Human Papillomavirus (HPV) is one of the most prevalent infections worldwide and a leading cause of cervical cancer, as well as anal, oropharyngeal, penile, vulval, and vaginal cancers. Despite the availability of safe and effective vaccines, coverage beyond female adolescent programmes remains often insufficient, leaving many adolescents and adults unprotected. The World Federation of Public Health Associations (WFPHA) convened a year-long global expert engagement forum to develop evidence-informed policy recommendations to advance HPV elimination. Building on this work, the resulting Call-to-Action urges countries to expand access to boys and adults. Adopting a life-course approach, integrated with screening, equitable access policies, and sustainable financing, can significantly increase coverage and reduce the burden of HPV-related cancers. This article outlines the main outcomes of the Call-to-Action and highlights key priorities for policy and decision makers committed to accelerating HPV elimination.

Purpose: A new assessment of the counseling relationship is presented, which is needed given the limitations of current assessments in the literature. Method: The research team developed 100 items to assess these three factors from the perspective of the counselor (50 items) and the client (50 items) then had 12 professional counselors serve as content validity judges. Based on their feedback, several items were deleted or modified. The modified assessment measures were then sent to 168 counselors and to 252 clients. Exploratory Structural Equation Modeling (ESEM) and then Confirmatory Factor Analysis (CFA) were used to examine their factors structure. Results: Analyses yielded two 6 items versions of the assessment measure (i.e., client and counselor forms), comprised of the underlying constructs of Frame Consensus, Collaborative Motivation, and Collaborative Action. Both forms displayed strong psychometric properties indicative of reliability and validity. Conclusions: The new measure can be used as a complement to or as an alternative to existing measures of the counseling relationship in research or practice.

Background Distinguishing emotional distress from mental health problems such as anxiety and depression can be difficult for clinicians. Both commonly present and are managed in primary care. There are likely to be important differences in the management of emotional distress compared with anxiety and/or depression, but the current nature of assessment and management is unclear. Aim To explore how emotional distress is understood and how people are managed by a range of practitioners in primary care settings in the UK. Design and setting A qualitative study using semistructured interviews with primary care practitioners in the UK. Method Online interviews were conducted with practitioners who directly assess patients with mental health symptoms, including GPs, nurse practitioners, social prescribers, and mental health practitioners. Recruitment was via a digital poster circulated by research delivery networks. Interviews covered how practitioners understood and identified distress, the support provided to patients, and challenges assessing and managing emotional distress. Verbatim transcriptions were analysed using an inductive thematic approach. Results In total, 29 interviews were conducted and four themes were developed in collaboration with the wider team, including public contributors: the multifaceted nature of distress; 'We're all doing very different things'; managing and understanding distress is challenging; and demedicalising distress in the face of increasing societal pressures. Complexity was driven by the wide-ranging professionals involved, complex patient circumstances, systemic challenges, and societal contexts. Conclusion Identifying and managing emotional distress is complex, variable, and challenging. Complexity appears to be increasing through the systemic challenges and range of professionals involved.

Abstract Depressive symptoms are commonly experienced by people with persistent musculoskeletal (MSK) pain. There is evidence for some individuals that this may be best characterised as pain-related distress; a reaction to living with the impact of pain, rather than a depressive illness. No explorations exist of how to differentiate between these in primary care. This study aimed to explore key factors that may differentiate between pain-related distress and depression, and the effectiveness of existing symptom screening tools (Patient Health Questionnaire-9 [PHQ-9] and 4-Dimensional Symptom Questionnaire [4DSQ]) in identifying distress through a mixed methods approach. First, 21 general practitioners and 21 people with pain were interviewed about their experiences of pain-related distress. Second, 597 primary care patients with MSK pain completed a cross-sectional questionnaire study reporting on their pain, mental health symptoms, and other life events. Qualitative data suggested key factors distinguishing between pain-related distress and depression included general positive outlook, physical function, and acceptance. Quantitative findings showed that the PHQ-9 may overcategorise participants as depressed; of the 207 participants classified as distressed (but not depressed) on the 4DSQ, 118 (57%) were categorised as moderately or severely depressed on the PHQ-9. Lower positive outlook and sleep interference scores, and higher PHQ-9 and perceived stress scores significantly predicted participants experiencing distress only compared with distress and depression, matching the qualitative findings. These findings indicate that differentiation between pain-related distress and depression may be possible in primary care consultations for persistent musculoskeletal pain. This is essential to ensure that patients are offered appropriate, acceptable, and effective management.

