b We undertook a before-and-after feasibility trial (non-randomised), introducing ePAMS+ in two English hospitals which were established users of the Cerner Millennium ePrescribing and Medicines Administration (EPMA) system. Several specialties were studied among the wards participating in the trial. Patient participants, but not prescribers, were blinded to whether ePAMS+ was in use. By applying a mixed-methods evaluation, we aimed to establish: the usability and acceptability of ePAMS+ and trial procedures; the feasibility of implementing ePAMS+ and recording quantitative outcomes; and, to measure the degree to which ePAMS+ was delivered as planned, a Fidelity Index. We performed a series of qualitative semistructured interviews of doctors, nurses and pharmacists, as well as non-participant observations; we derived quantitative summaries of prescribing data from the EPMA system. Through normal linear modelling of the defined daily dose (DDD) of antibiotic per admission, we informed the sample size calculation for a future large-scale evaluation of ePAMS+. Work package 3 We intended to evaluate ePAMS+ using a hybrid stepped-wedge cluster-randomised trial (with internal pilot study) to determine its impact on the coprimary outcomes of antibiotic usage (total DDD per admission) and mortality 30 days following admission, alongside a series of secondary outcomes and prescribing process measures. Work package 4 A scoping review of the literature on cost-effectiveness studies of Antimicrobial Stewardship Programmes (ASPs) was undertaken. In line with the original intention of the programme, we considered ASPs that affect the duration, route and type of antibiotic administered during follow-up after the initial antibiotic prescription. We selected studies that measured both cost (intervention cost, antibiotic cost or hospital costs) and clinical effectiveness. Only studies that included a valued (i.e. clinical) outcome [death, length of stay (LOS), Clostridioides difficile infection (CDI)] were included. We did not include studies that only mentioned process outcomes such as DDD and total antibiotic use. We also excluded antifungal stewardship programmes and studies using diagnostic tests to improve antibiotic utilisation (e.g. procalcitonin tests and rapid diagnosis tests). Following extensive consultation with experts, we identified three causal routes through which an ASP might affect patient health and health service costs: Reduction in opportunistic infection by a micro-organism agent that is normally held in control by other micro-organisms that are inactivated by antibiotic agents. We focused on Clostridioides difficile as it is, by a considerable margin, the most important of these opportunistic infections. Changing from intravenous (i.v.) to oral therapy, which has numerous advantages in terms of cost (including staff time) and patient comfort/mobility. Switching to a more appropriate antibiotic in the case of bug-antibiotic mismatch (BAM). In populating the model, we utilised 22 parameter estimates. Some of these estimates were taken from the literature. For many parameters, there was no estimate available from the literature (e.g. how often is a BAM mis-diagnosed), and for others, the link to the literature was tenuous (e.g. effect of DDD of antibiotic on risk of CDI). Some data (e.g. the proportion of patients on antibiotics where a sample was submitted for microbiological analysis) were estimated from hospital summary records. The model was subjected to deterministic and probabilistic sensitivity analysis. Work package 5 We carried out semistructured qualitative interviews with 38 AMS leads, pharmacists and microbiologists in 23 hospitals. We explored the participant experiences with AMS electronic prescribing systems and other activities relating to AMS. We sought to provide insights into the AMS functionality of EPMA systems and other related AMS activities, and make recommendations with regard to the interventions most valued by participants. We also sought to understand future strategic priorities and challenges and possible ways to tackle these. We analysed the data thematically using technology, people, organisations and macroenvironmental as a coding framework. Qualitative analysis was iterative, allowing emerging themes to be explored further and disconfirming evidence to be sought. Thematic analysis allowed exploration of various perspectives and contexts. Results We summarise our findings below by WP. Work package 1 phase 2a Antimicrobial prescribing and review processes were characterised by competing priorities and uncertainty of prescribers and reviewers around prescribing decisions. For example, medical prescribers often had to face trade-offs between individual patient benefit and more diffuse population health benefits, and the rationale for prescribing decisions was not always clear. Prescribing involved a complex set of activities carried out by various healthcare practitioners who each only had a partial and temporary view of the whole process, and whose relationships were characterised by deeply engrained hierarchies that shaped interactions and varied across specialties. For example, newly qualified doctors and pharmacists were hesitant to change a consultant’s prescribing decision when reviewing prescriptions. Multidisciplinary communication, collaboration and co-ordination promoted good AMS practices by reducing uncertainty. Work package 1 phase 2b Tracing the adoption and impact of the various components of the intervention was difficult as it had been introduced into a setting with competing pressures. These particularly affected behavioural/educational components (e.g. training, awareness building activities) which were often delivered ad hoc. We found that the participatory intervention design had addressed typical use cases but had not catered for edge cases that only became visible when the intervention was delivered in real-world settings (e.g. variations in prescribing workflows