Users’ modifications to electronic nicotine delivery systems (ENDS) products could increase initiation, inhibit cessation, or change the toxicity of the product. This study aims to begin to identify consumers’ common ENDS modification behaviors. We conducted audio-recorded, in-depth one-on-one interviews with 13 adult ENDS users in the metropolitan Atlanta area, who self-reported extensive modification experience. Modifications to coils, batteries, and e-liquids were commonly mentioned. Participants indicated that users modified devices to produce large clouds, change levels of nicotine delivery, alter tastes of e-liquids, and experience different throat hits. Because manufacturers have changed product characteristics to be in line with consumer preferences, interviewees indicated that fewer users currently engage in modifications to coils and batteries compared to the more widespread practice a few years ago. Hobbyists continue to perform modifications and many users continue to misuse or abuse e-liquids, despite the view that fewer users currently alter their ENDS than in the past. The Food and Drug Administration (FDA) regulatory actions that limit certain product characteristics may unintentionally increase the likelihood that users will once again make more extensive modifications to their products, and this should be considered as part of the FDA’s regulatory decision-making process. The use of electronic nicotine delivery systems (ENDS), also called e-cigarettes, e-hookahs, and vape devices, is a growing public health issue in the United States . Almost ENDS modifications include product misuse and tampering unintended by the manufacturers, as well as alteration, customization, adjustment, and user choice of e-liquid or accessories made within manufacturer parameters. For instance, users may modify the liquid materials to be aerosolized, such as making their own e-juice or adding substances such as cannabis. Users may substitute liquids intended by the manufacturer with materials of unknown origin and composition. Users may also modify the voltage of the heating coil, resulting in higher nicotine delivery and exposure to higher levels of other harmful substances in the aerosol . In addiHowever, very little is known about modifications made by users to ENDS. The Population Assessment of Tobacco and Health (PATH) survey has two items related to modifications: whether participants can change the voltage on their ENDS devices, and if they have ever modified their ENDS; in which, participants can only answer yes or no. This data does not have the degree of depth and specificity needed to adequately inform product standards or marketing decisions for specific product applications to minimize misuse of ENDS. Indeed, to the best of our knowledge, no studies have used these data from the PATH survey. Thus, the purpose of this study is to identify and understand consumers’ common ENDS modification behaviors. We conducted in-depth one-on-one interviews with 13 ENDS enthusiasts  in the metropolitan Atlanta area to explore how and why users modify their ENDS devices and develop hypotheses for quantitative surveys.John Snow Inc. (JSI), a public health consulting firm, utilized both online  and offline  recruitment strategies to invite potential participants. Interested individuals completed an online screener that assessed their demographics, tobacco use, and experience with modifying ENDS products. Participants were considered eligible for this study if they (a) were 18 years or older, (b) self-reported currently using ENDS every day or some days, and (c) stated that they had experience with modifying the ENDS devices they routinely used. For the purpose of this study, people who met our eligibility criteria were called “ENDS enthusiasts”. A total of 112 individuals completed the screener, 43 of whom were eligible and were contacted for an interview. We interviewed 12 ENDS enthusiasts from the metropolitan Atlanta area. This sample size is typically sufficient to reach theme saturation [JSI conducted 13 semi-structured interviews between January and May 2019. An experienced moderator led each interview, which was audio-recorded. Research team members also observed the interviews and took notes. The interviews ranged in length between 15 and 62 min. Most sessions were conducted at various vape shops for participants’ convenience. Some interviews were conducted in a private meeting space near the JSI Atlanta office. All participants signed informed consent and the study was approved by the Institutional Review Board of Georgia State University. Participant names have been substituted with pseudonyms to maintain confidentiality. Semi-structured interviews explored different ways participants modified their ENDS, the reasons for these modifications, and personal stories and experiences related to modified ENDS.We utilized a thematic analysis  approachParticipants were 31% cisgender women and 69% cisgender men; 46% African American, 31% European American, and 23% other races; 46% had a bachelor’s or graduate degree; and 31%, 54%, and 15% were aged 18–24, 25–44, and 45–64 years, respectively. No participants self-identified as Hispanic or Latino. All 13 participants were daily ENDS users and only one participant (Daniel) was a past 30-day dual user of cigarettes and ENDS. All participants modified the ENDS devices they routinely used. Overall, participants engaged in various ENDS modification practices. Modifications to coils and batteries were most commonly discussed. Users also refilled closed pods, changed e-liquids with different flavors, or even created their own e-liquids.Of the 13 participants, all but one mentioned that building and replacing coils were the most common and intensive modifications. Building coils refers to making users’ own coils from basic materials. While the exact techniques for coil building for each type of ENDS device differs, the major steps generally involve preparing a piece of wire, wrapping the wire around a small screwdriver a specific number of times, installing and testing the coils, and wicking the coils (inserting a wick). Some participants expressed that although building coils appears to be straightforward, it is actually quite time-consuming and requires intensive self-learning. Thus, instead of building their own coils, more often users replaced existing coils with pre-built coils from manufacturers. The new coils, either built or replacement, usually have different levels of wattage range, numbers of wire wraps, wire gauge, and/or wire materials  than the old ones. Anthony, a former vape shop worker, said he and other retailers always recommended customers change coils to meet their individual needs. In addition, George indicated that some users built and sold coils to other consumers full-time.Participants mentioned several reasons for modifying their coils. First, users built and replaced different coils so that they could experience various cloud densities. Several interviewees explained that coils with different forms of wire wrapping yield different heating speeds, which lead to more or less dense clouds. Anthony also stated that some ENDS users participated in cloud competitions at which people competed for the thickness and density of their clouds.Moreover, users sometimes preferred different levels of nicotine delivery and thus, switched between different types of coils with various wattage ranges, such as smaller coils with higher resistance for salt nicotine and bigger coils with lower resistance for regular or freebase nicotine. Similarly, altering the number of wire wraps, wire gauge, and wire materials results in different wattage ranges of coils, which affects the flavor and tastes of e-liquids. Jacob said, “Coils were so bad previously. They were fine, but the flavor wasn’t there. You had limited (control) over the cloud production, how much power you could push through the coil without burning the coil. So most of the people that got into building their own devices got into there so they can do higher wattage, lower nicotine, bigger cloud”. In addition, a couple of participants modified coils to experience stronger or weaker throat hits, or different sensory perceptions. Anthony explained, “If you want a smoother hit, you want to go something closer to a mesh coil, which has mesh fibers on the inside so it’s better airflow and it’s a smoother hit, rather than the T12 or the T10, which has higher wattage coils, which is a stronger hit, higher wattage”. Finally, Josh commented that some hobbyists built their own coils for aesthetical reasons, called “coil art”.More than half of the participants mentioned that they switched between different types of cotton wicks to identify the right choice. Three categories were discussed, including regular cotton, organic cotton, and Japanese cotton. The regular cotton refers to cotton materials purchased in regular stores that are not intended for vaping. Several participants expressed that regular cotton is often bleached and contains harmful chemicals, which makes the products unsafe and affects the tastes of e-liquids. Organic cotton is unbleached cotton designed for vaping. Charlotte pointed out a specific product named “cotton bacon” that is often in strips, offers faster e-liquid absorption, and has higher heat resistance. The last category is Japanese cotton, which is often pad-shaped, produced in Japan, and originally used for skincare purposes. Anthony believed that Japanese cotton has the finest quality and lasts longer than other cotton wicks. He also said, “If you had regular cotton where you’re buying from the store, it wasn’t organic, you would blow the cotton and that was to get the chemicals off of the cotton before you would put it in your mod”. Thus, users mainly modified their cotton wicks for safety, taste, and quality reasons.All but one participant mentioned modifying batteries in their ENDS devices. Several practices were commonly stated, including replacing an old battery with a new battery of the same type, upgrading from internal to external batteries, switching smaller mods with bigger ones, and installing specific batteries into devices that were not designed for those types of