BACKGROUND:Perinatal mental health (PMH) problems affect 10-20% of women and birthing people during pregnancy and the postnatal year, costing the UK an estimated £8.1 billion annually. Underserved groups - including women and birthing people from minority ethnic groups, deprived areas, and those facing multiple disadvantages - experience the greatest inequalities in access and outcomes. Despite national investment, many fall between primary care (general practice, NHS Talking Therapies) and specialist PMH services, with limited guidance on bridging this gap. AIM:To co-design an experience-based intervention to address unmet PMH needs among underserved women and birthing people, and to explore barriers to accessing care and gaps across PMH pathways. DESIGN & SETTING:A mixed-methods study using the Medical Research Council (MRC) framework and an adapted Accelerated Experience-Based Co-Design (AEBCD) approach in the UK. METHOD:Work package (WP) 1 will survey and interview professionals nationally across diverse roles and organisational contexts. WP2 will involve focus groups and interviews with underserved women and birthing people in Sheffield and Doncaster (South Yorkshire, UK), supported by bilingual community research link workers (CRLWs). Findings will be synthesised and used in co-design workshops (WP3) to develop an accessible, evidence-informed intervention tailored to the needs of an underserved group. CONCLUSION:The PRAMS (Perinatal Redesign for Accessing Mental Health Services) study will generate clinically relevant insights into improving access to and management of PMH care for underserved women and birthing people. By working collaboratively with practitioners, women and birthing people with lived experience, and community partners, PRAMS will deliver a co-designed intervention with potential to reduce inequalities. Findings will inform local service delivery and contribute national learning on user-led redesign of PMH services across primary and secondary care.

Background Multiple long-term conditions (MLTCs) are rising, especially among people experiencing socioeconomic deprivation, who develop MLTCs earlier and face barriers to selfmanagement. Primary healthcare professionals (HCPs) are central to supporting self-management but face systemic challenges, resource inequalities, and emotional strain. Understanding their perspectives is vital to developing effective solutions. Aim To explore how HCPs in general practices in deprived areas support people to self-manage MLTCs, and the barriers to, and facilitators of, providing best levels of care. Design and setting This was a qualitative study with GPs, general practice nurses, advanced nurse practitioners, and allied health professionals working in socioeconomically deprived areas of two cities in England. Method Online semi-structured interviews were conducted with 18 HCPs from 17 general practices. Transcripts were analysed inductively, underpinned by elements of reflexive thematic analysis and grounded-theory methodology. A socioecological framework was applied retrospectively to situate HCP experiences within wider socioecological discourses. Results Four themes were identified: 1) individual factors influencing self-management, such as motivation and health literacy; 2) the role of social connections and communitybased support; 3) enhancing primary care through continuity, longer appointments, and culturally sensitive, person-centred care; and 4) the impact of policy and inequitable funding on care provision. Key facilitators included accessible information, community signposting, and support navigating healthcare systems. Conclusion HCPs adapt care to meet patient needs but face systemic barriers, including underfunding and limited resources. Strengthening trust, cultural competence, and continuity of care, alongside policy and funding reform, is essential for delivering effective self-management support.

BACKGROUND:The introduction of advanced practitioners (APs) is one approach to addressing health and care workforce shortages, with around 6000 APs working in primary care in England. There is variation in implementation, regulation, and scope of the role, and limited knowledge on implications of their implementation on workforce organisation, staff and patients. There is a pressing need for research to understand what works in advanced practice implementation, for whom and in which contexts. AIM:To understand the contexts and mechanisms that influence key outcomes in the implementation of multiprofessional advanced practice in primary care in England and develop recommendations to support workforce development. DESIGN & SETTING:A realist evaluation using mixed methods across four work packages in primary care in England, incorporating research with advanced practice workforce leads, APs, key primary care staff (clinical and management), and patients and carers. METHOD:The following approaches will be taken: i) semi-structured interviews with advanced practice workforce leads in England to inform the development of an initial programme theory (IPT) (n=15); ii) online survey of APs in England to refine IPT (n>300); iii) case studies in five GP practices in England, interviewing staff members (n=10), conducting interviews or focus groups with patients (n=5) and gathering documentary data (to test and modify the IPT); iv) stakeholder workshops to share findings and develop policy and practice recommendations. CONCLUSION:Findings will be used to inform recommendations for the implementation of advanced practice in primary care, to support workforce development, enhance patient experience and improve health outcomes.