OBJECTIVES:Healthcare workers (HCWs) are a trusted source of vaccine-related information for patients and communities, but they can show hesitancy or reluctance towards vaccinations. The objective of our study was to investigate HCWs' sentiment and hesitancy towards vaccination, focusing on COVID-19 and influenza vaccination. STUDY DESIGN:A global cross-sectional study spanning four continents. METHODS:Utilizing a web-based survey, we gathered responses from 7793 HCWs across twelve countries. We used Latent Class Analysis models to build response profiles for respondents. We employed multilevel multivariable logistic regression models to assess the impact of individual determinants and country contextual effects on change in vaccine sentiment (ChVS) and COVID-19 vaccine hesitancy (CoVH). RESULTS:HCWs exhibited high agreement on the safety, effectiveness, and usefulness of vaccines. However, 21% reported strong or moderate CoVH. Country contextual effects significantly influenced ChVS and CoVH, with variations observed across nations, accounting for 6% of global variance in both ChVS and CoVH. Individual factors such as educational level, fear of contracting COVID-19, knowledge of COVID 19 vaccines, CoVH, influenza vaccination behaviour and general confidence in vaccines significantly influenced ChVS. CoVH was related to profession, influenza vaccination behaviour, fear of COVID-19 and main information sources. CONCLUSIONS:Individual factors played a major role in determining change in vaccine sentiment and COVID-19 vaccine hesitancy, but they can be modulated by other contextual elements at the country level. There is a need for tailored, nation-specific strategies to address vaccine hesitancy and enhance vaccine confidence among HCWs.

Introduction Acute uncomplicated urinary tract infection (UTI) is a common condition with potentially serious sequelae that is mostly diagnosed and managed in primary care settings. Around half of all women have a UTI in their lifetime, and a quarter experience an infection caused by organisms resistant to more than one antibiotic. Reducing inappropriate prescribing of antibiotics is a core tenet of antimicrobial stewardship. However, current diagnostics for UTI are unfit for purpose in acute (highest prescribing) settings, being too slow to inform the required immediate decision-making and often confounded by sample contamination.Rapid point-of-care diagnostic tests (POCTs) that facilitate timely decision-making are potential solutions to this problem. Several such tests have reached advanced stages of technology readiness, but their diagnostic performance has not been evaluated in primary care with clinical users. To progress novel tests towards implementation, a diagnostic field study is required, to allow for parallel and sequential evaluation of multiple tests in a primary care population.Methods and analysis We will recruit participants assigned female at birth from primary care clinics in England who contact their clinic with symptoms of acute uncomplicated UTI. Eligible participants will complete a short questionnaire to capture symptoms and symptom severity and will provide a urine sample. Samples will be split and initially tested using novel index tests (POCTs) and conventional urinalysis ‘dipstick’ at the primary care clinic. The second part of the sample will be processed at a National Health Service-based reference laboratory using a modified reference standard including microscopy, microbiological culture, pathogen speciation and antimicrobial susceptibility testing. The UTI reference standard culture, although based on the national methods, is modified to provide accurate bacterial counts, better to define a microbiological diagnosis of UTI. Susceptibility testing will be performed using ‘gold-standard’ methods, not usually performed in diagnostic laboratories. The primary outcome will be the diagnostic performance (sensitivity, specificity, positive and negative predictive values) of POCTs for detection of UTI and antimicrobial susceptibility for POCTs that include antimicrobial susceptibility testing. Secondary outcomes will include the symptom profile of patients presenting with uncomplicated UTI, a theoretical determination of how use of POCT results might change prescribing, an understanding of POCT failure rate and qualitative capture of the experiences of those using the POCT to deliver the study in primary care clinics.Ethics and dissemination Ethical approval was received from the London Central Research Ethics Committee (23/LO/0371) and the UK Health Research Authority. We will publish the findings of The plaTform fOr Urinary tract infection diagnostiC evAluatioN evaluations in peer-reviewed medical journals and more broadly following a dissemination plan formulated by a communications specialist in consultation with patients and the public.Trial registration number ISRCTN80937472.