batteries.Batteries can become worn out and malfunction as they age. Thus, for safety concerns, many users replaced the worn batteries with new ones. Alex said, “There have been rumors that vapes are expanding and exploding because of a battery malfunction, so if your battery is nice and clean like this, then it’s safe to go… If it’s torn, no matter if it’s torn by the littlest bit, I will just get a whole new battery itself”. In addition, users sometimes upgraded their old batteries to the same type of products with better quality. Jack explained that as lower-end batteries are running low, the throat hits become weaker. Therefore, some users upgraded to higher-end batteries that last longer and keep the throat hits consistent even when the batteries are low. Some interviewees stated that ENDS users sometimes switched an internal battery with an external battery or upgraded from a smaller mod to a larger mod. Internal batteries often have lower wattage outputs and heat coils more slowly than external batteries. Bigger mods hold a larger number of batteries and are compatible with stronger batteries. Thus, users who wanted to produce larger clouds and experience stronger throat hits would change their batteries and mods to increase the devices’ wattage outputs. Caleb, a vape shop worker, said, “A lot of people that come in here and upgrade from an internal battery to an external battery, just for the bigger cloud, the harder hit… Once you don’t get the wattage that you like, you grab the bigger mod, you have ‘Big Beast’ now, you put batteries in, you’re going to get that huge cloud that you were trying to look for”.Another common practice of battery modification is to install a battery in a device that was not designed for that battery. Participants expressed that sometimes they preferred a lower wattage output, below the designed wattage ranges of their devices. In those cases, they needed to install lower power batteries; yet, the battery sizes usually did not fit the devices, requiring them to put in “battery adapters”. Anthony described, “Pretty much that mod specifically is made to where it takes 2700 batteries. If I wanted to put an 18650 battery in there which is less power, I would have to do a build for that to pretty much feed that. And at the same time, 18650 wouldn’t fit into this bigger mod since it was made for 2700s. They have little adapters and little smaller pieces you would be able to say, ‘Okay, I want to put my battery in a sleeve and put it in my mod’, then it would work”.About half of the participants mentioned modifications to chipsets. Similar to those in computer systems, chipsets in ENDS devices include a set of electronic components that automate the process of charging and modifying the amount of power that the devices provide. Interviewees explained that chipsets are usually considered “higher-end” and provide an enhanced experience by allowing for automatic preheating, temperature control, and wattage control. The most commonly discussed modification was to change chipsets in order to alter the heating functions of the devices. Jacob mentioned that he replaced a chipset that offered only one wattage output with a new chipset that automatically increased wattage outputs as the device heated up. Adding manufactured chipsets to their own devices was also mentioned, but participants underlined that those modifications were often performed on devices not intended to be modified. Josh said, “I don’t think some manufacturers intend on having their devices altered, whether it’s dismantling the device and then people put in different chipsets. But there are a lot of people who actually try to build their own device. They take companies-like (manufactured) chipsets and they put it into a piece of wood, and they carve it out and build their own devices”.More than half of the participants mentioned modifications to e-liquids. Three practices were commonly discussed, including refilling closed pods that are not meant by the manufacturer to be refilled, changing e-liquids with different flavors or nicotine levels, and producing their own by mixing different e-liquids or other substances. First, many users bought pre-made e-liquids to refill their closed pods. Reasons often mentioned were to lower the cost and increase control over the products they use. Participants also suggested that certain closed pods were easy to open, which encouraged them to refill the pods. Kayla said, “I can just use my fingertips and open up the device very easily. It’s very easy to do. And with JUUL, I usually use a tool to open this bottom part and add the juice. I’m mostly doing it so I can have better control on what product I use, and I can save the money. It’s a lot cheaper to buy a bottle of juice than buy separate pods”.Another popular practice was to change different types of e-liquids. Participants mentioned that there are a lot of e-liquid options, which contain different flavors and various nicotine levels. Users often chose different flavors based on their personal tastes. Certain flavors that were perceived as better for ENDS devices and users’ health were also likely to be filled. Emily said, “We have some of the popular flavors that a majority of people will like, especially some of the juices that are less harsh on coils. And they’re made with all-natural flavorings. People tend to like that aspect of it, because they know they’re not getting a random chemical that tastes like this. It’s the actual fruit”. ENDS consumers also switch between different types of e-liquids so that they can control the amount of nicotine they vape and the throat hits. One product frequently mentioned was salt nicotine e-liquid. Compared to traditional e-liquids, salt nicotine e-liquids allow users to vape higher nicotine strengths while experiencing a less harsh throat hit . Due to Creating one’s own e-liquids was also commonly mentioned. Some users mixed different manufactured products to create the unique e-liquids they liked. Noah, for instance, mentioned that he mixed a watermelon-flavored e-liquid with a salt nicotine product, so that he can enjoy the high nicotine and the fruit flavor. In addition, some users added other substances in their e-liquids such as cannabidiol (CBD) and THC or marijuana. Participants mentioned that although there were no devices specifically designed for vaping CBD or THC, users had used “cartridge devices” or “dab pens” to vape those substances. The devices resemble a small pen with a cartridge at the top and a battery at the bottom. Users can take the top off and refill the cartridge with any type of e-liquids or install another cartridge that contains CBD or THC in it. Charlotte said, “I have CBD products that you would put into any of these devices, but specifically for a device made for that, no”. Jack mentioned, “There are some batteries which are cartridge devices, where people can put liquids which have THC in it, or, as you probably know, dab pens. These devices were not manufactured for that use, but a lot of people have used it in that sort of aspect”.According to the interviewees, the major reason that they add CBD to their e-liquid is for medical purposes as CBD helps reduce their pain from physical conditions. Beth stated, “I use CBD because I have rheumatoid arthritis. So instead of taking all the medicine, I use the CBD oils every day to control my flare-ups with rheumatoid”. Other participants mentioned that they vaped to quit smoking, and CBD helped them overcome negative reactions to medical treatment. Charlotte said, “I got diagnosed with breast cancer, and I was a smoker. I knew I was going to have withdraws  from the nicotine. So I came and talked to the guys here, who are the guys that manage the store, and started vaping, and went to my chemo and started adding CBD on a regular basis to help me with the nausea, the vomiting, the being able to eat”.A change in the popularity of ENDS modifications emerged from the interviews. Specifically, participants underlined that ENDS modifications, especially modifications to coils and batteries, were more widespread a couple years ago, but today, a smaller proportion of users engaged in modifications. Jacob said, “Two or three years ago, even four years ago, the only option you had to run high wattage was to build your own course. That has changed. Not many people do any modifications. There is a small hobby group, but I mean small hobby group compared to the average person”. Alex also stated, “There’s still a market. There’re still people going to cloud competitions … but it’s very small niche now compared to where it was two years ago”.Participants attributed the decline in ENDS modifications to the evolution of manufactured devices. As Emily mentioned, “The products that have the pre-made coils, which is the main thing you would modify in a device like that, have gotten so much better, that there’s really not a need to do that”. Similarly, Jacob said, “You don’t get a lot of edge out of building your own coils like you used to. Coils were so bad previously… now if it’s not a hobby, you’re not going to do it”. Moreover, Charlotte applauded her current device, “It’s rubberized. It’s waterproof. I mean they come up in style and you’re not going to break it”. Jack liked the small size of his JUUL, “So you can take one of those little devices and put it in your pocket and carry it easier… So the smaller the device, the easier it is to conceal and the easier it is to carry”.Those examples demonstrated that instead of merely updating their products, the industry has actively developed new products and modified their designs so that they can fit and foster users’ various needs. Emily highlighted, “And they really revolutionized a lot of products on the market. And their products have always been really great products. Stand up to the test of time. They’re durable. … If there’s a need in the vaping market, they’ll try to find a product, or make a product to fit that need”. Ultimately, Jacob felt that “Yeah, you could ride a horse everywhere, but if you’ve got a car, you’re probably just going to drive”. In other words, while users’ ENDS modifications were still prevalent, industry-led modifications have increasingly