Background/Aims Most birth-related ambulance calls occur without difficulty, but in some cases, complications can arise. Paramedics’ involvement in birth is infrequent; therefore, the knowledge and skills required to manage complications can atrophy over time, particularly without educational interventions. This may impact outcomes. The study's aims were to measure the knowledge, attitude, and practice of paramedics in managing obstetric cases. Methods This cross-sectional questionnaire-based study was carried out with 264 paramedics. Spearman's measure of correlation was used to observe linear correlations between ranks of the observations. Results The majority of participants were advanced care paramedics (81.1%). Participants reported infrequently attending births in the community, with under half feeling confident in managing these (44%). Antenatal complications and trauma in pregnancy were self-reported areas of weakness; this was consistent with assessed knowledge. Conclusions Paramedics self-reported infrequently responding to obstetric calls and the majority lacked confidence in managing these. Few indicated an excellent level of obstetric knowledge, reporting a desire to receive more education in this area. Implications for practice When paramedics lack confidence in managing obstetric emergencies, it can lead to delayed decision making, inadequate assessment, increased error rates and adverse maternal and neonatal outcomes.

Background Many emergency calls that are birth-related occur without complexity but in some cases difficult issues arise which require varying levels of assistance. Paramedics' involvement in birth is infrequent, therefore the practical and cognitive skills required to manage these cases have the potential to atrophy over time, particularly in the absence of interventions aimed at reducing their decline. The aim of this study was to examine the knowledge, attitude and practice of paramedics in managing obstetric cases in order to identify areas that may require targeted in-service education to address knowledge deficit. Methods We have undertaken a cross-sectional study to explore the practices and learning needs of Registered Paramedics. Data were collected by a self-administered, anonymous and piloted Knowledge, Attitude and Practice (KAP) survey. Results Four hundred and thirty-five participants commenced the survey, however 264 (39%) completed it. The median age of participants was 32 years (IQR 17, min/max 22,64). There were 150 (56.8%) female respondents, 112 (42.4%) males, and <1% of survey participants preferred not to describe their gender identity, or to self-describe. 81.8% were Advanced Care Paramedics and 12.1% Critical Care Paramedics. The median number of self-reported births attended during their career was n=2.0 (min/max 0,65). Antenatal complications and trauma in pregnancy were self-reported as areas of weakness, this was consistent with assessed knowledge evaluated. Participants agreed that having a comprehensive understanding in managing obstetric emergencies was important and strongly agreed to the need for regular in-service education. Conclusion This study revealed that of all domains tested few participants indicated an excellent level of obstetric knowledge. The provision of regular in-service training for the management of this type of emergency is valued by paramedics.

Background The purpose of this study was to explore perceived changes in physical activity (PA) due to Covid19 stay-at-home and social distancing guidance among older adults. Methods Participants ( n = 1429, 77% female, 84% ≥60 years) living in Scotland completed an online survey in Summer 2020 measuring PA and wellbeing (indexed through loneliness, and health-related quality of life). The survey included open- and closed-ended questions about how these variables changed in response to Covid19 social distancing and ‘shielding’ guidelines. Results From the International Physical Activity Questionnaire (IPAQ), the majority reported high volumes of PA, indicative of being ‘moderately’ or ‘highly’ active. When asked specifically about strength training, 12% reported engagement on ≥2d/wk. Most participants reported that PA had changed during this time, citing reduced use of exercise facilities, increased active travel, and online PA classes; although only 16% reported engaging in PA online. Conclusions Higher levels of PA were found to be associated with better health-related quality of life. Additional efforts should be made to support PA engagement in older adults, including strength training and other tailored approaches to support individual needs.