Abstract Supporting behavioural self-management is increasingly important in the care for chronic widespread pain (CWP), including fibromyalgia. Understanding peoples' experiences of these interventions may elucidate processes and mechanisms that lead to or hinder their intended impact. We conducted a systematic review and thematic synthesis of qualitative studies exploring peoples' experiences of self-management interventions for CWP, including fibromyalgia. MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science were searched. Primary qualitative or mixed-methods studies were included if they explored people's self-management intervention experiences for their CWP, including fibromyalgia. Screening, data extraction, and critical appraisal were conducted by 2 reviewers. Data analysis was conducted through thematic synthesis. Twenty-three studies were included, mostly were rated as high or moderate quality. We developed 4 analytic themes: A multifaceted experience of the intervention, potential for transformative experience of group cohesion, a new outlook, and striving for change after the loss of support. Broadly, personalisation was perceived as beneficial and people experienced a range of emotional experiences. These appeared to support positive behavioural and cognitive changes. For most, group activities promoted acceptance and support, fostering new perspectives and improved self-management, although some found aspects of group contexts challenging. Lack of on-going support after interventions led to challenges in applying behavioural strategies, and some struggled without social support from the group. The experiences of self-management interventions for CWP reflect a complex, multifaceted process. Although many reported positive experiences, addressing issues with integration of physical activity, group dynamics and postintervention support may improve effectiveness for a broader range of people.

INTRODUCTION:When ultrasound (US) is non-diagnostic in pediatric patients being evaluated for appendicitis, additional imaging may be required, which incurs delays and increased cost in diagnosis. Our baseline diagnostic rate of US for appendicitis was 27.1 % and was lower for patients with moderate pediatric appendicitis scores (PAS). Due to poor US performance, in our original pathway, patients with moderate PAS underwent magnetic resonance imaging (MRI) initially, resulting in increased emergency department length of stay (ED LOS). Our goal was to improve ultrasound performance so it could be used as first-line imaging for all patients. METHODS:In 2022, all appendix ultrasounds performed in 2020 were reviewed for diagnostic accuracy. During this review, scanning technique and ambiguity in the reporting of findings were identified as major contributors to suboptimal ultrasound performance. In August 2022, sonographers participated in focused bowel and appendix US training. In November 2022, a standardized template for ultrasound and MRI was implemented. Due to improved ultrasound performance, in May 2024, the pathway was adapted so that all PAS levels underwent ultrasound initially. We monitored the impact of this pathway change on: 1) need for MR imaging after ultrasound, and 2) clinical team time (CTT, defined as time from patient being placed in an ED room to disposition). RESULTS:Our diagnostic US rate increased to 56 % from baseline of 27 %. After adjustment of the imaging protocol to an US first approach for all patients as opposed to high PAS scores only, we did not see an increase in the percentage of patients requiring axial imaging after ultrasound. CTT decreased from 347 to 299 min and imaging cost per patient decreased from $6177.38 to $4812.30 (p < 0.001). CONCLUSION:Sonographer training and a standardized template for reporting ultrasound findings can improve appendix ultrasound performance, and in turn reduce ED LOS.