dominated the market, making users’ modifications to coils and batteries less necessary.Given the growing concerns about health effects of ENDS ,7,8 and A novel finding is that the prevalence of ENDS modifications might have peaked a couple of years ago. Participants mentioned that reliable, durable, and powerful devices had been largely absent from the market and to achieve higher power, a specific coil build, or a desired cloud density, users had to modify or build their own devices. However, over the last several years, manufacturers have caught up to the needs of the market, and instead of improving a device or building one from scratch, users can now buy premade products that meet their specific needs. In addition, JUUL and other pod-based ENDS have gained popularity in recent years. While users previously had to resort to artisanal ways to increase the nicotine delivery, such as by increasing the power of their devices or modifying the coil, salt nicotine pods afforded quick, convenient, and strong nicotine delivery, removing the need for user modifications. Notably, while average users may be less likely to alter their devices, those who do modify ENDS tend to be hobbyists and their modifications could be more extreme, resulting in higher health risks and more potential dangers.The findings also revealed users’ modifications to e-liquids, which directly affect the tastes, flavors, and nicotine levels that users experience. Despite the view that fewer average consumers modify coils and batteries, many participants pointed out that modifications of e-liquids, such as mixing different e-liquids and adding substances to the e-liquids, is widespread among users. Notably, although participants attributed the use of CBD to medical reasons, they rarely explicitly explained the use of THC but suggested that adding THC was mostly for recreational purposes. In addition, interviewees also acknowledged that there were no devices specifically designed and manufactured for vaping CBD and THC, raising the safety concerns of using those products.As of September 2019, New York and Michigan have banned the sale of flavored ENDS. On 2 January 2020, the FDA issued final guidance that indicated their highest enforcement priority was against any “flavored, cartridge-based ENDS product (other than tobacco- or menthol-flavored ENDS product)”. This policy indicates that they intend to “clear the shelves” of non-tobacco flavored ENDS, but will consider, as applications are made to FDA, whether these products are appropriate for the protection of public health and thus, meet the standard for marketing as new tobacco products.The results from our study have indicated that this group of ENDS enthusiasts has made a wide range of modifications to ENDS in order to achieve desired nicotine and flavor delivery and enable the generation of noticeable aerosol clouds. However, because manufacturers are providing products that meet the desired characteristics, participants indicated that the interest in consumer modification of products has waned compared to only a few years ago. FDA enforcement actions to remove manufactured ENDS with certain characteristics from the market could reinvigorate the enthusiasm for consumer modification. The FDA needs to carefully consider how to minimize the unintended consequences of its regulatory actions that shrink product variety or remove products with specific characteristics. Otherwise, consumer modifications could increase, and additional outbreaks may become increasingly more common as consumer modification resurges.The qualitative nature of the study limits the generalizability of the findings. Future quantitative research should examine the health and social impacts of ENDS modifications at the population level. We only examined the views of how and why ENDS users modify their devices among a limited group of ENDS enthusiasts. Other aspects of ENDS modifications, such as information sources, users’ perceptions of ENDS modifications, and whether those modifications actually met the needs of ENDS enthusiasts, remain underexplored and should be addressed by future research. Only three participants were young adults (18–24 years). As ENDS use may damage teens’ and young adults’ brain development and result in other health harms , more stAmong this group of enthusiasts, users’ modifications to ENDS focus on operational characteristics of the devices and e-liquids. They indicated that because the industry has constantly updated and developed new products to satisfy consumers’ needs, a smaller number of users seem to be altering their coils, batteries, and other operational features of ENDS in recent years. Yet, those who continue to modify their devices tend to be hobbyists, who perform more risky modifications, and users continue to misuse or abuse e-liquids. FDA should be aware of users’ modifications to ENDS as they consider related regulatory decisions and assess the resulting population health impact.


The explanation of epidural analgesia by anesthesiologist would often begin after the parturient is admitted to the hospital. Because of labor pain, the decision of receiving epidural analgesia would often be made by the family members, instead of the parturient herself. We aimed to test whether earlier prenatal shared decision-making (SDM) interventions increase parturient’s comprehension and satisfaction of epidural labor analgesia, compared to conventional explanation after labor pain begun.During the 28th week of gestation, we provided the SDM parturient health education as well as a leaflet with quick response codes. Scanning the code would link to education videoclips which explained what epidural analgesia is and its advantages and disadvantages. Original routine practice group parturients received explanation of analgesia after admission for delivery. To measure the satisfaction of labor pain service, the accessibility of information, and the communication with medical staff, we designed a questionnaire with reference to (1) Pregnancy and Maternity Care Patients’ Experiences Questionnaire (PreMaPEQ), (2) Preterm Birth Experience and Satisfaction Scale (P-BESS), and (3) Women’s Views of Birth Labor Satisfaction Questionnaire (WOMBLSQ). The questionnaire was amended after a pretest involving 30 parturients who had received epidural analgesia. Scree test analysis and exploratory factor analysis were performed; then, the questionnaire was revised again. A total of 200 valid questionnaires were collected—100 each from the original routine practice group and the SDM group.p < 0.001) and “The effect of epidural is just as what I have expected”  was demonstrated.The SDM group reported significantly higher satisfaction with and understanding of epidural analgesia, and a significantly higher satisfaction with the information received, and the quality of pain relief. After SDM intervention, significant increasement of the average satisfaction scores in question “my epidural is effective” . Labor pain is very stressful for many birthing mothers. Conventionally, the anesthesiologist explains the benefits and risks of epidural labor analgesia on maternal request when the parturient has admitted to the hospital for delivery and mostly labor pain has begun. Because distraction by labor pain, the decision of receiving epidural analgesia would often be made by the family member, such as her husband, instead of the parturient herself. On the other hand, although most of the parturients have good decision-making ability before the distraction of labor pain, she might not receive insufficient professional information provided by anesthesiologists. We hypothesized that the parturient would capture sufficient information about the options of epidural analgesia and would have higher satisfaction of pain service, if adequate education and discussion provided prenatally before her labor begins.In order to improve the quality of medical care, this study aimed to compare the satisfaction of and the level of comprehension in epidural analgesia between parturients that received the original routine practice  and those that received prenatal shared decision-making (SDM) –3 princiThis present “before and after” designed questionnaire study was conducted during June 14, 2018 to December 25, 2018, after the approval of the Chi Mei Medical Center Institutional Review Board (IRB: 10705–010).We included parturient aged ≧20 years and had used epidural analgesia during the natural birth process, and can read Chinese or communicate in Mandarin or Taiwanese.Women comorbid with mental, emotional, or psychological disorders, regardless of whether they are receiving psychiatric medication, were excluded from our study. We also excluded those women with a history of drug addiction or drug dependence of analgesics, for example, had a history of using morphine daily for more than 30 mg of oral morphine equivalent for more than 6 weeks, from our study. Women who are in the intensive care unit after delivery were also excluded.Because we did not find any ideal and validated questionnaires in Chinese to calculate the differences in satisfaction and comprehension , we therThe second step was modifying the adapted questions to fit specifically to epidural analgesia scenario  software  to perform Scree test analysis. The turning point of the Scree test corresponded to five categories, that is, the questionnaire could be simplified into five categories, and the characteristics of the questionnaire could still be maintained. Each category contained at least 3 questions and should load significantly to ensure all of the subscales to be successfully identified . Although, SDM parturients scored higher to questions about the understanding of the possibilities of “temporarily low blood pressure”, “having trouble urinating”, and “not able to walk due to leg numbness”; however, not reaching a statistical significance in MD.Table The scoring of questions related to satisfaction of information providing, such as” I received sufficient information about options for pain relief”,” before labor course started” and “stay at the labor room”, were all higher in SDM groups. Table .p = 0.007).As to the question related to decision talk,” the information