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Helene-Mari van der Westhuizen and colleagues argue that face coverings should be considered not as medical equipment but as a social practice informed by norms and expectations

BackgroundDespite climate change being described as a code red for humanity, health systems have been particularly slow in both climate mitigation and adaptation responses. The effects of climate change on health and health systems will not be felt equally, with underserved and marginalised communities disproportionately impacted. The circumpolar region is warming at 3–4 times the global rate, amplifying already existing socioeconomic barriers and health inequities, with particular amplified effects for the substantial Indigenous population in the area.Objectives and settingWe therefore sought to explore perspectives of physicians around patient-planetary health (P-PH) co-benefit prescribing in a circumpolar region in the Northwest Territories (NWT), Canada, known to be one of the ground zero levels for climate change.MethodsThirteen semi-structured physician interviews were carried out in the NWT region between May 2022 and March 2023 using purposive sampling. Interviews were transcribed verbatim and reflexive thematic analysis was carried out to identify key themes.ResultsThere were three main themes identified including (1) current healthcare system does not support planetary health, (2) supporting patient-planetary health is currently difficult for clinicians and (3) considering change in the NWT to support patient-planetary health. Participants noted key opportunities to move planetary health forward, with the NWT having the potential to be an innovative model for planetary health-informed change for other health systems.ConclusionThe NWT health system has unique features due to its rural and remote nature and smaller population base. Despite this, our study identified some key opportunities for advancing P-PH co-benefit efforts. The identified opportunities may be considered in future intervention, organisational change and policy-making efforts with potential relevance in other settings.

Clinical decision support systems (CDSSs) can promote adherence to clinical guidelines and improve patient outcomes. Exploring implementation determinants during the development of CDSSs enables intervention optimisation to promote acceptability, perceived appropriateness and fidelity during subsequent implementation. This study sought to explore how clinicians perceive the use of a CDSS which makes recommendations for asthma management based on factors including Fractional exhaled Nitric Oxide testing, and how CDSSs can be designed to promote their implementation. Twenty-three interviews were conducted with clinicians to explore perceptions about the CDSS. Participants included asthma nurses, pharmacists, General Practitioners and respiratory nurse specialists involved in conducting asthma reviews in primary care. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. Three themes were developed: Appreciating the recommendations of the CDSS, whilst wanting to retain control; Doubt about appropriateness of CDSS recommendations, especially when you can't see how they were produced; and Potential for the CDSS to increase patients' trust and adherence to their treatment. Clinicians perceived the CDSS could help them prioritise management options and consider broader factors relating to patients' asthma symptoms, but it was important to be able to override the recommendation. Lack of transparency over how recommendations were generated and concern about appropriateness of recommendations for specific patients led to uncertainty about adhering to the CDSS. Clinically tailored recommendations were perceived to help reassure patients and/or to support their adherence to asthma management. Even small changes to the content of CDSS recommendations, such as explaining how recommendations were generated and showing they are consistent with guidance, may help to overcome barriers to acceptability and perceived appropriateness for clinicians. Focusing on implementation during the development of CDSS interventions is worthwhile to help reduce the evidence-practice gap.