BACKGROUND:Cardiovascular disease (CVD) risk increases following adverse pregnancy outcomes (APOs) including hypertensive disorders of pregnancy (HDP), preterm labour, and foetal growth restriction. APOs disproportionately affect women of certain ethnic minorities and those who are socio-economically deprived. Risk of CVD after APOs is approximately doubled and two-thirds of women experiencing pre-eclampsia die prematurely from CVD. AIM:This review examines women's perspectives on postnatal lifestyle interventions to address long-term CVD risk, focusing on highest-risk groups. METHOD:Qualitative systematic review and thematic synthesis. A protocol was registered on PROSPERO (CRD420250654735). Papers were included if they contained qualitative components reporting views on addressing CVD risk in women experiencing APOs. RESULTS:Of 1887 screened articles 33% of included papers demonstrated recruitment of an ethnically diverse participant group, 39% demonstrated diversity of socioeconomic status. Themes from the synthesis were 1) pregnancy is a motivator for lifestyle change but many barriers exist, including lack of physical and psychological recovery and guilt at self-prioritisation, and 2) women felt abandoned, seeing a contrast between highly monitored pregnancies and inadequate post-partum care. They desire structured post-partum follow-up with formal recalls, those from higher risk groups are particularly unlikely to seek follow-up independently. We will run a series of community-based workshops with minority ethnic groups in early 2026. Workshops will be co-facilitated by community link workers. Review findings will be presented and future research priorities will be identified. Findings of both the qualitative evidence synthesis and community-based workshops will be presented at conference.

ABSTRACT Introduction Underserved women experience disproportionately high rates of perinatal mental health (PMH) difficulties but face substantial barriers to accessing appropriate care. Evidence on how services can be redesigned to improve equitable access remains limited. The Perinatal Redesign for Accessing Mental Health Services (PRAMS) study aimed to co‐produce an intervention to improve access to PMH support for underserved women and birthing people. Methods PRAMS is a mixed‐methods study informed by Accelerated Experience‐Based Co‐Design and the Medical Research Council framework for complex intervention development. This paper reports findings from Work Packages 1 and 2. Work Package 1 included a national survey of professionals ( n = 129) and semi‐structured interviews ( n = 19) exploring service provision and barriers to care. Work Package 2 involved 10 focus groups and 4 interviews with underserved women and birthing people ( n = 50) recruited through Community Research Link Workers with lived experience. Data were analysed using framework analysis guided by the Candidacy Framework. Results Barriers to PMH care were identified across all domains of candidacy. Structural barriers included fragmented services, unclear referral pathways, and limited resources. Cultural stigma, language barriers and fears regarding child protection services limited help‐seeking. Trust, continuity of care and community‐based services facilitated engagement. Both professionals and women described a mismatch between rigid service models and women's preferences for relational, flexible and culturally responsive support. Conclusion Access to PMH care among underserved populations is shaped by complex structural and relational factors. Findings highlight the need for flexible, community‐based and relationship‐centred models of care. Co‐production with underserved communities offers a promising approach for developing equitable PMH services to better meet the needs of women facing multiple vulnerabilities.