BACKGROUND:Despite having marginal beneficial effects, antibiotics are routinely prescribed in adults with acute sinusitis. Alternative interventions for this common condition are urgently needed. AIM:To assess the feasibility and acceptability of saline nasal irrigation for acute sinusitis. DESIGN & SETTING:Randomised controlled pilot trial with nested process evaluation in 24 English general practices between October 2019 and May 2021. METHOD:Participants were randomised to advice to high-volume hypertonic saline nasal irrigation with a delayed antibiotic prescription or usual care. Feasibility outcomes included recruitment and follow-up rates, adherence, and acceptability of the intervention. RESULTS:Of those invited, n = 81/107 (76%) consented and were randomised (42 intervention, 39 usual care). Two participants were excluded owing to ineligibility. Antibiotic prescribing strategies were recorded at baseline for n = 79/79 (100%), with no or delayed antibiotics prescribed in 60% (n = 24/40) of the saline group versus 38% (n = 15/39) of the usual care group. At follow-up, 80% (n = 63/79) of participants recorded whether they consumed antibiotics or not. Among those from the intervention group who returned a symptom diary, 96% (n = 22/23) and 65% (n = 15/23) reported using saline nasal irrigation during the first and second week, respectively. Semi-structured interviews with 16 participants revealed that most were positive about trial participation and viewed saline nasal irrigation as acceptable, noting it as an alternative to antibiotics. CONCLUSION:Saline nasal irrigation is deemed acceptable for adults with acute sinusitis and a trial of such intervention is feasible. A large trial is warranted to assess the effectiveness of this intervention for this common condition.

Confusion, restlessness, and fatigue are common among older adults living in nursing homes. These nonspecific symptoms are often treated with antibiotics since they are frequently misinterpreted as urinary tract infections. Therefore, it is crucial to investigate other potential causes of these nonspecific symptoms. Impaired cognitive function in older adults may be associated with vitamin D deficiency and could lead to nonspecific symptoms. Currently, it is unknown whether there is a correlation between nonspecific symptoms, often misinterpreted as acute cystitis, and vitamin D deficiency. A cross-sectional study in which blood samples were collected from residents of 22 Swedish nursing homes for 25OHD (25-hydroxyvitamin D) analysis. Demographics and presence of nonspecific symptoms, such as: fatigue, restlessness, confusion, aggressiveness, reduced appetite, tendency to fall or a sense of not being oneself as well as symptom duration, were registered. Exclusion criteria: incontinence, dementia too severe to cooperate when taking a blood test, terminally ill or refusing participation. Logistic regressions were performed to determine if nonspecific symptoms persisting ≥ 3 months were associated with vitamin D deficiency. Out of 901 residents in 22 nursing homes blood samples were taken from 545 participants, of whom 370 (68

# Background Vaccine hesitancy (VH) and vaccine sentiment (VS) among healthcare workers (HCWs) play a crucial role in vaccination programs. In response to this global challenge, an international project was initiated to investigate the determinants of VS. # Method From 2022 to 2023, an anonymous cross-sectional online survey was disseminated to assess Brazilian HCWs’ characteristics, attitudes, and information sources regarding the COVID-19 vaccine. Five psychological constructs were derived using exploratory factor analysis (EFA), and associated with five VS (vaccination attention, vaccine intention, vaccine confidence, general attitude, and health system confidence) through multivariate logistic regressions. # Results The prevalence of VH was low among 634 participants (3.9%), and VS was generally positive. Most HCWs reported strong knowledge confidence (7.3/10), high fear of infection (8.0/10), broad agreement on vaccine necessity (98%), and frequently adopted institutional websites (85.4%) or scientific societies (70.8%) as information sources. Extended from the 5C model, obligated collective responsibility (OCR), representing a professional sense of duty, was significantly associated with vaccine intention, confidence, and attention. Trust in institutional websites emerged as a key determinant of positive VS, while institutional skepticism persisted, especially among HCWs in hospitals, universities, and research settings. “Calculation” was not a significant factor, potentially due to HCWs’ time constraints. Social media, friends, or community members did not significantly link to VS. # Conclusions This study identifies key determinants of VS and introduces OCR as a novel expansion to the 5C model. Enhancing VS will require trusted, concise institutional communication and ethics-driven workplace policies that appeal to HCWs’ professional responsibilities.