across different specialties and conditions). Work package 2a An online learning tool was developed to develop knowledge relating to AMS and to communicate information about the EPAMS. Online AMS and ePAMS+ training (approximately 30 minutes of learning): Hosted online using an NHS-approved URL: https://epams.helmlms.com/login. The online module had the following learning outcomes: List the factors to consider when initiating antibiotics, switching the route of administration, and stopping treatment. Discuss the risks of staying on antibiotics for longer than is clinically needed. List the tools provided by the ePAMS+ intervention in this hospital. Explain how order plans work and how these have been set up to aid your decision-making. Explain the components of the antibiotic reduction and conservation decision aid and how these can encourage good stewardship within ePAMS+. A pre/post-test was developed so learners can assess baseline knowledge and knowledge acquisition. The module comprised videos of the ePAMS+ tool to explain to learners how the tool is accessed and utilised in practice. Work package 2b It was feasible to gather 20 of the 43 planned outcome and process measures using data extracted from the Cerner EPMA system. Overall, where data extraction was possible, data completeness was high. We successfully derived total antibiotic DDD per admission, a key outcome measure for future research on ePAMS+, and analysed its variability to inform the sample size calculation for future studies. The small number of antibiotic review records available confirmed the limited use of ePAMS+ within wards during the feasibility trial. Future data extraction efforts should focus on obtaining antibiotic indication data, to allow indication-based outcomes to be measured (e.g. the number of antibiotic courses for the same indication). In developing the Fidelity Index, we identified the critical decision-making points for prescribers that are linked to adherence to the ePAMS+ intervention, enabling proxy measures for these to be developed using the electronic patient record data. The limited use of ePAMS+ order sets during the feasibility trial meant that we could not, as originally planned, develop a scoring system to quantify each decision point and specify automation of the scoring within the Cerner EPMA system. Work package 3 Due to the challenges in recruiting sufficient study sites because of the changing landscape of AMS across NHS Cerner sites, as well as the further ePAMS+ development requirements identified during the feasibility trial, the planned pilot and hybrid stepped-wedge cluster-randomised trial was not undertaken. Work package 4 Our literature review on economic evaluations of ASPs found that the intervention types evaluated research methods, outcomes assessed and contexts all varied widely across studies. Given this heterogeneity, any attempt to estimate a ‘typical’ cost-effectiveness parameter would be a quixotic undertaking. It was this analysis that led us to a completely different approach – namely, the generation of a causal model to help derive the essential effectiveness and cost parameters that might drive the decision-analytic (cost–utility) model. The base-case results from our model suggests that, even at the low absolute health gains estimated and despite uncertainty as to intervention costs, the intervention is highly likely to dominate by yielding a net saving of money and a health benefit – albeit a small one. The sensitivity analyses found that the cost savings predominately turn on the impact of i.v. to oral switch on LOS, so this should be a parameter that is closely monitored. Work package 5 We found there was considerable variety across the 23 English hospitals studied in terms of their adoptions of functionality and other interventions to support AMS and a lack of evidence base to support these approaches. Secondary uses of data allowing AMS pharmacists and microbiologists to view prescribing data remotely (e.g. which patients are on antibiotics) were viewed as important in improving AMS. An indication of the source of infection was viewed as an important part of prescribing antibiotics to help other clinicians in the patient’s journey. The views of interviewees varied on the usefulness of order protocols (prescribing on the basis of infection, e.g. community acquired pneumonia). For those with ePrescribing systems without in-built protocols, designing them took some time. Conclusions We developed the ePAMS+ intervention and conducted a feasibility trial of this in hospital medical inpatient settings. This feasibility work was, however, undertaken during challenging circumstances resulting from a combination of the COVID-19 pandemic and NHS strikes, making it difficult for clinicians to find time to engage with the intervention. Challenges with the feasibility trial and delays to the research associated with the pandemic resulted in the wider AMS landscape having changed such that it would not have been prudent to proceed with the planned follow-on pilot and definitive trials. Our qualitative work mapping the NHS landscape has identified a number of promising areas for further development and evaluation to support AMS in NHS hospitals. In summary, the ePAMS+ intervention has been pre-empted by the adoption of similar measures, often resulting from local innovation which in consequence may lack an evidence base. The landscape into which complex interventions supporting AMS may be implemented is extremely heterogeneous in terms of both technological functionality and organisational practices. Interventions need to be overlaid onto this installed base. More systematic research is needed to better understand the context for further improvement. Trial registration This trial is registered as ISRCTN13429325. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0617-20009) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 12. See the NIHR Funding and Awards website for further award information.