given by whom give me epidural”, it showed significant higher scores in SDM groups  and” sufficient pain relief during delivery” . The scoring of questions about the expectation and reality of labor analgesia, for example, the question” my epidural analgesia is effective” , and question” epidural is just as what I have expected” , showed a lower expectation gap in SDM group than that of the original group.In addition, SMD group parturients all gave significant higher scores to these questions related to the expectation of epidural analgesia, including “excellent pain relief during labor” , and “I was treated politely and with respect “, indicating higher satisfaction score for SDM group about the service in the labor room and the delivery room.As the question” I was well taken care of by the staffs, there is no need for improvement”  and “The effect of epidural is just as what I have expected” (increasement 10.41%).To the best of our knowledge, this is the first prenatal SDM concept-applying research in parturients for improving the comprehension and satisfaction of epidural analgesia. We found the benefit of setting an earlier epidural analgesia education protocol before labor pain is in progress. Thus, parturient may have enough time to discuss with her family and anesthesiologist about the individual concern before making the final decision of receiving epidural analgesia or not. These earlier education and communication will eventually increase the satisfaction of labor analgesic service and promote the harmony between parturients and health care-givers.Several studies reported that parturient having epidural analgesia does not often receives enough information before the procedure was conducted –18. SincThe benefits of using a video-assisted education is as follows: 1. The film can describe the procedure steps in details . 2. UsinIn today’s medical settings, most parturients have a feeling of lacking some information if the doctors only communicate by words , 26. Lit“The effect of epidural is just as what I have expected” showed significant higher score in SDM group than original, might provide some evidence for prenatal SDM reducing the fear of the unknown. Base on the above, health education film is a better way of accessing information than traditional face-to-face interviews alone.According to previous research, the use of video has been proven to reduce anxiety before general anesthesia . They usAs far as intervention is concerned, everyone should know the course and risk of any procedure . An IrisKnowing the procedure well including understanding possible complications, as part of a medical treatment , 30, mayLabor pain is subjective so it is different from person to person. However, it is important to let pregnant women know how effective the epidural analgesia will be. After prenatal education, parturient will understand that a heavy dose of epidural analgesia could ease the pain but would also weaken the muscle of the lower part of body, such as the pelvic muscle, which might delay the labor process . AlthougWe also notice a higher pain tolerance in SDM group than original. Our question such as” I received sufficient pain relief during delivery” and” I received excellent pain relief during labor” showed some evidence that the smaller the gap between expectation and reality is, the higher pain tolerance she would have .p = 0.008) (Table Moreover, the rate of C/S after receiving labor epidural analgesia was significant lower in the SDM group (original: SDM: 28%: 14%, Previous study showed once parturients are admitted, “maternal participation in anesthesia decision” is an important key to satisfaction . AccordiSDM group showed satisfaction score not only improved towered the anesthesiologist who perform epidural injection but also the overall impression on the delivery room. For example, SDM group had higher score in the question of “I am satisfied with my experience in the labor room and the delivery room”, “I was well taken care of by the staffs in the labor room and the delivery room, there is no need for improvement”, and “I was treated politely and with respect by the healthcare personnel in the labor room and the delivery room”.This study has several limitations. First, some of the laboring mothers, who have had prenatal SDM education, but eventually did not have epidural labor analgesia, were excluded from the study. Although, they might answer those questions about SDM talks very well. This questionnaire contains questions about satisfaction of the labor analgesia, which these parturients cannot answer. Second, the C/S rate was significant higher in original group than that in SDM group. One of the possible explanations is that SDM parturient did not had an overly-high expectation of the analgesic effect, therefore, did not request a C/S so frequent as original group, instead of C/S by clinical indication. However, this speculation cannot be confirmed, because we did not record of the reason of C/S. Third, since this is a single hospital study, and popularization of higher education in Taiwan, our results might not be generalized to other developing or under-developing countries.Prenatal sharing decision-making interventions supported by online educational video may contribute to maternal understanding and satisfaction with epidural labor analgesia services. We recommend that further studies be conducted in more countries, especially those that higher level of education not so popularized, for confirming whether earlier SDM intervention before labor promotes maternal understanding and satisfaction with epidural analgesia.Additional file 1. The references of our questions. Questions in our study and where it adapted from.Additional file 2. The Version 1 questionnaire. This is the pre-testing questionnaire administered to the parturients, and the English version is only translated for the publication of this research.Additional file 3. Exploratory factor analysis results. Exploratory factor analysis results of all the version 1 questionnaire questions after pre-testing.Additional file 4. The Version 2 questionnaire. This is the English version of Version 2 questionnaire, whose categories were based on the above-methodology chapter-mentioned statistical method.Additional file 5. Exploratory factor analysis results. Exploratory factor analysis results of all the version 3 questionnaire questions after pre-testing.Additional file 6. The raw data. The raw data of the 200 file-questionnaires.


Infidelity and romantic jealousy (RJ) are commonly cited relational level drivers of intimate partner violence (IPV) but remain undertheorized and underutilized in IPV research and prevention. This global systematic review aims to characterize the existing research on real or suspected infidelity and RJ in relation to IPV and inform future research and programming. We systematically searched 11 databases for peer-reviewed research, published between April 2009 and 2019, that provided data on the prevalence or a measure of association (quantitative), or pathway , between real or suspected infidelity or RJ, and IPV. Fifty-one papers from 28 countries were included and the evidence showed a consistent association between real or suspected infidelity, RJ and IPV. Our findings identify three overarching mechanisms and six pathways between infidelity, RJ and IPV. These provide support for prominent theories in the field related to patriarchal culture, threatened masculinities and femininities and a lack of emotional regulation and conflict resolution skills, but not evolutionary theories. Our findings suggest that researchers should use standardized measurement tools that make the distinction between RJ and suspected, confirmed and accusations of infidelity. Policy and programming should aim to transform traditional gender roles, accounting for infidelity and RJ and improving couple’s communication and trust. Globally, an estimated one-fourth of women are expected to experience a form of intimate partner violence (IPV) in their lifetime . IPV canThe World Health Organization (WHO)  identifiInfidelity is defined as “(the act of) having sex with someone who is not your husband, wife, or regular sexual partner” . A partnThe ecological framework for understanding violence against women conceptualizes IPV as originating at the individual, relational, community and structural levels, and it is essential to tackle drivers at all of these levels to successfully reduce IPV ,11,12,13Findings from a recent systematic review on RJ in relationships, and studies on women’s experiences of IPV, indicate strong evidence of association between male RJ and physical, psychological and sexual male-to-female IPV (referred to as IPV here-on-out unless otherwise specified) ,16,17. BThe relevance of relational level drivers is also highlighted in interventions that have been successful in reducing IPV. Interventions in Ecuador and Uganda for example, specifically found that decreasing men’s suspicion of partner infidelity played a major role in their success ,24. SociDespite these findings, there has been limited research conducted on infidelity, RJ and IPV. The aim of this review is to characterize and synthesize the existing literature, elucidating the frequency with which infidelity and RJ are cited as triggers for IPV across different regions, how widespread the association between them is, and the mechanisms and pathways of infidelity and RJ leading to IPV. Ultimately, this review expands the knowledge base on relational level drivers of IPV, identifying gaps in the literature and recommendations for programming and research.We systematically searched 11 medical and social sciences databases , CENTRAL , CINAHL , Embase (Excerpta Medica Database), IBSS , Medline , PsycINFO , Social Policy and Practice, Social Services Abstracts, Sociological Abstracts and Web of Science) with key search terms related to IPV adapted from Cochrane protocols ,29, and To be eligible for inclusion, studies had to: (1) provide data on prevalence or measure of association (quantitative), or pathway , between infidelity or RJ in male-to-female IPV, (2) focus on adults 18 years and older (studies that sampled adolescents and adults were