Abstract Background COVID-19 has overwhelmed health services across the world; its global death toll has exceeded 5.3 million and continues to grow. There have been almost 15 million cases of COVID-19 in the UK. The need for rapid accurate identification, appropriate clinical care and decision making, remains a priority for UK ambulance service. To support identification and conveyance decisions of patients presenting with COVID-19 symptoms the Scottish Ambulance Service introduced the revised Medical Priority Dispatch System Protocol 36, enhanced physician led decision support and prehospital clinical guidelines. This study aimed to characterise the impact of these changes on the pathways and outcomes of people attended by the SAS) with potential COVID-19. Methods A retrospective record linkage cohort study using National Data collected from NHS Scotland over a 5 month period (April–August 2020). Results The SAS responded to 214,082 emergency calls during the study time period. The positive predictive value of the Protocol 36 to identify potentially COVID-19 positive patients was low (17%). Approximately 60% of those identified by Protocol 36 as potentially COVID-19 positive were conveyed. The relationship between conveyance and mortality differed between Protocol 36 Covid-19 positive calls and those that were not. In those identified by Protocol 36 as Covid-19 negative, 30 day mortality was higher in those not conveyed (not conveyed 9.2%; conveyed 6.6%) but in the Protocol 36 Covid-19 positive calls, mortality was higher in those conveyed (not conveyed 4.3% conveyed 8.8%). Thirty-day mortality rates of those with COVID-19 diagnosed through virology was between 28.8 and 30.2%. Conclusion The low positive predictive value (17%) of Protocol 36 in identifying potential COVID-19 in patients emphasises the importance of ambulance clinicians approaching each call as involving COVID-19, reinforcing the importance of adhering to existing policy and continued use of PPE at all calls. The non-conveyance rate of people that were categorised as COVID-19 negative was higher than in the preceding year in the same service. The reasons for the higher rates of non-conveyance and the relationship between non conveyance rates and death at 3 and 30 days post index call are unknown and would benefit from further study.

Background As well as patient impact, COVID-19 also considerably impacts on staff who have been required to make challenging patient care decisions in uncertain circumstances. This study investigated ambulance clinicians’ experiences and use of decision support strategies during the COVID-19 pandemic. Methods Forty-eight percent (16/33) of paramedics invited agreed to be interviewed. Telephone/video interviews were undertaken between September and December 2020. Framework analysis was undertaken. Data were indexed and charted by one researcher. A sample was then checked by two other researchers. Analytical interpretation was collectively undertaken by all three researchers to identify a higher-level conceptual understanding. Results Four key themes were identified: Impact on clinical decision making – Deciding whether to take a patient to an Emergency Department is often challenging. Paramedics reported that COVID-19 increased the complexity of this process. Decision Support – Enhanced decision support was perceived as unequally available across the ambulance service. Where present, several paramedics reported that it was highly valuable. Use of Personal Protective Equipment (PPE ) – Routine use of extensive PPE was a very new experience for all participants. Some reported that the number of calls initially exceeded PPE availability. Personal impact of dealing with COVID-19 – Several paramedics stated that media reports combined with paramedics appearing in full PPE increased levels of anxiety among many patients they attended. Some participants were worried about catching COVID-19 and the possibility of taking the virus home to their families. Conclusions Our findings suggest that COVID-19 has placed considerable stress on the ambulance service at both organisational and individual levels. These findings could inform implementation processes surrounding rapid clinical guideline development and communication. *This abstract was presented by Edward Duncan

Background: The lifestyle behaviours, and the physical and mental health of nurses, are poorer than those of other allied health professionals, and of the general population. However, these were no less favourable among first year undergraduate nursing students at a Scottish Higher Education Institution (HEI) than among similar people of the same age. We compared health and health behaviours among the same cohort of undergraduate nursing students over the course of their degree. Methods: An anonymous self-complete repeat cross-sectional survey was administered during a timetabled teaching session at three time-points to undergraduate nursing students at the start of Years 1, 2 and 3 of their programme. They had received written information about the study previously. Results: Self-reported health did not change significantly over time, but there was a clear decline over the three years in the proportions of students rating their mental health as excellent/very good/good and a concomitant increase in those rating their mental health as fair/poor. Correspondingly, the mean WEMWBS wellbeing score declined over the three years, with the proportion of students with a score of <46 (indicating either high risk of major depression, or in high risk of psychological distress and increased risk of depression) increasing from one quarter to one half. This effect was captured and described using a Bayesian regression analysis. The most noticeable change in health behaviours was a decline in physical activity levels over the study period. The proportion of students managing 150 minutes of weekly physical activity decreased from three quarters to two thirds. This was reflected in higher self-reported sedentary time, although there were no observable trends over time in mean BMI, or proportions of students categorised as overweight or obese. Conclusions: This paper suggests that there may be a decline in mental health and in participation in physical activity among nursing students over the course of their degree. We recommend the incorporation of an intervention into the undergraduate nursing curriculum that promotes and encourages regular physical activity, offering students the opportunity to learn about health promotion and lifestyle change in practice, to improve their own physical health, and to address mental wellbeing.