Background:Cognitive impairment affects health and social care. Intensive multicomponent interventions work but are impractical for primary care. The study aimed to trial brief approaches for cognitive health. Methods:This was an open-label trial among adults aged 60-85 years with internet access and low cognitive scores (SD ≥1 below normal on the Baddeley verbal reasoning test, the cognitive criteria for age-associated-cognitive decline [AACD]). We used computer-generated random numbers to allocate participants to one of three groups: (1) Active Brains website (supporting physical activity, a Mediterranean diet, and cognitive exercises); (2) Active Brains plus brief support (three email or telephone sessions); or (3) control (evidence-based advice for cognitive health). The primary outcome was Baddeley verbal reasoning score at 12 months analysed by intention-to-treat with multiple imputation for missing data; follow-up for a co-primary outcome of dementia at 5 years is ongoing. The key secondary outcome was to describe the clinically important cutpoints of the Baddeley test. The trial is registered with International Standard Randomised Controlled Trial (ISRCTN17349359), is closed to new participants, and follow-up is ongoing. Findings:Between Oct 3, 2020, and Oct 30, 2023, 11 563 participants from 670 practices were randomly assigned to either the active brains group (n=3169), active brains plus support (n=3087), or control (n=3927; intention-to-treat population). Participants were predominantly White (11 087 [95·8%]), 6697 (57·9%) were female, and 8142 (70·4%) were retired. Recruitment and 12-month follow-up (median 366 days in all groups) are complete. Baseline mean Baddeley verbal reasoning score was 15·1 (SD 6·4) in the control group, 15·3 (6·2) in the Active Brains group, and 15·1 (6·4) in the Active Brains plus support group. 12-month data were available for the primary outcome for 3113 (79·3%) of 3927 participants in the control group, 2564 (67·3%) of 3810 in the Active Brains group, and 2566 (67·1%) of 3826 in the Active Brains plus support group. At 12 months, mean Baddeley verbal reasoning score was 18·3 (SE 0·14) in the control group, 18·7 (SE 0·16) in the Active Brains group (adjusted mean difference vs control +0·50, 95% CI 0·13-0·87), and 19·2 (SE 0·16) in the Active Brains plus support group (+0·97, 0·59-1·34). This resulted in a substantial minority in all groups no longer meeting the cognitive criteria for AACD (883 [28·4%] of 3113 in the control group; 842 [32·8%] of 2566 in the Active Brains group; 811 [31·6%] of 2546 in the Active Brains plus support group), and fewer in the Active Brains plus support group (but not the Active Brains group) met cognitive criteria for mild or severe cognitive impairment. Serious adverse events and deaths, all unrelated to treatment, were similar in all groups. Serious adverse events occurred in 33 (0·87%) of 3810 in the Active Brains group, 32 (0·84%) of 3826 in the Active Brains plus support group, and 28 (0·71%) of 3927 in the control group. Deaths occurred in 20 (0·5%) in the Active Brains group, 17 (0·4%) in the Active Brains plus support group, and 19 (0·5%) in the control group. Interpretation:Very brief intervention (eg, cognitive testing, documenting brain-stimulating activities, and evidence-based advice on brain health) in primary care is likely to improve cognitive health among individuals with low cognitive functioning. This study further supports the additional use of scalable online interventions for cognitive impairment in that require minimal support. Research is needed to assess the longer term effects of these interventions. Funding:National Institute for Health and Care Research Programme Grants for Applied Research.