only included if they provide disaggregated data on adults 18 years and older) and (3) include participants in any kind of current, heterosexual partnership , and provide disaggregated results for them.Studies were excluded if they: (1) did not base their findings on empirical research  or were case studies or grey literature, (2) sampled university students or people with diagnosed medical conditions , (3) measured predicted or feared IPV, or infidelity or RJ as part of a bigger variable and did not report disaggregated findings for them or (4) used proxy’s for infidelity or RJ such as “women who have a child by another man” see .Following PRISMA  guidelines  we firstAuthors MP, STK, HS and AMB extracted data from quantitative studies using a customized excel spreadsheet that included: sample characteristics, study design, measures of infidelity or RJ and IPV used, findings of prevalence and association and explanations provided by authors of their results. Authors dual-extracted 30% of papers to ensure consistency. Findings of prevalence and association were organized by region and compared, and explanations provided by authors of their results were thematically analysed.MP, Erin Stern (ES), NK and AMB coded and analysed qualitative studies using a deductive and inductive approach supported by NVivo 12. MP first created a coding framework based on the preliminary coding of 15 data-rich papers. All authors then independently coded the same paper and discussed findings, refining the coding framework before independently coding the remaining included papers. MP then reviewed all coding and standardized discrepancies.Quantitative studies were quality appraised using criteria adapted from a validated tool  and the n = 14), Turkey (n = 4), India (n = 3) and South Africa (n = 3). Most participants were married or living with a long-term partner. Physical IPV was the most common form of IPV studied in relation to infidelity or RJ, while economic IPV was the least common.A total of 51 papers met our inclusion criteria. These papers were derived from 50 studies, 25 of which used quantitative methods and 25 of which used qualitative methods. They included evidence from 28 countries, covering all world regions; the most well represented were the USA (n = 10) and Europe and Central Asia (n = 4), and almost all studies were cross-sectional in design (n = 22) and used random or convenience sampling  and 17 low-quality studies (one or two stars). The main reasons studies received low scores were because they were not representative of the population, the missing data policy was not described or the missing data were excluded without a sensitivity analysis being conducted, or a non-response bias assessment was not described (see ling see .n = 8) including the negotiation subscale of the revised Conflict Tactic Scale (CTS2)  behaviors while drinking. This suspicion frequently resulted in the husband physically or verbally abusing them. The women said that their husbands often assumed such questions reflected the wife’s own infidelity, which further angered the husbands” (p. 818)Reports of bidirectional IPV  triggered by infidelity or RJ also emerged ,100,102.Participants noted that when men drank alcohol and used drugs, women became more suspicious of infidelity, and men became more violent, leading to increased IPV ,102,103,In the USA there was also evidence of women using accusations of infidelity and homosexuality to threaten their partners’ heteronormativity and attainment of hegemonic masculinities, leading to IPV. As a man said:“That’s what really made me snap when you said, ‘go fuck [male friend], go fuck [male friend], go back to your boyfriend…” That really hurt my whole manhood, my dignity, my pride, my everything” (p. 945)Findings of bidirectional IPV came primarily from the USA and Europe—contexts with more equal gender dynamics, and where women are less likely economically dependent on their partners—which may partially explain higher rates of bidirectional violence ,95,102.These findings about bidirectional IPV triangulate quantitative results that the association between mutual RJ and IPV is greater among reciprocally violent couples. It also provides some support for the explanation put forth by authors of the included quantitative studies citing a “lack of emotional regulation and conflict resolution skills” among intimate partners as the reason for the association between infidelity, RJ and IPV, which also arose primarily from those studying populations in the USA. Additional support for this theory emerged from quantitative findings that intimate partner femicides committed with excessive injury were more common when RJ was the motive.Pathway 3.Men who anticipate partner infidelity use controlling behaviours and economic IPV.A widespread finding was that men often used controlling behaviours to limit woman’s autonomy and prevent infidelity. Participants reported that men controlled their partners by destroying their property , monitor“This man used to keep his wife inside the house, when he goes to work, he locks the door and sweeps the garden neatly, so that [he will know] if someone comes to the house [because] they will leave foot prints [in the sand]” (p. 7).Underlying these behaviours—according to participants—were men’s fear of losing their partner, a lack of trust in their partner and a perception that women were easily persuaded into infidelity ,96,101. “As you know women admire a lot and so at work is where she might find someone to admire her and then change her mind into cheating”  (p. 5)Evidence of economic IPV also emerged, where women who were repeatedly accused of infidelity reported their husbands threatened to “chase them” from home ,98. A wo“He directly came to the school principal and raised negative speculations [accused her of infidelity] that ruined my reputation. He said, “if something bad happened in the future at this school, don’t blame me as I’ve already warned you about her.” So the next day the principal called me and cancelled my promotion for the master program”  (p. 6)This example highlights how the social stigma associated with female infidelity in a patriarchal context gave men and institutions power and leverage over women; they could use accusations of infidelity to justify IPV, and had the ability to leave them destitute, or to hinder their ability to get an education and join the workforce.Studies from developing countries found that as countries modernized, and gender norms shifted—with women becoming more empowered—these triggers could be exacerbated ,92,94,98In a study conducted in Nicaragua, male and female participants reported that when control was exerted in the name of RJ, it was often interpreted as an expression of love and the behaviour was tolerated . As a ma“If I’m not interested in her, I don’t care what she does. If she goes out with some person, she can do what she wants with her life. But if I had feelings for her, it will affect [hurt] me” (p. 627)It was not always clear, however, to what extent and in which contexts controlling behaviours were used because of a real anticipation of infidelity, or as an excuse to maintain hegemonic masculinities (Mechanism A). In the post-war context of Sri Lanka, for example, a study found that increases in female employment coincided with decreases in men’s employment opportunities, leading to shifting power dynamics, and tensions in the relationship. Men who had been replaced by their wives as the main provider for the family tried to reassert control through monitoring their wife’s movements and through physical violence .Pathway 4.Women experience accusations of infidelity as a form of psychological IPV.Accusations of infidelity reportedly caused female participants great emotional distress ,98,102. Sometimes triggers such as HIV or pregnancy—in which paternity doubts triggered male RJ—were found to precipitate accusations of infidelity experienced as psychological IPV ,100. For“Lots of swearing at me, abusing me, saying that the child was not his… After we had the child it became worse… So all the agony began, the bad relationship, him complaining about everything, saying that I should’ve taken care of myself (the pregnancy) [had an abortion]” In these examples it is unclear how much the accusations of infidelity were spurred by a real suspicion of infidelity or actual infidelity (Pathway 1), versus as an intention to hurt the recipient.Pathway 5.Women who anticipate partner infidelity and male suspicion of their own infidelity experience sexual coercion.A gendered double standard around infidelity emerged. In some studies male infidelity was seen as “normalized” and something that “has to be” ,91, whilStudies found that both men ,91 and wRelatedly, we found that men sometimes believed that when women did not want to have sex, it was a sign that they had been unfaithful ,91,103. In India and Nicaragua women reported fear that if they did not have sex with their husband, then he would seek sex with other women, so they engaged in sex even when they did not want to ,84,103. “My sister-in-law and my mother also told me that men go to other women when his wife did not satisfy him [sexually]. So when he wants to do [have sex] I make myself ready” (p. 132)Some women blamed themselves for their partner’s infidelity ,81,84, d“I felt dishonored when others knew my husband had engaged in an affair with another woman. Some friends looked down on me and said I could not control my husband. It looked like I could not complete the roles of a wife… some gossiped and told me… I might have something wrong with me so he couldn’t stand me... It is my karma in my past life that made me live with my husband in this life” (p. 352)This quote exemplifies the stigma and discrimination many women faced because of their partner’s infidelity due to patriarchal beliefs about male entitlement to sex, and the hopeless tone women took when discussing it.Pathway 6.Women who suspect male infidelity are unable to negotiate condom use.Having sex without a condom was seen as a sign of love and trust in some studies ,91, and In studies from India and Puerto Rico women reported that they had no power to negotiate condom use in their