ObjectivesTo develop a behavioural intervention package to support non-allergist healthcare workers (HCWs) to remove incorrect penA records from medical and surgical adult inpatients. This paper describes the development of the penicillin allergy de-labelling (PADL) intervention and the implementation intervention that will support non-allergist-delivered PADL.DesignWe combined evidence-based, theory-based and person-based approaches. Qualitative research with healthcare professionals and patients explored barriers and enablers to implementation of the proposed PADL pathway. Key intervention design objectives and the key features of the implementation intervention required to achieve each objective were then developed and captured as guiding principles. We produced a logic model, integrating the theoretical domains framework to identify the behavioural influences on PADL and the behaviour change wheel to show how the implementation intervention is hypothesised to address the target behaviours. The implementation intervention package was then reviewed by stakeholders and topic experts for further refinement and optimisation. Finally, we outline how the implementation intervention will be evaluated.SettingSingle-centre District General Hospital in the SW England servicing a rural community of 575 000 people without local allergy services.ResultsHCWs reported PADL needed to be structured, standardised, evidence based and supported by hospital approved guidelines with easy to access patient information leaflets, supported by a sustained programme of education and training with named PADL leaders and visible PADL champions. Patients wanted a good explanation of the benefits and risks of testing and the benefits of having their ‘penA’ record removed. The identified HCW target behaviours were: taking a penA allergy focused history and to risk assess the patient’s penA history; to then either de-label the patient on history alone (direct de-label; DDL) or prescribe a direct oral challenge (DOC) dose; to perform baseline and post-test observations and counsel the patient on the risks of penA records and on the risks and the benefits of PADL. We identified barriers to target behaviours that we considered both important and modifiable, which included: lack of confidence in taking a penA focused history, PADL not viewed as a priority, low confidence with differentiating low-risk and high-risk penA histories, concerns about the safety of DOC, a requirement for senior support for nurses to deliver the observations and senior support for the other HCWs to deliver PADL, access to an expert for advice when required, a lack of PADL champions to promote PADL, and PADL not being supported by the organisation. The identified patient target behaviours were acceptance of the opportunity to be de-labelled via either DDL or DOC and willingness to take penicillin when prescribed. We developed intervention components to target the HCW and patient target behaviours which included: Education, expert advice made available from Infection specialists, a named PADL champion, hospital endorsed PADL guideline with necessary tools to enable PADL and patient information leaflets. The implementation intervention was further optimised through workshops with PADL researchers and stakeholders. The Consolidated Framework for Implementation Research outcome addendum was used to define both implementation intervention and PADL intervention outcomes.ConclusionsWe have developed a theory-based and stakeholder-developed implementation intervention to support inpatient PADL delivered by a multiprofession workforce. The intervention will be tested in a single hospital and scalability explored.

To identify the experiences and concerns of health workers (HWs), and how they changed, throughout the first year of the COVID-19 pandemic in the UK. Longitudinal, qualitative study with HWs involved in patient management or delivery of care related to COVID-19 in general practice, emergency departments and hospitals. Participants were identified through snowballing. Semi-structured telephone or video interviews were conducted between February 2020 and February 2021, audio-recorded, summarised, and transcribed. Data were analysed longitudinally using framework and thematic analysis. We conducted 105 interviews with 14 participants and identified three phases corresponding with shifts in HWs' experiences and concerns. (1) Emergency and mobilisation phase (late winter-spring 2020), with significant rapid shifts in responsibilities, required skills, and training, and challenges in patient care. (2) Consolidation and preparation phase (summer-autumn 2020), involving gradual return to usual care and responsibilities, sense of professional development and improvement in care, and focus on learning and preparing for future. (3) Exhaustion and survival phase (autumn 2020-winter 2021), entailing return of changes in responsibilities, focus on balancing COVID-19 and non-COVID care (until becoming overwhelmed with COVID-19 cases), and concerns about longer-term impacts of unceasing pressure on health services. Participants' perceptions of COVID-19 risk and patient/public attitudes changed throughout the year, and tiredness and weariness turned into exhaustion. Results showed a long-term impact of the COVID-19 pandemic on UK HWs' experiences and concerns related to changes in their roles, provision of care, and personal wellbeing. Despite mobilisation in the emergency phase, and trying to learn from this, HWs' experiences seemed to be similar or worse in the second wave partly due to many COVID-19 cases. The findings highlight the importance of supporting HWs and strengthening system-level resilience (e.g., with resources, processes) to enable them to respond to current and future demands and emergencies.