This study examined the impact of social distancing during the COVID-19 pandemic on loneliness, wellbeing, and social activity, including social support, in Scottish older adults. A mixed methods online survey was used to examine these factors during social distancing mid-lockdown, July 2020. Participants were asked to state whether loneliness, wellbeing, social activity, and social support had changed since pre-social distancing, and to provide details of strategies used to keep socially active. A total of 1429 adults (84% aged 60+ years) living in Scotland took part. The majority reported that social distancing regulations made them experience more loneliness and less social contact and support. Loneliness during lockdown was higher than reported norms for this age group before the pandemic. A larger social network, more social contact, and better perceived social support seemed to be protective against loneliness and poor wellbeing. Positive coping strategies reported included increasing online social contact with both existing social networks and reconnecting with previous networks, as well as increasing contact with neighbours and people in the community. This underlines the importance of addressing loneliness and social support in older adults but particularly during situations where risk of isolation is high.

BACKGROUND:The diagnosis of lower urinary tract symptoms related to suspected bladder outflow obstruction from benign prostate hyperplasia/enlargement in men is increasing. This is leading to high demand on healthcare services; however, there is limited knowledge of differences in pharmacotherapy prescribing for this condition based on geography.OBJECTIVE:To investigate potential variation in drug prescribing for suspected bladder outflow obstruction in Scotland, based on analysis of publicly available data, to identify trends and inform future prescribing.STUDY DESIGN:A longitudinal register-based data study of prescribing and patient data publicly available from Scottish registries. All information is available as monthly aggregates at the level of single general practices.SETTING AND PARTICIPANTS:903 (97%) general practices in Scotland, over a 50-month period (October 2015 to November 2019).OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:We analysed numbers of daily doses of drugs for suspected bladder outflow obstruction prescribed per month using a Bayesian Poisson regression analysis, incorporating random effects to account for spatial and temporal elements.RESULTS:Prescriptions for suspected bladder outflow obstruction medications increased during the observation period (overall average rate of change 1.24±0.28, ranging from 0.893 in Orkney to 1.95 in Lanarkshire). While some determinants of health inequality regarding prescribing practices across health boards are consistent with those known from the literature, other inequalities remain unexplained after accounting for practice-specific and patient-specific characteristics such as deprivation and rurality.CONCLUSIONS:Inequalities in prescribing for suspected bladder outflow obstruction medications exist in Scotland, partially ascribable to accepted sociodemographic and geographic factors.

BackgroundLittle is known about how patients with COVID-19 present to ambulance services or their outcomes. Between 1st March and 31st August 2020 we investigated individuals who called the Scottish Ambulance Service (SAS) with COVID-19 symptoms and those that were later tested COVID-19 positive. We analysed i) their demographic and clinical characteristics; ii) their disposal; and iii) their admission and mortality outcomes.MethodsSAS and NHS Scotland Health Board data are routinely linked in a national database. These data evidence a patients journey from ambulance call to hospital attendance and subsequent outcome. Evidence of COVID-19 testing was identified 10 days either side of the call.Results171,169 patients made 257,207 calls during the study period. Of these, 2.8% (n=7,305) were categorised as possible COVID-19 patients during telephone triage. From the flagged +ve patient calls 6% had a COVID-19 positive result, 29% had a negative COVID-19 result and the other 65% had no evidence of being tested. The majority (54%) were taken to the Emergency Department; 73% received further hospital care. The proportion of patient calls admitted within 10 days of the call was 31% for those not conveyed against 82% for conveyed. Final prehospital physiology for COVID-19 positive patients demonstrated lower oxygen saturations, higher respiratory rates and temperatures. 4.9% and 11.7% of patients conveyed to hospital died within 3 and 30 days vs 5.2% and 19.6% of patients not conveyed respectively.ConclusionsThis study suggests telephone triage is not a reliable identifier of COVID-19 patients reinforcing existing requirements for Personal Protective Equipment. 30-day mortality rates differed between those patients initially conveyed vs not conveyed. Clinical characteristics of COVID-19 positive patients suggest they were clinically less well than other patients.