relationships, but underlying this lack of control was an inability to voice their suspicions of infidelity for fear of physical violence (Pathway 2) ,103. EviOther studies found that women who did report asking their partners to use condoms were met with refusal ,84, mockThis is the first review—to our knowledge—that systematically examines the evidence on the association between real or suspected infidelity and RJ, and IPV against women. Across quantitative and qualitative studies conducted in all regions, we found that real or suspected infidelity and RJ were strongly related to IPV, which merits significant investment in the field of IPV prevention. Three mechanisms emerged from the data: (1) hegemonic masculinities, which when threatened can lead to physical and psychological violence; (2) hegemonic femininities, which are a powerful tool for controlling behaviours and inflicting economic and psychological IPV and 3) patriarchal beliefs about infidelity and sex, which can be used to justify sexual IPV; making up a total of six pathways see . The pathways describe how both male and female suspected infidelity and anticipated infidelity, as well as anticipated partner suspicions of female infidelity and accusations of female infidelity, can all lead to different forms of IPV against women. Notably, we found evidence that women experience the pathways in an iterative way—moving fluidly within and between them—which is important when considering how they represent lived experiences of IPV. These pathways provide an unprecedented opportunity to unpack the association between infidelity, RJ and IPV, with important implications and applications for programming and research. Additionally, we found a lack of communication skills, economic control and dependency, and alcohol interacted with these pathways to increase risk of IPV. Finally, our study results highlight several gaps in the literature base, including the need to increase internal and external validity of quantitative studies, and transferability of qualitative findings.Our synthesis of the literature provides critical evidence for the theories underpinning research on infidelity, RJ and IPV. The “patriarchal culture” and “threatened masculinities” explanations put forth by authors of included quantitative studies were strongly supported by our identified mechanisms and pathways derived from qualitative studies, while the “lack of emotional regulation and conflict resolution skills” explanation received some support in the context of bidirectional IPV in the USA and Europe see . We did The patriarchal context is responsible for the creation of hegemonic masculinities and femininities , and we We also found that these patriarchal norms, along with beliefs that men are entitled to sex and it is a women’s role to fulfil those sexual desires, acted as mechanisms for sexual violence (Mechanism C). Additionally, condom use appeared to be inconsistent with ideas of fidelity, “real love” and trust in intimate relationships, an observation that is well documented in the literature . FinallThere has been heavy investment in the field testing strategies to target structural patriarchal norms and institutions ,113, andMissing from much of this work, are couples-based interventions, an understudied component of IPV-related work. While couples-based work has demonstrated success for HIV-prevention and treatment programming , this haQualitative work conducted in rural South Africa in the context of gender-transformative programming, not designed for couples, found that for many participants who wanted to enact more gender equitable and non-violent behaviours, it was difficult to consistently act upon those new values, especially for those with a previous history of either experiencing or perpetrating violence . As the Female economic empowerment has been an increasingly popular IPV prevention strategy too, as economic dependence has been identified as a major risk factor for all types of IPV . Our resPrograms and policies aimed at increasing women’s economic independence and empowerment must reckon with the deep interplay between economics and gender norms. Cash transfer projects have shown success across settings in reducing IPV ; with quOur review highlights important gaps in the literature. Women were disproportionately sampled, with little evidence available on men’s experiences of RJ and real or suspected partner infidelity leading to IPV, and this should be explored further. Additionally, few included studies measured economic IPV, although this was an important qualitative theme, and economic IPV has been found to have an independent negative effect on women’s health, beyond other types of IPV . FurtherThe available evidence documented in the review suggests substantial variation in the frequency with which RJ or infidelity was cited as a reason for IPV. This may be due in part to differing cultural attitudes towards RJ and infidelity , and IPVHeterogeneity of measurement outcomes and tools may also provide an explanation for the wide range of quantitative findings reported. Only approximately one-third of reviewed studies used a validated questionnaire or scale to measure infidelity or RJ. Historically, RJ has been subsumed into bigger psychological aggression variables—such as in the multidimensional measure of emotional abuse restrictive engulfment subscale , which wOur findings also support distinctly measuring accusations of infidelity, anticipated infidelity, suspicions of infidelity, confirmed infidelity and RJ, as they lead to IPV along differing pathways. Accusations of infidelity can be experienced as psychological IPV, but these accusations do not always stem from RJ, and they may sometimes be used intentionally to hurt their partner, or as a mechanism to justify controlling behaviours and violence. We also found that infidelity and RJ are often distinct from IPV and precede it on a pathway to violence. Measures of infidelity should be precise, and clearly indicate which partner has been unfaithful and the degree of the respondent’s certainty, as these can operate along different pathways to violence.Our review was limited to studies published within the last 10 years, the aim of which was to yield recent findings relevant to ongoing and future research and prevention efforts. With the intent of only including rigorously evaluated studies, we also limited our search to peer-reviewed publications. We did not conduct a forward or backward reference search of our included studies given the large number of studies included and the strong search strategy implemented. However, a particular strength of this study is our inclusion of quantitative and qualitative data, which allowed us to make meaningful programming and research recommendations. We also followed methods used in previous peer-reviewed publications to ensure analytical rigor by only reporting on trends supported by abundant evidence that emerged across multiple studies  and drawTo our knowledge, this review is the first to comprehensively analyse the peer-reviewed evidence from the past 10-years on infidelity, RJ and IPV, making an important contribution to the field. Our results highlight opportunities to improve research and IPV prevention efforts, in particular around the relational level of the ecological model, which has been historically understudied.Fifty-one papers from 28 countries were included in our review and the evidence showed a consistent association between real or suspected infidelity or RJ and IPV against women. Three mechanisms—with two pathways within each mechanism—emerged from the data, for a total of six pathways that further elucidate this association see . As outl


Since 2015, pharmacists have been integrating into English general practices and more recently into primary care networks. General practice-based pharmacists provide a range of patient-facing services, such as medication reviews, management of long-term conditions and minor ailments, prescribing duties and answering queries over the telephone. Literature reports patients’ satisfaction with general practice-based pharmacists’ services, however, previous research captured only limited experiences. The aim of the current study was to pursue an extensive exploration of patients’ experiences of pharmacists in general practice.General practice-based pharmacists, working in practices in West London, Surrey and Berkshire, handed invitation packs to patients seen during consultations. Patients that wanted to take part in the study were invited to undertake a qualitative, in-depth, face-to-face, semi-structured interview within the practice with which each patient was registered. Interviews lasted from 15 min to more than 1 h and were audio-recorded. Recruitment continued until data saturation. Audio-recordings were transcribed verbatim and transcripts analysed thematically.Twenty participants were interviewed. Four themes were discerned: awareness (“I had been coming to this practice for 24 years and I didn’t know that there was a pharmacist”); accessibility ; interactions ; and feedback .Findings indicate that pharmacists’ integration into general practices could improve accessibility to, and the quality of, care received. The findings will assist policy development to provide general practice-based pharmacists’ services as per patients’ needs.The online version contains supplementary material available at 10.1186/s12875-021-01393-0. English general practices have been facing ongoing workload pressures stemming from an ageing population and reductions in the general practitioner (GP) workforce . As a reOfficial statistics from NHS England show that in September 2020 there were 1582 full-time equivalent general practice-based pharmacists in England compared to 1249 in September 2019, which translates to an increase of 26.7% . DespiteCommon roles of English general practice-based pharmacists include face-to-face clinics with patients for structured medication reviews and long-term condition management; telephone consultations for minor ailments and triage; prescribing duties, for those qualified; and supporting staff in medication-related queries and meeting targets of incentive programmes –21.Several