Background Self-sampling and self-testing have been increasingly used for sexually transmitted infections (STIs) and quickly became widespread during the COVID-19 pandemic. User acceptability, preferences, and experiences are important factors affecting self-sampling/self-testing uptake. Understanding these factors is key to managing infections and planning responses to health emergencies. This review aimed to identify user views and experiences related to the acceptability, usability, motivations and preferences for self-sampling/self-testing for infections. Methods We conducted a rapid systematic review. We searched Medline, EMBASE, PsycINFO, CINAHL, and Web of Science, limiting records to those published in English between 2014 and 2023. We also searched manually for additional peer-reviewed and grey literature. We included reports of public users’ views on self-sampling/self-testing for any symptomatic and asymptomatic infections (except human papillomavirus) with qualitative, mixed-methods or survey data relevant to the review aim. Data were extracted into tables and qualitative findings were coded in NVivo. We synthesised data narratively. Results We identified 194 eligible reports, including 64 from Europe (which we prioritised for detailed synthesis) and 130 from outside of Europe. In Europe, the studied infections were respiratory ( n  = 42, including 37 for COVID-19), STIs/HIV/genital infections ( n  = 20), and hepatitis C ( n  = 2). Findings indicate that users found self-sampling/self-testing acceptable across infection/sampling types, populations, settings, and countries. Users wanted self-sampling/self-testing to help determine infection status and protect others. The main benefits were privacy and convenience, helping reduce the potential stigma of STIs/HIV/genital infections, and (for COVID-19) informing behaviour (e.g., socialising, self-isolating) and contributing to research. Easier to perform and less invasive sampling approaches were more acceptable. However, some participants reported challenges to self-sampling/self-testing, such as not understanding instructions, pain/discomfort in collecting samples, and lack of confidence in interpreting results. Conclusions This review synthesised evidence on the acceptability of SS/ST and factors affecting it across different infections, sampling approaches, settings, and populations. Evidence shows that most people with experience of self-sampling/self-testing found it acceptable and were willing to accept some discomfort in favour of several perceived benefits. This amenability to self-sampling/self-testing could be leveraged for diagnosing infections and preventing transmission. It can be used to support the viability of new models of clinical care and pandemic preparedness. Trial registration The review was pre-registered on PROSPERO (ref. CRD42024507656 ).

IntroductionIn order to tackle the pandemic, governments have established various types of advisory boards to provide evidence and recommendations to policy makers. Scientists working on these boards have faced many challenges, including working under significant time constraints to produce ‘evidence’ as quickly as possible. However, their voices are still largely missing in the discussion. This study explores the views and experiences of scientists working on government advisory boards during the COVID-19 pandemic, with the aim to learn lessons for future pandemic management and preparedness.MethodsWe conducted online video or telephone semi-structured interviews between December 2020 and April 2021 with 21 scientists with an official government advisory role during the COVID-19 pandemic in Belgium, the Netherlands, UK, Sweden and Germany. The interviews were audio-recorded and transcribed and analysed using a combination of inductive and deductive thematic analysis techniques.ResultsScientists viewed the initial focus on biomedically oriented work during the pandemic as somewhat one-dimensional, but also highlighted difficulties of working in an interdisciplinary way. They found it difficult at times to ensure that the evidence is understood and taken on board by governments. They found themselves taking on new roles, the boundaries of which were not clearly defined. Consequently, they were often perceived and treated as a public figure.ConclusionScientists working on advisory boards in European countries faced similar challenges, highlighting key lessons to be learnt. Future pandemic preparedness efforts should focus on building interdisciplinary collaboration through development of scientists’ skills and appropriate infrastructure; ensuring transparency in how boards operate; defining and protecting the boundaries of the scientific advisor role; and supporting scientists to inform the public in the fight against disinformation, while dealing with potential hostile reactions.

Working under pandemic conditions exposes health care workers (HCWs) to infection risk and psychological strain. A better understanding of HCWs' experiences of following local infection prevention and control (IPC) procedures during COVID-19 is urgently needed to inform strategies for protecting the psychical and psychological health of HCWs. The objective of this study was therefore to capture the perceptions of hospital HCWs on local IPC procedures and the impact on their emotional wellbeing during the first wave of the COVID-19 pandemic in Europe. Participants were recruited in two sampling rounds of an international cross-sectional survey. Sampling took place between 31 March and 17 April 2020 via existing research networks and between 14 May and 31 August 2020 via online convenience sampling. Main outcome measures were behavioural determinants of HCWs' adherence to IPC guidelines and the WHO-5 Well-Being Index, a validated scale of 0-100 reflecting emotional wellbeing. The WHO-5 was interpreted as a score below or above 50 points, a cut-off score used in previous literature to screen for depression. 2289 HCWs from 40 countries in Europe participated. Mean age was 42 (±11) years, 66% were female, 47% and 39% were medical doctors and nurses, respectively. 74% (n = 1699) of HCWs were directly treating patients with COVID-19, of which 32% (n = 527) reported they were fearful of caring for these patients. HCWs reported high levels of concern about COVID-19 infection risk to themselves (71%) and their family (82%) as a result of their job. 40% of HCWs considered that getting infected with COVID-19 was not within their control. This feeling was more common among junior than senior HCWs (46% versus 38%, P value < .01). Sufficient COVID-19-specific IPC training, confidence in PPE use and institutional trust were positively associated with the feeling that becoming infected with COVID-19 was within their control. Female HCWs were more likely than males to report a WHO-5 score below 50 points (aOR 1.5 (95% confidence interval (CI) 1.2-1.8). In Europe, the COVID-19 pandemic has had a differential impact on those providing direct COVID-19 patient care, junior staff and women. Health facilities must be aware of these differential impacts, build trust and provide tailored support for this vital workforce during the current COVID-19 pandemic.