Most adolescent mental health issues remain undetected and untreated, with insomnia a potent risk factor for psychopathology and suicidality. Digital single-session interventions (SSIs), targeting sleep, offer scalable, accessible opportunities for preventive solutions that may overcome barriers such as stigma and low engagement, particularly among underserved groups. This study evaluated the feasibility of a mobile-based sleep intervention delivered through educational settings. This study employed a non-randomised, mixed-methods, longitudinal design to evaluate the feasibility of a multi-level intervention in young people aged 14-18 years. 1,046 participants were recruited from schools and colleges across England. Participants accessed a stepped-care mobile intervention and completed self-report measures at baseline and 6-week follow-up. Outcomes included feasibility (recruitment, retention), engagement (usage analytics, completion rates), and changes in insomnia (Insomnia Severity Index) and mental health symptoms (Revised Children’s Anxiety and Depression Scale). Logistic regression models examined predictors of attrition and engagement 1048 participants completed baseline assessments and 656 (62.6%) completed 6-week follow-up. Among participants with linked usage data (n=603), 57.7% completed the core intervention content. Attrition was higher among males and lower among participants from more deprived areas. Significant improvements were observed in insomnia symptoms (Cohen d=0.29, p<.001), as well as anxiety and depression (d=0.11-0.19, all p<.01). Among participants with baseline insomnia symptoms, 26.9% achieved remission at follow-up. The intervention was well-received across diverse groups, supporting the acceptability and scalability of brief, school-based digital interventions to reduce sleep-related mental health disparities Not applicable.

Introduction Diabetic foot ulceration represents a prevalent, persistent and resource-intensive complication of diabetes. These ulcers are slow to heal, prone to recurrence and impose a substantial burden on both patients and healthcare providers. The reducing the impact of diabetic foot ulcers (REDUCE) intervention has been designed as a multifaceted approach targeting psychological and behavioural determinants linked to diabetic foot ulcer (DFU) outcomes. Following a successful pilot trial, the REDUCE trial has been designed as a pragmatic, multicentre randomised trial to compare the effectiveness and cost-effectiveness of the REDUCE intervention plus usual care versus usual care alone in reducing recurrence in people with healed DFUs. Additionally, there is an embedded process evaluation and two sub-studies which will be carried out alongside the main trial.Methods and analysis Adults over 18 years of age, with a recently healed DFU and two lower limbs, will be identified from around 30 specialist multidisciplinary diabetic foot clinics at participating National Health Service Trusts in the UK. Patients with active Charcot neuro-osteoarthropathy, active DFU or ulcers healed for more than 12 weeks will be excluded. We will aim to recruit 544 participants (1:1 randomisation). The primary outcome for this trial will be total ulcer-free days with limbs intact (ie, without amputation) between randomisation and the end of follow-up (18 months post-randomisation). Secondary outcomes include time to re-ulceration, total number of ulcers, amputation, quality of life (EQ-5D-5L), Patient Health Questionnaire-9, Nottingham Assessment of Functional Footcare, ICEpop capability measure for adults and resource use. As part of the process evaluation, up to 20 REDUCE intervention patient-participants will be interviewed, and the healthcare professionals delivering the intervention will also be interviewed. An assessment of intervention fidelity will also be carried out.Ethics and dissemination Ethics approval was granted by Wales 3 Research Ethics Committee (REC reference 22/WA/0053) on 16 March 2022. The findings will be presented at relevant conferences and disseminated via peer-reviewed research publications and to relevant stakeholders.Trial registration number ISRCTN15570706.