countries have attempted to implement general practice-based pharmacists’ services, including Australia , Canada Existing literature, both nationally –39 and iPrevious research efforts in England, however, were conducted some years ago and were limited to specific geographical regions, hence unlikely to have accounted for the whole range of employment models and roles of general practice-based pharmacists. Additionally, the waves of pharmacists still being integrated into English general practices might translate to varying patients’ experiences as a result of increasing exposure to pharmacists’ services as well as to diverse skillsets of pharmacists. The aim of the current study was to pursue an exploratory approach and explore patients’ experiences of general practice-based pharmacists in three different locations in England and therefore contribute to a more universal mapping of experiences. In particular, the current study set out to answer the following research question: What are the patients’ experiences and views of pharmacists working in general practice?A realistic qualitative interview design was chosen to allow for an in-depth exploration of experiences, using interpretive thematic analysis.Participants were recruited from large general practices located in West London, Surrey and Berkshire, targeted as recruitment points due to working connections with the research team’s organisation. The West London practice, with a list of approximately 16,000 registered patients, has participated in the ‘pharmacists in general practice’ scheme since inception. This practice was composed of two sites and, at the time of the study, had 12 GPs, four nurses and three pharmacists. Pharmacists  served approximately 170 patients per week, both through face-to-face and telephone sessions. Practices in Surrey and Berkshire were not part of the initial scheme but at the time of data collection they also employed pharmacists. The practice in Surrey was composed of a single site, had 16,000 patients registered and 13 GPs, two trainee GPs, five nurses and one pharmacist. The pharmacist dealt with approximately 100 patients on a weekly basis (both face-to-face and over the telephone). The practice in Berkshire consisted of two sites, had 14,000 registered patients and employed nine GPs, two nurses and two pharmacists. Pharmacists there served approximately 60 patients per week in total, both via face-to-face and telephone appointments.A purposive sampling approach was followed to recruit people who have visited a pharmacist in general practice. General practice-based pharmacists, working in the above-mentioned practices, handed invitation packs to eligible patients they met during consultations. Patients were eligible if they were aged 16 years or over, English speakers and able to consent for themselves as determined by the recruiting pharmacist. Invitation packs contained the study’s invitation letter; information sheet, providing details of the study and research team; consent form; reply form; and a business reply envelope. The study’s documents asked potential participants to directly contact a member of the research team (GDK), either via email or by filling in the reply form and posting it within the pre-paid envelope. GDK is a doctoral research student with experience in qualitative research. Once interest for participation was expressed, GDK contacted potential participants and a mutually convenient time for the interview was arranged. No other reminders were sent. Recruitment continued until data saturation. The research team interpreted data saturation as the point in data collection at which no new information was discernable, also known as ‘informational redundancy’ –48. WhenRecruitment and data collection took place between December 2018 and February 2020. Involvement in the study was voluntary and without monetary incentives. Audio-recorded interviews were conducted by GDK in private meeting or consultation spaces within the general practice with which each participant was registered. Just before each interview, mutual introductions took place to establish rapport and any questions that participants had were answered. In addition, the confidentiality of the interviews was highlighted by emphasising that discussions could not be overheard by general practice-based pharmacists, that findings would only be discussed between the research team without any disclosure to pharmacists and that any data to be used in research outputs would be anonymised. All interviews were face-to-face and semi-structured. An interview schedule, consisting of some open-ended questions and prompts, was used. The interview schedule was developed exclusively for this study and can be found as an additional file  . Data waTwenty participants were interviewed in total. There was an equal proportion of male to female participants. All had some contact with a general practice-based pharmacist. Participants were from different age-groups but all were aged 40 years or older. Most were from a white British and other white backgrounds. Table Four predominant themes were discerned in the data: awareness; accessibility; interactions; and feedback. Figure I had been coming to this practice for 24 years and I didn’t know that there was a pharmacist here. It’s possibly not my fault, they don’t advertise, promote, they don’t explain enough … I got a text [message] saying “make an appointment with the pharmacist” … [I was thinking] “What are they talking about”? “Where”? (Participant 5)There was also uncertainty, and often confusion, about the roles of general practice-based pharmacists and whether or not contact would be ongoing.I still don’t know why a patient would want to see a pharmacist in the general practice. I can’t get my head around that. ‘Cause if I want to ask the pharmacist something I go into the actual pharmacy. I’m not aware of the full extent of what they do. (Participant 10)Nearly all participants emphasised the need to promote the presence of pharmacists in general practice, to raise patients’ awareness and therefore encourage the uptake of pharmacists’ services. Numerous methods of promotion were proposed, such as television advertisements; messages on practice websites, social media accounts, waiting room screens and noticeboards, including introducing the pharmacist amongst the healthcare team photographs; posters and leaflets; and establishing visible consultation spaces for pharmacists.Most participants claimed that patients were largely ignorant of the presence of pharmacists in general practice due to a perceived absence of relevant information material. They all realised by chance the existence of general practice-based pharmacists, just before or only at the time of consultation.I have three housemates registered in this practice and I can spread it by mouth, “You know that there’s a pharmacist that attended to me today, they helped me a lot by giving me information”. (Participant 13)If a GP feels “well, this particular problem would be better decided by a pharmacist” [then they should] refer. But that doesn’t seem to happen very often. (Participant 20)Apart from the existence of general practice-based pharmacists, additional information needs of patients included the specific services offered by pharmacists; reasons to contact pharmacists; what is outside the pharmacist’s remit; and the potential benefits of seeing the pharmacist.Word of mouth was largely seen as an effective way to promote services, including through outreach activities and referrals.The receptionist says “Oh yes, the [pharmacist is] in today. I’ll just ask them to chat to you”, and it’s done within a day. Or the reception will say, “They’re not in today but they’ll be in tomorrow and I’ll get them to call you”. (Participant 15)Similarly, some participants claimed that there was far less waiting time with pharmacists’ appointments, both with scheduling an appointment and in the waiting room. There were some suggestions that seeing the pharmacist should become the first stage when an appointment at the practice is required.People ring for a GP appointment and they can be at death’s door … [and] it’s Monday and they [receptionist] tells you “We can slot you in on Friday”. With a pharmacist on board, they can [see] you and if it’s something more serious they would speak to the doctor. It’s a faster system … you could have an 11 o’clock appointment for a GP and you won’t be seen until 12-12.30. With the pharmacist, it may run over five minutes, it may be ten minutes but no more than that. (Participant 1)A few participants, however, reported occasional difficulties in getting appointments with pharmacists covering multiple practices, due to reduced availability and/or uncertainty about the exact days pharmacists were present in a specific practice. Likewise, one participant was frustrated not to directly be put through to the pharmacist, as phone calls were often returned at inconvenient times. Another one complained about pharmacists sometimes cancelling their appointments last moment. Some participants called for larger numbers of pharmacists, weekend sessions, appointments on the same day as GP appointments and availability of drop-in clinics.General practice-based pharmacists were perceived, by several participants, to be readily available to take patients’ queries over the telephone, in contrast to GPs who were much more difficult to contact.