Background: Reducing health inequity is essential. The FAIRSTEPS (Framework to Address Inequities in pRimary care using STakEholder PerspectiveS) study developed and prioritised 28 vignettes describing complex primary care interventions targeted to disadvantaged groups, through Delphi consensus ranking by primary care practitioners for feasibility and perceived usefulness. Aim: To build on FAIRSTEPS by quantifying potential impacts of prioritised vignettes on costeffectiveness and health equity. Design & setting: Simplified distributional costeffectiveness analysis (DCEA) in England. Method: Pragmatic literature searches were carried out around each vignette to identify the following: (1) available economic evidence; and (2) information about size and distribution of populations targeted. Economic evidence was quality assessed using adapted National Institute for Health and Care Excellence (NICE) appraisal checklists. Extracted cost and quality-adjusted life-year (QALY) data and population data, were combined with published distributions of health opportunity costs and baseline lifetime health, to estimate net health benefits and equity measures for each vignette. Results: Suitable costeffectiveness evidence was identified for 17 of 28 vignettes, with variable study quality and applicability. Fourteen vignettes were both costeffective and equity-generating, with the most beneficial on both dimensions relating to community champions for health promotion; integrated care for people sleeping rough, engaged in sex work, or using drugs; and weight-loss programmes targeted at people on low incomes. Conclusion: Simplified DCEA using published data can be used to provide additional evidence to help prioritise complex primary care interventions aimed at disadvantaged populations, although the analysis is hindered by low quality economic data and limited study comparability. Further research estimating baseline health and health opportunity cost distributions across disadvantaged groups would improve accuracy of health equity assessments.

Background: Suicide is a major public health issue. More than one third of patients will visit their GP in the month leading up to a suicide attempt, thus highlighting the key role GPs play in suicide prevention. Aim: To explore the qualitative research on GPs' perspectives of suicide prevention in primary care. Design & setting: A systematic scoping review of qualitative studies relating to the research question. Method: This review is reported in accordance with Preferred Reporting Items for Systematic reviews and Meta- Analyses extension for Scoping Reviews (PRISMA- ScR) guidance. Articles at full- text review were assessed for inclusion in the study against eligibility criteria (English language, qualitative research, focus on GPs' perspectives of suicide prevention). Data were extracted using a standardised form and a thematic synthesis approach was used to describe the themes elicited from the studies. Results: In total, 2210 abstracts were screened. Twelve studies from seven countries were included at full- text review. The following four main themes were elicited: challenges to managing suicidal behaviour; fragmented relationships with mental health services; personal attitudes of GPs regarding suicidal behaviour; and identified needs to improve suicide prevention in primary care. Conclusion: Understanding GPs' perspectives can lead to improved training, resources, and support for primary care professionals, who are frontline providers of mental health care. This scoping review suggested there is a lack of evidence around what approaches GPs find effective in managing suicidality and how relationships can be strengthened with mental health services to deliver personcentred integrated care for those identified at risk of suicide.

Background Following the 2019 NHS Long Term Plan, link workers have been employed across primary care in England to deliver social prescribing. Aim To understand and explain how the link worker role is being implemented in primary care in England. Design and setting This was a realist evaluation undertaken in England, focusing on link workers based in primary care. Method The study used focused ethnographies around seven link workers from different parts of England. As part of this, we interviewed 61 patients and 93 professionals from health care and the voluntary, community, and social enterprise sector. We reinterviewed 41 patients, seven link workers, and a link worker manager 9-12 months after their first interview. Results We developed four concepts from the codes developed during the project on the topic around how link workers are integrated (or not) within primary care: (or not) within primary care: centralising or diffusing power; forging an identity in general practice; demonstrating effect; and building a facilitative infrastructure. These concepts informed the development of a programme theory around a continuum of integration of link workers into primary care - from being 'bolted on' to existing provision, without much consideration, to 'fitting in', shaping what is delivered to be accommodating, through to 'belonging', whereby they are accepted as a legitimate source of support, making a valued contribution to patients' broader wellbeing. Conclusion Social prescribing was introduced into primary care to promote greater attention to the full range of factors affecting patients' health and wellbeing, beyond biomedicine. For that to happen, our analysis highlights the need for a whole-system approach to defining, delivering, and maintaining this new part of practice.