Background:Anxiety and depression are among the most prevalent mental health problems affecting adolescents. Digital mental health interventions have emerged as promising means of addressing these challenges. Understanding adolescents' experiences and perspectives, and incorporating them into intervention design, can enhance their relevance, engagement, and effectiveness, ensuring interventions meet young people's needs. Objective:This qualitative study aimed to identify how adolescents aged 16-19 years engaged with 2 distinct interventions (Bite Back [Black Dog Institute] and Project YES [Youth Empowerment & Support; Lab for Scalable Mental Health and Koko]). It explored (1) barriers and facilitators to engagement, (2) young people's preferred design features and content, and (3) perceptions of their potential usefulness and helpfulness. Methods:Adolescents aged 16-19 years living in the United Kingdom were eligible to take part and were recruited through a university and a charity using convenience sampling. The final sample comprised 22 participants aged 18-19 years. They were asked to use Bite Back and Project YES for 30 minutes each over a 2-week period. Following this, 1-hour semistructured online interviews were conducted between January and March 2025. Anonymized transcripts were managed in NVivo (version 14; Lumivero) and analyzed using a pragmatic, inductive thematic analysis. Results:Seven themes were identified that captured young people's views on factors influencing engagement, preferred design features and content, and the perceived usefulness of digital mental health interventions. Participants' views were shaped by whether the content felt age-appropriate, culturally relevant, and relatable, and by how clear and transparent the interventions were. Interactive, visually appealing, and tailored features were generally preferred. Although most participants found Bite Back helpful, useful elements were identified in both interventions. Conclusions:This study contributes to the growing understanding of how young people engage with digital mental health interventions by identifying a set of interconnected factors that influence young people's experiences. It highlights the importance of designing interventions that align with young people's stage of life, culture, and experiences. Even small age differences appeared to influence how relevant the interventions felt to the individual. Furthermore, involving young people in co-design and ensuring clear, accessible communication may support trust and engagement, ultimately enhancing the benefits of such interventions.

Background: People who use criminalised drugs often face high levels of stigma, leading to a range of health and social disadvantages. To contribute to wider efforts to address this problem, we co-produced a series of 11 anti-stigma films titled ‘Drugs: It’s Complicated’, which were tailored for young adults in the UK. Aim: Evaluate the impact of the ‘Drugs: It’s Complicated’ films on the attitudes of young adults living in the UK towards people who use heroin and people who use powder cocaine. Design: Parallel-group randomised controlled experimental trial with 1:1 allocation to the experimental and control group. Setting: Online Qualtrics survey with participants from the UK. Participants: Participants (n=1074 after exclusions) were recruited from Prolific. Inclusion criteria: age 18-30, living in the UK, English fluency, internet access. Intervention and comparator: The experimental group viewed two films from the ‘Drugs: It’s Complicated’ series: (i) ‘Reimagining Drug Use’; (ii) a second film they chose based on its title. The control group received no intervention. Measurements: The Drug Use Stigmatization Scale was used as the co-primary outcome measure for each drug. Six secondary outcome measures for each drug included a social distance scale and five co-produced measures related to structural stigma (opportunities for accommodation, employment, parenting, healthcare, and harm reduction). Outcomes were compared using independent T tests with bias corrected accelerated bootstrapping (10,000 iterations). Results: There was strong evidence that the intervention improved Drug Use Stigmatization Scale scores for heroin (d=0.26, 95% CI 0.14-0.38, p&lt;0.001) and moderate evidence it improved Drug Use Stigmatization Scale scores for powder cocaine (d=0.14, 95% CI 0.02-0.26, p=0.022). There was strong evidence for positive effects on all secondary outcome measures for both drugs, except for support for equitable healthcare, which may have represented a floor effect. Summary: Overall, the evaluation provided strong evidence that viewing two of the ‘Drugs: It’s Complicated’ films caused modest reductions in stigmatising attitudes towards people who use heroin and people who use powder cocaine.