BackgroundSore throat is a common problem and a common reason for the overuse of antibiotics. A web-based tool that helps people assess their sore throat, through the use of clinical prediction rules, taking throat swabs or saliva samples, and taking throat photographs, has the potential to improve self-management and help identify those who are the most and least likely to benefit from antibiotics. ObjectiveWe aimed to develop a web-based tool to help patients and parents or carers self-assess sore throat symptoms and take throat photographs, swabs, and saliva samples for diagnostic testing. We then explored the acceptability and feasibility of using the tool in adults and children with sore throats. MethodsWe used the Person-Based Approach to develop a web-based tool and then recruited adults and children with sore throats who participated in this study by attending general practices or through social media advertising. Participants self-assessed the presence of FeverPAIN and Centor score criteria and attempted to photograph their throat and take throat swabs and saliva tests. Study processes were observed via video call, and participants were interviewed about their views on using the web-based tool. Self-assessed throat inflammation and pus were compared to clinician evaluation of patients’ throat photographs. ResultsA total of 45 participants (33 adults and 12 children) were recruited. Of these, 35 (78%) and 32 (71%) participants completed all scoring elements for FeverPAIN and Centor scores, respectively, and most (30/45, 67%) of them reported finding self-assessment relatively easy. No valid response was provided for swollen lymph nodes, throat inflammation, and pus on the throat by 11 (24%), 9 (20%), and 13 (29%) participants respectively. A total of 18 (40%) participants provided a throat photograph of adequate quality for clinical assessment. Patient assessment of inflammation had a sensitivity of 100% (3/3) and specificity of 47% (7/15) compared with the clinician-assessed photographs. For pus on the throat, the sensitivity was 100% (3/3) and the specificity was 71% (10/14). A total of 89% (40/45), 93% (42/45), 89% (40/45), and 80% (30/45) of participants provided analyzable bacterial swabs, viral swabs, saliva sponges, and saliva drool samples, respectively. Participants were generally happy and confident in providing samples, with saliva samples rated as slightly more acceptable than swab samples. ConclusionsMost adult and parent participants were able to use a web-based intervention to assess the clinical features of throat infections and generate scores using clinical prediction rules. However, some had difficulties assessing clinical signs, such as lymph nodes, throat pus, and inflammation, and scores were assessed as sensitive but not specific. Many participants had problems taking photographs of adequate quality, but most were able to take throat swabs and saliva samples.

Background: Vaccination is one of the most effective available public health tools, preventing infectious diseases to safeguard public health and save millions of lives annually. However, in recent years vaccine hesitancy has increased among all populations, including healthcare workers. Healthcare providers are central to vaccination efforts due to their increased exposure to disease and vulnerable patients, and their role in patient confidence and decision-making. These decreasing uptake rates highlight a critical need to address specific barriers within this target group. This systematic review aims to explore the strategies used to improve vaccine uptake among healthcare providers. Methods: A literature search was conducted in PubMed, EMBASE, and MEDLINE databases, alongside a grey literature search, to identify studies describing interventions to improve vaccine uptake among healthcare providers. This was followed by de-duplication and double-blinded screening processes using Rayyan. Data extraction and thematic analysis focused on categorising interventions and identifying frequencies of use, to develop recommendations for further interventions tailored to target regions. Results: 60 studies were identified, predominantly concerning influenza vaccination. Interventions included educational initiatives, reminders, incentives, access solutions, feedback, and policy implementation. Key strategies included targeted educational lectures, posters, and pamphlets; mobile vaccination units; extended vaccination hours; and leadership engagement. The findings underscore the importance of a multifaceted approach combining educational efforts, enhanced accessibility, and motivational incentives to improve vaccination rates within the healthcare providers, especially where mandatory vaccination is controversial. Conclusions: This review evaluates tailored strategies to enhance vaccine confidence and uptake among healthcare providers, advocating for a holistic approach that includes educational initiatives, reminder systems, incentives, improved access, feedback mechanisms, and policy enactment to effectively address hesitancy and promote public health.