This study examined the impact of social distancing during the COVID-19 pandemic on loneliness, wellbeing, and social activity, including social support, in Scottish older adults. A mixed methods online survey was used to examine these factors during social distancing mid-lockdown, July 2020. Participants were asked to state whether loneliness, wellbeing, social activity, and social support had changed since pre-social distancing, and to provide details of strategies used to keep socially active. A total of 1429 adults (84% aged 60+ years) living in Scotland took part. The majority reported that social distancing regulations made them experience more loneliness and less social contact and support. Loneliness during lockdown was higher than reported norms for this age group before the pandemic. A larger social network, more social contact, and better perceived social support seemed to be protective against loneliness and poor wellbeing. Positive coping strategies reported included increasing online social contact with both existing social networks and reconnecting with previous networks, as well as increasing contact with neighbours and people in the community. This underlines the importance of addressing loneliness and social support in older adults but particularly during situations where risk of isolation is high.

Background Adherence to medication regimens is essential for preventing and reducing adverse outcomes among patients with coronary artery disease (CAD). Greater understanding of the relation between negative illness perceptions, beliefs about cardiac rehabilitation (CR) and medication adherence may help inform future approaches to improving medication adherence and quality of life (QoL) outcomes. The aims of the study are: 1) to compare changes in illness perceptions, beliefs about CR, medication adherence and QoL on entry to a CR programme and 6 months later; 2) to examine associations between patients’ illness perceptions and beliefs about CR at baseline and medication adherence and QoL at 6 months. Methods A longitudinal study of 40 patients with CAD recruited from one CR service in Scotland. Patients completed the Medication Adherence Report Scale, Brief Illness Perception Questionnaire, Beliefs about CR questionnaire and the Short-Form 12 Health Survey. Data were analysed using the Wilcoxon Signed Ranks test, Pearson Product Moment correlation and Bayesian multiple logistic regression. Results Most patients were men (70%), aged 62.3 mean (SD 7.84) years. Small improvements in ‘perceived suitability’ of CR at baseline increased the odds of being fully adherent to medication by approximately 60% at 6 months. Being fully adherent at baseline increased the odds of staying so at 6 months by 13.5 times. ‘Perceived necessity, concerns for exercise and practical barriers’ were negatively associated with reductions in the probability of full medication adherence of 50, 10, and 50%. Small increases in concerns about exercise decreased the odds of better physical health at 6 months by about 50%; and increases in practical barriers decreased the odds of better physical health by about 60%. Patients perceived fewer consequences of their cardiac disease at 6 months. Conclusions Patients’ beliefs on entry to a CR programme are especially important to medication adherence at 6 months. Negative beliefs about CR should be identified early in CR to counteract any negative effects on QoL. Interventions to improve medication adherence and QoL outcomes should focus on improving patients’ negative beliefs about CR and increasing understanding of the role of medication adherence in preventing a future cardiac event.