OBJECTIVES:The overuse of antibiotics for respiratory tract infections in primary healthcare in rural China is a particular challenge and is highly related to antibiotic resistance. Our research team designed a multi-component intervention focusing predominantly on health practitioners to reduce antibiotic prescriptions in rural communities of China. The effects of the intervention were evaluated through a randomised controlled trial. This study was conducted alongside the trial to develop a contextualised understanding of the implementation of the intervention and related influencing factors. DESIGN:Qualitative process study nested in a randomised controlled trial, including observation and semi-structured interviews. SETTING:Primary healthcare in rural China. PARTICIPANTS:27 health practitioners from township health centres assigned to the intervention arm. INTERVENTION:A complex intervention to reduce antibiotic prescriptions in rural communities of China, which includes the following components: training for health practitioners, a public letter of commitment, patient leaflets, a decision support system and a peer support group. PRIMARY AND SECONDARY OUTCOME MEASURES:Not applicable. ANALYSIS:Data were analysed using thematic analysis. RESULTS:The overall multi-component intervention was described as useful in reducing antibiotic prescribing, with a particularly high acceptance and use of patient leaflets and the public letter of commitment among health practitioners. There were mixed views on the decision support system and peer support group. Practitioners reported usability-related barriers to using the decision support system during consultations. Practitioners did not understand the role or benefits of the peer support group and found it difficult to initiate group discussions, due to the lack of any existing clinical team at the primary care level. CONCLUSIONS:The multi-component intervention appears to be acceptable and useful in primary healthcare in rural China. Successful implementation requires a comprehensive understanding of the contextual characteristics of the setting. Interventions to reduce antibiotic prescribing in China in the future could consider wider stakeholders including patients, retail pharmacies and health authorities. TRIAL REGISTRATION NUMBER:ISRCTN30652037 (01/12/2020).

Hypertensive disorders of pregnancy affect around 10

Abstract Background The Vertigo Symptom Scale – Short Form (VSS-SF) is a widely used questionnaire to measure vestibular symptoms such as dizziness and vertigo. Most cross-cultural validations focus only on translation and basic psychometrics, providing limited insight into cross-national comparability. This study aimed to (1) develop and validate a Dutch version of the VSS-SF, and (2) provide novel insights into cross-cultural differences in symptom reporting and the methodological robustness of the scale. Methodology Following international guidelines, we translated and linguistically validated the Dutch VSS-SF. We then compared its dimensional structure, reliability, and differential item functioning (DIF) with the original British version, using bifactor modeling to test essential unidimensionality. We used data from patients aged 50 years and older with chronic vestibular symptoms who participated in British ( n = 296) and Dutch ( n = 322) randomized controlled trials. Results The Dutch version was well understood. Psychometric evaluation supported essential unidimensionality in both versions (structural coefficient bias < 15%). Reliability was excellent (omega-total 0.920 Dutch; 0.956 British). DIF analysis revealed cultural differences: Dutch patients were less likely to report nausea/vomiting but more likely to report unsteadiness, even at the same symptom level. However, these differences had negligible impact on total scores. Conclusions The Dutch VSS-SF is valid and reliable, with scores directly comparable to the British version. Beyond translation, this study shows how advanced psychometric methods reveal both the robustness of the VSS-SF and subtle cultural differences in symptom perception, strengthening its use in multinational research and clinical practice.

OBJECTIVES:To identify the effective components of interventions to increase vaccine uptake and to explore variations in effectiveness by population group and in relation to the covid-19 pandemic. DESIGN:Component network meta-analysis. SETTING:Systematic review of randomised controlled trials in high and upper middle income countries. PARTICIPANTS:237 studies with 570 intervention arms and 4 361 717 participants. INTERVENTIONS:Any intervention targeting vaccine recipients or their caregivers aiming to increase demand for, or access to, vaccinations on the UK immunisation schedule. Key content and delivery features of interventions were identified using a bespoke coding framework co-developed with stakeholders. MAIN OUTCOME MEASURES:The outcome of interest was vaccine uptake. Bayesian component level meta-regression estimated relative effects of intervention components as ratios of odds ratios with 95% credible intervals (CrIs). RESULTS:Of the included studies, 110 were at low