Introduction Evaluating the safety and acceptability of reusing catheters for intermittent catheterisation (IC) is one of the top 10 continence research priorities identified by the UK James Lind Alliance Priority Setting Partnership in 2008. There are an estimated 50 000 IC users in England and this number is rising. Globally, both single-use catheters (thrown away after use) and multi-use/reusable ones (cleaned between uses) are used. Using multi-use catheters as well as single-use ones (mixed-use) could bring benefits (eg, reducing plastic waste and patients never running out of catheters) and offer more choice to users. Evidence is needed that mixed-use is at least as safe and acceptable as using only single-use catheters.Methods The MultICath Trial is a non-inferiority randomised controlled trial involving 578 participants. The aim is to compare mixed-use catheter management with single-use catheter management over 12 months. Participants are randomised on a 1:1 basis to either mixed-use catheter management, which includes an evidence-based cleaning method for the multi-use catheters (intervention) or single-use catheter management (control). Following randomisation, participants are followed up for 12 months. The primary outcome is at least one episode of microbiologically confirmed symptomatic urinary tract infection with help-seeking or self-help behaviour over the 12-month follow-up period. Laboratory analysis of patient-initiated urine samples is blind. Secondary outcomes include antibiotic use, microhaematuria, visible blood on catheter/in urine, quality of life and health economics. A qualitative sub-study to examine participant experiences using mixed-use is included.Ethics and dissemination Ethical review was undertaken by South Central-Hampshire A Research Ethics Committee and favourable opinion was granted on 12 July 2019 (reference: 19/SC/0334). Written, informed consent to participate was obtained from all participants. Results will be disseminated in peer-reviewed publications, in the National Institute for Health and Care Research journal library and to participants and the public via a lay summary published on the trial website.Trial registration number ISRCTN42028483.

ImportanceThere is significant concern regarding increasing long-term antidepressant treatment for depression beyond an evidence-based duration.ObjectiveTo determine whether adding internet and telephone support to a family practitioner review to consider discontinuing long-term antidepressant treatment is safe and more effective than a practitioner review alone.Design, Setting, and ParticipantsIn this cluster randomized clinical trial, 131 UK family practices were randomized between December 1, 2018, and March 31, 2022, with remote computerized allocation and 12 months of follow-up. Participants and researchers were aware of allocation, but analysis was blind. Participants were adults who were receiving antidepressants for more than 1 year for a first episode of depression or more than 2 years for recurrent depression who were currently well enough to consider discontinuation and wished to do so and who were at low risk of relapse. Of 6725 patients mailed invitations, 330 (4.9%) were eligible and consented.InterventionsInternet and telephone self-management support, codesigned and coproduced with patients and practitioners.Main Outcomes and MeasuresThe primary (safety) outcome was depression at 6 months (prespecified complete-case analysis), testing for noninferiority of the intervention to under 2 points on the 9-item Patient Health Questionnaire (PHQ-9). Secondary outcomes (testing for superiority) were antidepressant discontinuation, anxiety, quality of life, antidepressant withdrawal symptoms, mental well-being, enablement, satisfaction, use of health care services, and adverse events. Analyses for the main outcomes were performed on a complete-case basis, and multiple imputation sensitivity analysis was performed on an intention-to-treat basis.ResultsOf 330 participants recruited (325 eligible for inclusion; 178 in intervention practices and 147 in control practices; mean [SD] age at baseline, 54.0 [14.9] years; 223 women [68.6%]), 276 (83.6%) were followed up at 6 months, and 240 (72.7%) at 12 months. The intervention proved noninferior; mean (SD) PHQ-9 scores at 6 months were slightly lower in the intervention arm than in the control arm in the complete-case analysis (4.0 [4.3] vs 5.0 [4.7]; adjusted difference, −1.1; 95% CI, −2.1 to −0.1; P = .03) but not significantly different in an intention-to-treat multiple imputation sensitivity analysis (adjusted difference, −0.9 (95% CI, −1.9 to 0.1; P = .08). By 6 months, antidepressants had been discontinued by 66 of 145 intervention arm participants (45.5%) who provided discontinuation data and 54 of 129 control arm participants (41.9%) (adjusted odds ratio, 1.02; 95% CI, 0.52-1.99; P = .96). In the intervention arm, antidepressant withdrawal symptoms were less severe, and mental well-being was better compared with the control arm; differences were small but significant. There were no significant differences in the other outcomes; 28 of 179 intervention arm participants (15.6%) and 22 of 151 control arm participants (14.6%) experienced adverse events.Conclusions and RelevanceIn this cluster randomized clinical trial of adding internet and telephone support to a practitioner review for possible antidepressant discontinuation, depression was slightly better with support, but the rate of discontinuation of antidepressants did not significantly increase. Improvements in antidepressant withdrawal symptoms and mental well-being were also small. There were no significant harms. Family practitioner review for possible discontinuation of antidepressants appeared safe and effective for more than 40% of patients willing and well enough to discontinue.Trial RegistrationISRCTN registry Identifiers: ISRCTN15036829 (internal pilot trial) and ISRCTN12417565 (main trial)