Background: Urinary incontinence affects one in three women worldwide. Pelvic floor muscle training is an effective treatment. Electromyography biofeedback (providing visual or auditory feedback of internal muscle movement) is an adjunct that may improve outcomes. Objectives: To determine the clinical effectiveness and cost-effectiveness of biofeedback-mediated intensive pelvic floor muscle training (biofeedback pelvic floor muscle training) compared with basic pelvic floor muscle training for treating female stress urinary incontinence or mixed urinary incontinence. Design: A multicentre, parallel-group randomised controlled trial of the clinical effectiveness and cost-effectiveness of biofeedback pelvic floor muscle training compared with basic pelvic floor muscle training, with a mixed-methods process evaluation and a longitudinal qualitative case study. Group allocation was by web-based application, with minimisation by urinary incontinence type, centre, age and baseline urinary incontinence severity. Participants, therapy providers and researchers were not blinded to group allocation. Six-month pelvic floor muscle assessments were conducted by a blinded assessor. Setting: This trial was set in UK community and outpatient care settings. Participants: Women aged ≥ 18 years, with new stress urinary incontinence or mixed urinary incontinence. The following women were excluded: those with urgency urinary incontinence alone, those who had received formal instruction in pelvic floor muscle training in the previous year, those unable to contract their pelvic floor muscles, those pregnant or < 6 months postnatal, those with prolapse greater than stage II, those currently having treatment for pelvic cancer, those with cognitive impairment affecting capacity to give informed consent, those with neurological disease, those with a known nickel allergy or sensitivity and those currently participating in other research relating to their urinary incontinence. Interventions: Both groups were offered six appointments over 16 weeks to receive biofeedback pelvic floor muscle training or basic pelvic floor muscle training. Home biofeedback units were provided to the biofeedback pelvic floor muscle training group. Behaviour change techniques were built in to both interventions. Main outcome measures: The primary outcome was urinary incontinence severity at 24 months (measured using the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form score, range 0–21, with a higher score indicating greater severity). The secondary outcomes were urinary incontinence cure/improvement, other urinary and pelvic floor symptoms, urinary incontinence-specific quality of life, self-efficacy for pelvic floor muscle training, global impression of improvement in urinary incontinence, adherence to the exercise, uptake of other urinary incontinence treatment and pelvic floor muscle function. The primary health economic outcome was incremental cost per quality-adjusted-life-year gained at 24 months. Results: A total of 300 participants were randomised per group. The primary analysis included 225 and 235 participants (biofeedback and basic pelvic floor muscle training, respectively). The mean 24-month International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form score was 8.2 (standard deviation 5.1) for biofeedback pelvic floor muscle training and 8.5 (standard deviation 4.9) for basic pelvic floor muscle training (adjusted mean difference –0.09, 95% confidence interval –0.92 to 0.75; p = 0.84). A total of 48 participants had a non-serious adverse event (34 in the biofeedback pelvic floor muscle training group and 14 in the basic pelvic floor muscle training group), of whom 23 (21 in the biofeedback pelvic floor muscle training group and 2 in the basic pelvic floor muscle training group) had an event related/possibly related to the interventions. In addition, there were eight serious adverse events (six in the biofeedback pelvic floor muscle training group and two in the basic pelvic floor muscle training group), all unrelated to the interventions. At 24 months, biofeedback pelvic floor muscle training was not significantly more expensive than basic pelvic floor muscle training, but neither was it associated with significantly more quality-adjusted life-years. The probability that biofeedback pelvic floor muscle training would be cost-effective was 48% at a £20,000 willingness to pay for a quality-adjusted life-year threshold. The process evaluation confirmed that the biofeedback pelvic floor muscle training group received an intensified intervention and both groups received basic pelvic floor muscle training core components. Women were positive about both interventions, adherence to both interventions was similar and both interventions were facilitated by desire to improve their urinary incontinence and hindered by lack of time. Limitations: Women unable to contract their muscles were excluded, as biofeedback is recommended for these women. Conclusions: There was no evidence of a difference between biofeedback pelvic floor muscle training and basic pelvic floor muscle training. Future work: Research should investigate other ways to intensify pelvic floor muscle training to improve continence outcomes. Trial registration: Current Controlled Trial ISRCTN57746448. Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 70. See the NIHR Journals Library website for further project information.

BACKGROUND Numbers of people with an intellectual disability and dementia present a global health and social challenge with associated need to reduce stress or agitation and improve quality of life in affected individuals. This study aimed to identify effectiveness of psychosocial interventions in social care settings and, uniquely, explore use of photovoice methodology to develop dialogue about dementia. METHODS This mixed-method participatory action study used individualised goal-setting theory with 16 participants with intellectual disability and dementia, and 22 social care staff across 11 sites. Five co-researchers with intellectual disability were part of an inclusive research team collecting data using existing and bespoke tools including photovoice. Analysis used descriptive and inferential statistics and framework analysis. RESULTS Seventy four percentage of individual goals met or exceeded expectations with reduction in some "as required" medication. Qualitative findings include themes of enabling care and interventions as tools for practice. Photovoice provided insight into previously unreported fears about dementia. CONCLUSIONS Individualized psychosocial interventions have potential to reduce distress or agitation.