risk of bias, 96 had some concerns, and 31 were at high risk. 40% (n=1 744 686) of the participants were male. For children, there was evidence of beneficial effects for payments to cover costs (ratio of odds ratios 3.01, 95% CrI 1.49 to 6.06) and decision aids (2.73, 1.14 to 7.06), and some evidence for extended opportunities (1.37, 0.98 to 1.95) and social factors (1.27, 0.99 to 1.65). For adolescents and young adults, there were beneficial effects for personal delivery formats (2.13, 1.09 to 4.40), delivery by community members alongside healthcare professionals (6.42, 1.94 to 25.62), and social factors (2.62, 1.45 to 5.04), and negative effects for decision aids (0.43, 0.18 to 0.98) and human versus non-human interaction (0.47, 0.21 to 1.02). For adults, beneficial effects were shown for human interaction (1.86, 1.42 to 2.45), extended opportunities (1.63, 1.35 to 2.00), help with appointment scheduling (1.38, 1.06 to 1.78), payments to cover costs (1.47, 1.03 to 2.16), and motivational interviewing (1.79, 1.21 to 2.64), and there was some evidence for financial incentives (1.15, 0.99 to 1.35) and information on vaccine safety and/or efficacy (1.15, 0.99 to 1.32). For adults, evidence also showed a negative effect of non-human interaction versus no interaction (0.72, 0.57 to 0.92). Subgroup analyses showed variation for underserved populations and in relation to the covid-19 pandemic (before 2020 and 2020 onwards). CONCLUSION:Overall, extended opportunities, appointment scheduling help, financial incentives, payments to cover costs, and motivational interviewing were effective content components of interventions to increase vaccine uptake. Effective delivery components overall were human interaction and delivery by community members alongside healthcare professionals. However, effective components varied by age group, for underserved populations, and in analyses investigating the impact of the covid-19 pandemic. These findings have important implications for designing, optimising, and implementing targeted interventions, highlighting which components are effective across different populations and contexts. Consideration of the economic data on interventions should further support resource informed decision making.

IMPORTANCE:Most antibiotic prescribing takes place in primary care, driving antimicrobial resistance, a top-10 threat to global public health. There is considerable international interest in whether rapid multiplex microbiological point-of-care testing (RM-POCT) can safely reduce antibiotic prescribing in primary care. OBJECTIVE:To investigate whether the use of a RM-POCT can safely reduce same-day antibiotic prescribing for children and adults presenting to primary care with respiratory infections. DESIGN, SETTING, AND PARTICIPANTS:This parallel-group randomized clinical trial was conducted at 16 general practices in Southwest England between December 2022 and April 2024. Patients were eligible if they were aged 12 months or older, presented with any clinician-diagnosed acute (≤21 days) respiratory tract infection, and the patient or clinician believed antibiotic treatment was, or might be, necessary. Participants were randomized (1:1) to RM-POCT or usual care. The research team, including those conducting statistical analyses, were unaware of group allocation. Data were analyzed from November 21, 2024, to March 13, 2025. INTERVENTION:Patients in the intervention group were tested with RM-POCT to indicate the presence or absence of 19 respiratory viral pathogens and 4 atypical bacteria in approximately 45 minutes. MAIN OUTCOMES AND MEASURES:The primary outcome was same-day antibiotic prescribing. The safety outcome was patient-reported symptom severity on days 2 to 4. RESULTS:Among 552 included patients (mean [SD] age, 40.0 [21.2] years; 349 [63%] female), 276 were randomized to the intervention group and 276 to usual care. Primary outcome data were available for all participants, and safety outcome data were available in 216 intervention participants (78%) and 203 usual care participants (74%). Same-day antibiotics were prescribed to 124 participants (45%) in each group (odds ratio [OR], 1.00 [95% CI, 0.71 to 1.41]; P > .99). Prespecified subgroup analyses showed evidence of differentially reduced antibiotic prescribing in participants from whom a virus was detected (OR, 0.35 [95% CI, 0.20 to 0.63]; P for interaction < .001) and those with chronic lung disease (OR, 0.55 [95% CI, 0.28 to 1.09]; P for interaction = .046) but not children younger than 16 years (OR, 1.75 [95% CI, 0.64 to 4.74]; P for interaction = .24), nor where patients and clinicians disagreed on antibiotic necessity (OR, 1.12 [95% CI, 0.63 to 1.98]; P for interaction = .53). There was no difference in symptom severity on days 2 to 4 between groups (difference in means, 0.09 [95% CI, -0.10 to 0.27]; P = .36). CONCLUSIONS AND RELEVANCE:In this randomized clinical trial among patients with respiratory tract infections being considered for antibiotic treatment in primary care, use of an RM-POCT did not reduce same-day antibiotic prescribing or worsen patient outcomes. Trial Registration:isrctn.org Identifier: ISRCTN16039192.