Background: People with persistent musculoskeletal (MSK) pain often report depressive symptoms. Distress and depression have been found to predict the development of chronic pain conditions. Evidence suggests pain-related distress is qualitatively different from depressive illness, and current referral pathways and available interventions are sub-optimal for people with persistent MSK pain and distress. We aimed to develop and test the acceptability and proof of concept of an intervention to reduce pain-related distress in people with chronic MSK pain. Methods: The Person-Based Approach (PBA)(1) informed the processes undertaken to inform intervention development. This included semi-structured interviews with people with persistent pain and with General Practitioners (GPs); and a stakeholder discussion with social prescribers. Patient and Public Involvement (PPI) representatives had input throughout all development work. Findings from these activities were triangulated to inform the development of a prototype intervention which was tested in a repeated-measures, mixed methods proof-of-concept study called De-Stress Pain. The De-Stress Pain intervention offered 4-6 social prescriber sessions over 12 weeks, and access to a study website. 16 participants were recruited from general practices, and 4 social prescribers were recruited from Primary Care Networks (PCNs) and charitable organisations. Both quantitative measures and qualitative interviews were completed by participants at baseline and 12 weeks post-baseline. Quantitative measures included questions about mood (DAPOS, WEMWBS, 4DSQ), pain chronicity, pain intensity and musculoskeletal health (MSK-HQ). Semi-structured interviews with participants explored the participants’ context, their experiences of pain related distress, and their experiences of the intervention. Social prescribers were interviewed to explore their experiences of delivering the intervention. Interviews were analysed using thematic analysis. Results: The De-Stress Pain intervention was acceptable both to patients and to social prescribers. Some participants experienced positive changes such as improved mood, increased hope and increased activity. The social prescribers (“De-Stress Coaches”) provided accountability and supported motivation. All measures of mood showed improvement. Limited time and money were identified as barriers to engagement, along with participants holding the view that increasing pleasurable activities was indulgent. Some participants were already socially engaged and busy at the point of entering the study. Conclusions: We have confirmed the intervention is needed, acceptable and welcomed by people with pain. Social prescribers found the intervention acceptable to deliver. We identified the barriers that need to be addressed in future versions of the intervention. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by Versus Arthritis. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee London- Bloomsbury Research Ethics Committee of Health Research Authority gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