PURPOSE:1) To compare levels of emotional symptoms and health-related quality of life between patients with heart failure and their family caregivers; and 2) to examine whether patients' and caregivers' emotional symptoms were associated with their own, as well as their partner's health-related quality of life.METHOD:In this cross-sectional study, 41 patients-caregiver dyads (78% male patients, aged 68.6 years; and 83% female caregivers, aged 65.8 years) completed all nine dimensions of the Brief Symptom Inventory and the Minnesota Living with Heart failure Questionnaire. Dyadic data were analysed for 6 sub-scales of the Brief Symptom Inventory, using the Actor-Partner Interdependence Model.RESULTS:There were no statistically significant differences in emotional symptoms and health-related quality of life between patients with heart failure and their caregivers. Patients' and caregivers' emotional symptoms were associated with their own health-related quality of life. Caregivers' anxiety, phobic anxiety, obsession-compulsion, depression and hostility negatively influenced their partner's (i.e. the patient's) health-related quality of life. There were no partner effects of patients' emotional symptoms on the health-related quality of life of caregivers.CONCLUSIONS:The results of this study suggest that patients may be particularly vulnerable to the emotional distress, i.e. thoughts, impulses and actions of their caregivers. It may be possible to improve patients' health-related quality of life by targeting specific detrimental emotional symptoms of caregivers.

Background Patients’ negative illness perceptions and beliefs about cardiac rehabilitation (CR) can influence uptake and adherence to CR. Little is known about the interpartner influence of these antecedent variables on quality of life of patients with coronary artery disease (CAD) and their family caregivers. The aims of the study were: 1) to assess differences in illness perceptions, beliefs about CR and quality of life between patients with CAD and their family caregivers upon entry to a CR programme and at 6 months follow-up; and 2) to examine whether patients’ and caregivers’ perceptions of the patient’s illness and beliefs about CR at baseline predict their own and their partner’s quality of life at 6 months. Methods In this longitudinal study of 40 patient-caregiver dyads from one CR service, patients completed the Brief Illness Perception Questionnaire and Beliefs about Cardiac Rehabilitation Questionnaire at baseline and 6 months; and caregivers completed these questionnaires based on their views about the patient’s illness and CR. The Short-Form 12 Health Survey was used to assess patients’ and caregivers’ perceived health status. Dyadic data were analysed using the Actor–Partner Interdependence Model. Results Most patients (70%) were men, mean age 62.45 years; and most caregivers (70%) were women, mean age 59.55 years. Caregivers were more concerned about the patient’s illness than the patients themselves; although they had similar scores for beliefs about CR. Patients had poorer physical health than caregivers, but their level of mental health was similar. Caregivers’ poorer mental health at 6 months was predicted by the patient’s perceptions of timeline and illness concern (i.e. partner effects ). Patient’s and caregiver’s illness perceptions and beliefs about CR were associated with their own physical and mental health at 6 months (i.e. actor effects ). Conclusions Overall, the patients and caregivers had similar scores for illness perceptions and beliefs about CR. The actor and partner effect results indicate a need to focus on specific illness perceptions and beliefs about CR, targeting both the individual and the dyad, early in the rehabilitation process to help improve patients and caregivers physical and mental health (outcomes).

In this paper, a class of resampling techniques for finite populations under complex sampling design is introduced. The basic idea on which it rests is a two-step procedure consisting in : (i) constructing a pseudo-population on the basis of sample data; (ii) drawing a sample from the predicted population according to an appropriate resampling design. From a logical point of view, this approach is essentially based on the plug-in principle by Efron, at the "sampling design level". Theoretical justifications based on large sample theory are provided. New approaches to construct pseudo-populations based on various forms of calibrations are proposed. Finally, a simulation study is performed.