BACKGROUND:People from ethnic minority and socioeconomically deprived backgrounds remain underrepresented in primary healthcare research despite experiencing worse health outcomes and healthcare experiences. Traditional engagement approaches often maintain power imbalances by keeping control within academic institutions, failing to achieve meaningful representation or change. AIM:This paper describes the iterative development of a model of community engagement across four research projects, aimed at increasing research participation from underserved communities through culturally appropriate co-design and building reciprocal academic-community relationships. METHODS:Using Participatory Action Research methodology, we developed the IBISES model and Community Research Link Worker (CRLW) role through partnerships with voluntary sector organisations serving Black African and African Caribbean, Roma, Chinese, and South Asian communities in South Yorkshire. CRLWs were identified through community organisations, received research training, and joined project teams to lead recruitment, data collection, and support analysis. After each research activity, we conducted debriefing discussions and team meetings to refine the approach. RESULTS:The CRLW approach was implemented across four studies: a prostate cancer priority-setting project with African &Caribbean men, a contraception research study with women from ethnic minorities, a lung health priority-setting initiative with the Roma community, and a photovoice study examining diverse experiences of aging and dementia services. These projects demonstrated the CRLW model's effectiveness in accessing traditionally excluded communities, uncovering crucial cultural contexts, and generating meaningful research outputs and community impacts. Through iterative development, we established the IBISES model (Identify community, Build relationships, Investment in training, Support CRLWs, Empower through co-production, Sustain relationships), which provides a framework for implementing the CRLW approach. CONCLUSION:The CRLW role enables authentic power-sharing in research, addressing both moral imperatives for inclusion and practical needs for representative evidence. By investing in communities and recognising cultural expertise, this approach moves research engagement toward genuine citizen control and partnership. The IBISES model offers a practical framework for researchers seeking to enhance inclusivity while potentially contributing to greater diversity in academic research careers over time. Further work is needed to explore scalability across different research contexts and evaluate the impact on CRLWs themselves.

Despite successful suppression of plasma HIV replication by antiretroviral therapy (ART), some women living with HIV (WLHIV) can still experience genital HIV shedding (discordant shedding). Female genital tract (FGT) bacterial and viral microbiome (bacteriome and virome) community dynamics during long-term ART in WLHIV are poorly understood but might contribute to discordant HIV shedding, as the bacteriome and virome are known to influence FGT health. Here, using metagenomic next-generation sequencing, we characterize the bacteriome and virome in 125 cervicovaginal specimens collected over two years from 31 WLHIV in Lima, Peru, and show that FGT bacteriome instability is associated with discordant HIV shedding, while longitudinal changes in FGT virome composition are associated with ART duration. Intrapersonal bacteriome variation is higher in discordant HIV shedders compared to non-shedders. Cervicovaginal virome composition changes over time, particularly in non-shedders. Specifically, anellovirus relative abundance is inversely associated with ART duration and CD4 counts. Our results suggest that discordant HIV shedding is linked with FGT bacteriome instability, and immune recovery during ART influences FGT virome composition.

BACKGROUND:General practice has a key role in reducing inequity in access to care relating to sexual and reproductive health (SRH). Unplanned pregnancy, abortion, and sexually transmitted infections are increasing and disproportionately affect deprived communities and minoritised ethnic groups. The Candidacy Framework is a practical and theoretical framework for understanding the complex interactional processes of access to SRH care in general practice. AIM:To use the Candidacy Framework to explore access to SRH care in general practice. The seven interaction stages are: identification of need; navigation of services; permeability of services; appearing and asserting need; adjudication by healthcare professional (HCP); offers or resistance of offer; and the local operating conditions or local production of candidacy. DESIGN & SETTING:Systematic review with qualitative evidence synthesis using a framework approach. METHOD:A systematic search of MEDLINE, Embase, PubMed, and the Web of Science was conducted to identify primary qualitative research exploring access to SRH care in general practice from practitioner, public, and patient perspectives in countries with universal health care. The Candidacy Framework was used to synthesise the findings. RESULTS:Analysis of 42 studies revealed the impact of stigma, shame, and embarrassment among individuals, communities, and HCPs. Findings showed limited inclusion of demographics, such as ethnicity and socioeconomic status. Barriers to access were more evident for those from lower socioeconomic communities, minoritised ethnic groups, and the LGBTQ+ community. There are multiple barriers, which include the behaviours of HCPs, who have a crucial role in recognising an individual's SRH need. CONCLUSION:General practice offers a cradle-to-grave healthcare service that should have SRH as a priority area of provision. Further understanding is needed about the impact of historic harms by medicine and health care on racialised individuals and minoritised genders.