BackgroundPrimary care clinicians see people experiencing the full range of mental health problems. Determining when symptoms reflect disorder is complex. The Four-Dimensional Symptom Questionnaire (4DSQ) uniquely distinguishes general distress from depressive and anxiety disorders. It may support diagnostic conversations and targeting of treatment.AimTo explore peoples’ experiences of completing the 4DSQ and their perceptions of their resulting score profile across distress, depression, anxiety, and physical symptoms.Design and settingA qualitative study was conducted in the UK with people recruited from primary care and community settings.MethodParticipants completed the 4DSQ then took part in semi-structured telephone interviews. They were interviewed about their experience of completing the 4DSQ, their perceptions of their scores across four dimensions, and the perceived utility if used with a clinician. Interviews were transcribed verbatim and data were analysed thematically.ResultsTwenty-four interviews were conducted. Most participants found the 4DSQ easy to complete and reported that scores across the four dimensions aligned well with their symptom experience. Distinct scores for distress, depression, and anxiety appeared to support improved self-understanding. Some valued the opportunity to discuss their scores and provide relevant context. Many felt the use of the 4DSQ with clinicians would be helpful and likely to support treatment decisions, although some were concerned about time-limited consultations.ConclusionDistinguishing general distress from depressive and anxiety disorders aligned well with people’s experience of symptoms. Use of the 4DSQ as part of mental health consultations may support targeting of treatment and personalisation of care.

Objective This study tests a model to improve the management of patients with an osteoporotic fracture. Methods Patients with fractures potentially due to osteoporosis were identified from imaging reports using computerised near natural language processing. A coordinator notified the referring GP about the finding and provided follow-up to remind GPs of the need for management. This provided an opportunity to assess action taken by the GP. Results Near natural language processing efficiently detected fractures in patients at risk of osteoporosis. GPs reported that they are managing osteoporosis in over 40% of patients identified. Notification of GPs coincided with a small increase in osteoporosis management. Conclusion Information technology can identify patient populations with clinically important risks such as osteoporosis. Methods to engage GPs to optimally address this risk have yet to be developed.

BackgroundAntimicrobial resistance is a global patient safety priority and inappropriate antimicrobial use is a key contributing factor. Evidence have shown that delayed (back-up) antibiotic prescriptions (DP) are an effective and safe strategy for reducing unnecessary antibiotic consumption but its use is controversial.MethodsWe conducted a realist review to ask why, how, and in what contexts general practitioners (GPs) use DP. We searched five electronic databases for relevant articles and included DP-related data from interviews with healthcare professionals in a related study. Data were analysed using a realist theory-driven approach - theorising which context(s) influenced (mechanisms) resultant outcome(s) (context-mechanism-outcome-configurations: CMOCs).ResultsData were included from 76 articles and 41 interviews to develop a program theory comprising nine key and 56 related CMOCs. These explain the reasons for GPs' tolerance of risk to different uncertainties and how these may interact with GPs' work environment, self-efficacy and perceived patient concordance to make using DP as a safety-net or social tool more or less likely, at a given time-point. For example, when a GP uses clinical scores or diagnostic tests: a clearly high or low score/test result may mitigate scientific uncertainty and lead to an immediate or no antibiotic decision; an intermediary result may provoke hermeneutic (interpretation-related) uncertainty and lead to DP becoming preferred and used as a safety net. Our program theory explains how DP can be used to mitigate some uncertainties but also provoke or exacerbate others.ConclusionThis review explains how, why and in what contexts GPs are more or less likely to use DP, as well as various uncertainties GPs face which DP may mitigate or provoke. We recommend that efforts to plan and implement interventions to optimise antibiotic prescribing in primary care consider these uncertainties and the contexts when DP may be (dis)preferred over other interventions to reduce antibiotic prescribing. We also recommend the following and have included example activities for: (i) reducing demand for immediate antibiotics; (ii) framing DP as an 'active' prescribing option; (iii) documenting the decision-making process around DP; and (iv) facilitating social and system support.