Background Antibiotic misuse is a major preventable driving factor for antimicrobial resistance (AMR). Most antibiotics are prescribed in primary care where demand for consultations for common self-limiting infections is greatest, meaning public knowledge may influence antibiotic prescribing. This study aims to explore how public knowledge of and attitudes towards antibiotics have changed over time. Methods Ipsos conducted interviews as part of routine surveys across England in 2020, 2021, 2022 and 2024. Random and quota sampling were used to ensure a representative sample. Questionnaire responses were weighted to ensure the results are broadly representative of the population. Pearson’s Chi-squared test was used to test for differences in proportions across levels of categorical variables and between responses across the four years. Results Responses were obtained from 2,022 (pre-pandemic); 1,676 (pandemic-Y1); 1,663 (pandemic-Y2) and 3,024 (post-pandemic) respondents. The proportion of respondents who felt they had personal responsibility to tackle AMR increased from 57% pre-pandemic to 62% in pandemic-Y1 ( p  < 0.05), reducing to 46% post-pandemic. The proportion of respondents correctly answering the statement antibiotics will always speed up my recovery from an infection increased from 58% pre-pandemic to 65% in pandemic-Y1 and Y2 ( p  < 0.05), reducing to 56% post-pandemic. Knowledge regarding the use of antibiotics to treat ear, urine infections and COVID-19 was lowest post-pandemic. Trust in healthcare professionals (HCPs) regarding whether antibiotics are needed peaked during (range: 77% to 91%) and declined post-pandemic (range: 72% to 86%). The proportion of respondents who reported they would be pleased if their GP did not prescribe antibiotics was highest pre-pandemic (84%), decreasing to 65% post-pandemic. The proportion of respondents who were likely to request antibiotics from their GP declined from pre-pandemic (21%) to pandemic-Y1 (19%) but increased post-pandemic (25%). Demographic variations were observed across nearly all questions. Conclusions This paper highlights some concerning trends. Knowledge regarding AMR and the specific infections that antibiotics can treat has reverted to pre-pandemic levels, while levels of uncertainty about AMR and antibiotic use have increased. Although high, trust in HCPs has declined. Therefore, future interventions may wish to support HCPs to build trust with their patients and consider how care pathways can promote this.

Broad-spectrum antibiotics are routinely prescribed empirically in the resource-poor settings for suspected acute common infections, which drive antimicrobial resistance. Point-of-care testing (POCT) might increase the appropriateness of decisions about whether and which antibiotic to prescribe, but implementation will be most effective if clinician’s perspectives are taken into account.ObjectivesTo explore the perceptions of South African primary care clinicians working in publicly funded clinics about: making antibiotic prescribing decisions for two common infection syndromes (acute cough, urinary tract infection); their experiences of existing POCTs; their perceptions of the barriers and opportunities for introducing (hypothetical) new POCTs.Design, method, participants, settingQualitative semistructured interviews with 23 primary care clinicians (nurses and doctors) at publicly funded clinics in the Western Cape Metro district, South Africa. Data were analysed using thematic analysis.ResultsClinicians reported that their antibiotic prescribing decisions were influenced by their clinical assessment, patient comorbidities, social factors (eg, access to care) and perceived patient expectations. Their experiences with currently available POCTs were largely positive, and they were optimistic about the potential for new POCTs to: support evidence-based prescribing decisions that might reduce unnecessary antibiotic prescriptions; reduce the need for further investigations; support effective communication with patients, especially when antibiotics were unlikely to be of benefit. Resources and workflow disruption were seen as the main barriers to uptake into routine care.ConclusionsClinicians working in publicly funded clinics in the Western Cape Metro of South Africa saw POCTs as potentially useful for positively addressing both clinical and social drivers of the overprescribing of broad-spectrum antibiotics, but were concerned about the resource implications and disruption of existing patient workflows.