BACKGROUND:The career pathway of clinical academics in the UK is challenging. To pursue academic endeavors, trainees often undertake approved time 'Out of Programme for Research' (OOPR), a standalone research fellow post or join an 'Integrated Academic Training' pathway. Time out of training may impact their clinical skills, confidence and competency. The aim of this qualitative study was to explore the challenges associated with returning to clinical training after prolonged leave for academic trainees. METHODS:Stakeholders were clinical academic trainees and supervisors within the Yorkshire and Humber region of England, and training programme academic leads from universities across England. Qualitative data-analyses of verbatim recorded data from three focus groups and 12 individual telephone interviews were conducted within an a priori framework. RESULTS:Returning to a high-stress environment with a perceived lack of specialty-level advocacy and support, feeling isolated from peers, struggling to balance competing demands, meet clinical and academic expectations and managing clinical deskilling in a trainee's return to clinical training were common experiences described by stakeholders. There was a lack of recognition from academic leads, however, on the impact of such challenges on the trainees' subsequent ability to successfully integrate their clinical and academic careers. Various solutions were identified by stakeholders to overcome such barriers, including a normalised, phased, individualised supported return to work and capacity building for supervisors. CONCLUSIONS:There is an apparent disconnect between the clinical and academic world, with clinical academic trainees stuck between the two, being pulled by each, feeling like they are not quite meeting the expectations of either. Time away from training for trainees on OOPR is often longer than for other reasons for time out of programme (typically 3-4 years if completing a doctoral degree). Given the importance of clinical academics in bridging clinical research and practice, and the concerns recently raised about the rate of attrition of clinician scientists within the NHS, it is of the utmost importance that clinical academic trainees are supported throughout all stages of their careers.

Bacterial vaginosis (BV), characterized by an imbalance in the vaginal microbiota, is a prevalent condition among women of reproductive age and a risk factor for human immunodeficiency virus, sexually transmitted infections, and preterm birth. BV is generally considered to induce mucosal inflammation, but the specific pathways and cell types involved are not well characterized. This prospective study aimed to assess associations between microbial changes and mucosal immune responses in BV patients. Therefore, samples from 20 premenopausal women with BV and treated with metronidazole were analyzed. Vaginal swabs, menstrual cup, and endocervical cytobrush samples were collected before treatment, weekly for four weeks, and at 2, 4, and 6 months for Nugent scoring, immune cell populations and cytokine analysis. Of 105 study intervals, 27 (25.7%) showed improvement in Nugent category, 61 (58.1%) remained unchanged, and 17 (16.2%) worsened. Improvement correlated with decreased monocytes (p = 0.005), while worsening was linked to increased monocytes (p < 0.001) and dendritic cells (p = 0.02). B cells (p = 0.02) and IFN-γ-induced chemokines - IP-10 (p = 0.007), MIG (p = 0.049), and ITAC (p = 0.005) - were associated with improvement. In conclusion, although the T-cell-associated chemokines IP-10, ITAC, and MIG were strongly associated with improvements in Nugent category, our findings indicate that antigen-presenting cells, particularly monocytes, show the most dynamic response to shifts in the vaginal microbiota in patients with BV.

Vaginitis is the presenting symptom at millions of office visits each year in the United States. Although treatment of sporadic cases is often straightforward, recurrent cases present both diagnostic and treatment challenges. Molecular diagnostic tests are likely superior to in-office microscopy for most clinicians and most cases. In both recurrent bacterial vaginosis and recurrent vulvovaginal candidiasis, national treatment guidelines recommend an extended treatment duration with one of the first-line agents. In cases in which such treatment is not successful, vaginal boric acid is likely the cheapest and easiest alternative option. New antifungal medications offer additional but limited treatment options. Probiotics are not recommended for prevention of vulvovaginal candidiasis; however, vaginal products containing Lactobacillus crispatus may have promise for recurrent bacterial vaginosis. Trichomoniasis should be treated with a 1-week course of metronidazole; this is the only sexually transmitted infection for which treatment recommendations vary by sex. In cases in which patients do not respond to initial treatment, the diagnosis should be reconsidered, and other potential causes such as desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia should be considered.

Background:Social prescribing link workers formed part of the Additional Roles Reimbursement Scheme introduced into primary care in England from 2019. Link workers assist patients experiencing issues affecting their health and well-being that are 'non-medical' (e.g. lack of social connections, financial difficulties and housing problems). They give patients space to consider these non-medical issues and, when relevant, connect them to support, often within the voluntary-community-social-enterprise sector. We conducted an earlier realist review on the link worker role in primary care. We then carried out a realist evaluation, described in this report, to address the question: When implementing link workers in primary care to sustain outcomes - what works, for whom, why and in what circumstances? Aim:To develop evidence-based recommendations to optimise the implementation of link workers in primary care and to enable patients to receive the best support possible. Design:A realist evaluation, involving two work packages. Setting:Data were collected around seven link workers in different parts of England. Methods:For work package 1, researchers spent 3 weeks with each link worker - going to meetings with them, watching them interact with patients, with healthcare professionals and with voluntary-community-social-enterprise staff. During this time, researchers had a daily debrief with the link worker, inviting them to reflect on their working day, and they collected relevant documents (e.g. job descriptions and information on social prescribing given to patients). They also conducted interviews with 93 primary care/voluntary-community-social-enterprise staff and 61 patients. As part of this work package, data on patient contact with a general practitioner before and after being referred to a link worker were collected. Work package 2 consisted of follow-up interviews (9-12 months later) with patients; 41 were reinterviewed. In addition, link workers were reinterviewed. A realist logic of analysis was used to test (confirm, refute or refine) the programme theory we developed from our realist review. Analysis explored connections between contexts, mechanisms and outcomes to explain how, why and in what circumstances the implementation of link workers might be beneficial (or not) to patients and/or healthcare delivery. Results:We produced three papers from the research - one on link workers 'holding' patients, one on the role of discretion in their job, and another exploring patient-focused data and readiness to engage in social prescribing. Data from these papers were considered in relation to Normalisation Process Theory - a framework for conceptualising the implementation of new interventions into practice (e.g. link workers into primary care). By doing so, we identified infrastructural factors required to help link workers to: (1) offer person-centred care; (2) develop patients' self-confidence, sense of hope and social capital; (3) facilitate appropriate general practitioner use; (4) foster job satisfaction among those delivering social prescribing. Discussion:Our research highlighted the importance of a supportive infrastructure (including supervision, training, leadership/management, clarity about the role, link workers' ability to use existing skills and knowledge and having capacity to connect with providers in the voluntary-community-social-enterprise sector) in order to produce person-centred care, to nurture hope, self-confidence and social capital among patients, to ensure they receive the right support (medical or non-medical), and to promote link workers' job satisfaction. Data showed how link workers can contribute to the offer of holistic care beyond a purely medical lens of health and illness. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130247.

BACKGROUND:Suicide is the largest killer of men aged <50 years in the UK. Priority areas in the government's National Suicide Prevention Strategy include tailoring mental health support to at risk groups and addressing the common risk factors linked to death by suicide. Primary care is well placed to address these areas in the system wide approach to suicide prevention. AIM:The aim of this research is to explore GP's perspectives on suicide prevention in primary care settings in the Yorkshire and Humber Region. METHOD:GP and GP trainees were recruited from across the Yorkshire and Humber Region using a snowball sampling method. Participants underwent semi-structured qualitative interviews using a topic guide that was informed by a scoping review and mental health PPI group. The interview transcripts were analysed using Framework Analysis. RESULTS:Fourteen interviews were completed (10 female, 4 male). The patient populations served were diverse (middle-class, working-class mining community, asylum seeker practice and Roma population). The main themes include the 'importance of the third sector' in improving the social capital of patients and reducing suicide risk; 'Continuity of care' was viewed as important by GP's when managing mental health but was being challenged by new models of working such as 'same-day triage'; and 'Postcode lottery' described the differences in mental health services within the Yorkshire and Humber Region. CONCLUSION:An integrated system of mental health practitioners in the community with equitable access to third sector support may be important in suicide prevention.