[Seeing] the pharmacist should be an equal opportunity [to the GP], a choice for patients. Even if you went through a telephone screening … [also] to have an online booking system which would incorporate the pharmacist. (Participant 3)Some participants mentioned that contact with the pharmacist should always be offered as a choice to the patient, in triage and online booking systems.I have colitis [and] I have a suspicion that it is triggered by sugar. I tried to have a discussion with the doctor but they didn’t want to discuss it, they just said, “There is no research on that at all”. At my last meeting with the pharmacist here, I mentioned it to them. They had a really useful discussion with me about it. And I came away feeling that I had been listened to. I felt that I had an informed and adult discussion. With the doctor, often they treat you like children “the doctor knows best, this is what you’re gonna [do]”. (Participant 2)The perceived absence of hierarchies and judgemental approaches by nearly all participants made them feel at ease with pharmacists and established mutual familiarity and relationships.Well sometimes when you come to the doctor, I am always conscious of the time and I don’t waffle. I don’t just waste the doctor’s time … So, there’s a certain level of anxiety, stress ... I found that with the pharmacist there was a less judgemental attitude, they were very approachable, immediate, very easy to talk to. (Participant 6)The pharmacist, I’ve seen them once and I feel like I’ve known them for a long time. That’s unusual ... I know the pharmacist’s name. That’s the difference. I’ve seen loads and loads of doctors here, more than once, and I don’t know their names. (Participant 3)Pharmacists, several participants claimed, visually connected with patients during consultations, which they took as an expression of being paid attention to.They [pharmacist] looked me straight in the eye and I think sometimes if you’re not looking at someone, you’re probably wandering with your mind, whereas, they were concentrating on me. (Participant 12)Many participants emphasised the caring attitude of pharmacists, which they attributed to fewer time-constraints compared to GPs.They [pharmacists] are very dedicated in what they do, they’re empathetic … the doctors, once the ten minutes are up, they stand up [and] you haven’t even finished and you have to go. I hate that. I think that’s dreadful. (Participant 8)Several participants claimed that, as a result of longer appointment times, pharmacists were thorough in their approach, including concomitantly managing multiple co-ailments and developing structured care plans.I had a new set of blood tests done which showed that my cholesterol levels had increased … They [pharmacist] went through my lifestyle, diet, exercise, where I live … They were thorough … [and] set a good plan to go forward, [to] have a review after three months and see how we go … I [also] had some twitching in my calf muscle, they weren’t quite sure what it was, so they saw one of the GPs in the practice and chased it through with them. (Participant 7)One participant, however, was afraid that pharmacists occasionally exceeded competency and requested more referrals to specialist care.The vast majority of participants emphasised the high quality of the interactions they had with general practice-based pharmacists. They reported that their consultation with a pharmacist was a two-way interactive process. Pharmacists were believed to treat patients as equal fellow-speakers, rather than passive recipients of instructions, and to welcome patients’ thoughts and questions.The [pharmacist] went through my list of other medications [as well] and dismissed the ones that I didn’t really need to keep on my repeat because I wasn’t having them … They said “Let’s take them off because if you do need them in the future, they can be put back on again”. No GP has ever said that to me before. So, you can see how older people just have this long list of medications that they may, if they don’t realise, still be taking. (Participant 17)Nearly all participants emphasised the information/explanation that pharmacists provided, including the analytical way this was conveyed, which was seen to allow patients to fully understand their medication or condition and convince them to accept the pharmacist’s advice.The [pharmacist] has given me some reading material to take away with regards to possible injection [for my diabetes]. They showed me with a dummy pen how it would be administered. So, yeah, it was very informative. They took the time to actually explain [everything] … the book of information, they took the time to actually go through the pages, give a brief outline, how it may or may not influence me. (Participant 14)Conversely, a few participants stated that pharmacists should consider potential side effects of medications upfront (rather than trailing different medications) and explain everything about medications without having to be prompted. One participant mentioned that pharmacists should also consider alternative therapies, such as natural substances and homeopathic remedies. Another participant was disappointed about pharmacists not recording condition−/medication-related history, hence having to re-provide these details in subsequent consultations.Pharmacists were reported, by several participants, to always review every single medication patients had, regardless of whether they related to the presenting complaint.My fear was that the medical people were going to keep pushing statins at me, regardless of my side effects. But they [pharmacist] said, “Look, we won’t try any more”. So, I was reassured by the fact that I’m not going to be pushed statins forever and I feel completely reassured that my interests are being properly looked after in terms of prescribing medication. (Participant 11)A lot of doctors made me feel quite a hypochondriac … with the pharmacist, you feel a sense of security after leaving them. (Participant 1)All participants left consultations with pharmacists feeling confident, reassured and with peace of mind that their problems had been resolved.Usually the feedback, the result of that doesn’t go back to the people … Is that [feedback] making any difference, is that making any improvement? Did anybody read it? Has it been put in practice? (Participant 4)There was no consensus amongst participants on the preferred way to collect patient feedback on general practice-based pharmacists. Various means were proposed, such as face-to-face interviews; questionnaire forms, either as hard copies or online, including using tick-boxes or rating scales or human faces mirroring satisfaction level; and politely reporting concerns directly to pharmacists. Most participants stated that the overall process of feedback provision should be quick, to encourage participation. As such, participants claimed, any feedback collection tool should be short in length.Some participants doubted if patient feedback on general practice-based services was taken seriously into consideration.It’s easier [to collect feedback instantly] because I could have forgotten half of what [the pharmacist] told me in an hour or so’s time. I’d go “What did they say about my tablet”? … So, [it would be good] to get at me [for feedback] quickly afterwards, while I remember things. (Participant 19)The public wants [to give feedback] right at the time they are having the consultation … because if they give [a form] to you, then you go back to your office and you set it down and two or three days later you have more things piled up and you never send the feedback. (Participant 5)The majority of participants also stated that feedback should be collected straight after consultations.Findings indicate that patients are unaware of pharmacists’ presence in general practice and/or unclear when to contact pharmacists. When they do interact with general practice-based pharmacists, however, patients highly appreciate the quality of care they receive. Some ways to enhance the availability of pharmacists and collection of patient feedback were suggested.The findings of the current study could best be interpreted in light of ‘scientific realism’, which views ‘realities’ in the contemporary world as meanings constructed by human minds , 52. TheMore simply, elements with pharmacists’ presence in general practice that ‘work’ for patients include pharmacists’ availability, providing that pharmacists do not cover many practices and patients consciously seek pharmacists’ care; and the high standard of interactions, which lead to positive emotions and a strong relationship between patients and pharmacists, and occur when there are no time-pressures during appointments. In contrast, the aspect with pharmacists in general practice that ‘does not work’ for patients is the existence of multiple information needs, due to the absence of relevant information, which limit the uptake of pharmacists’ services.Below, findings are related to pre-existing literature whilst also taking into account current ‘social’ circumstances which could affect patients’ satisfaction with aspects of pharmacists’ presence in general practice.The current study highlights the limited awareness of pharmacists in general practice amongst patients. Previous UK research has also reported unawareness due to absence of relevant communication from practices, including patients not realising that they had a consultation with a pharmacist, and confusion between community and general practice-based pharmacists’ roles , 38. PosParticipants who consciously sought access to general practice-based pharmacists’ services found pharmacists more accessible than GPs, something that has also been widely reported in literature , 36–38. Our findings around the long duration and thoroughness of pharmacists’ consultations repeat those of previous studies –42. The In our case, the function of ‘fostering relationships’ was achieved by suppressing hierarchies/judgements and maintaining eye contact that established a welcoming environment for patients and generated mutual bonds. The function of ‘gathering information’ was illustrated by pharmacists’ keenness to “listen to the patient” and constant effort to collect details on condition or lifestyle or medications, thereby avoiding unwarranted conclusions and leaving patients feeling that they had been heard. ‘Providing information’ was mirrored in the detailed explanations, including using graphic and/or descriptive means. ‘Decision making’ was indicated by the absence of pressure on the patient to follow certain treatments and the development of structured care plans. ‘Enabling disease- and treatment-related behaviour’ was obvious in the better understanding of medications patients developed post contact with the pharmacist. The ‘responding to emotions’ function was obvious in the caring attitude and reassurance offered by pharmacists, and the opportunity for patients to speak freely and express their concerns. Therefore, all key functions of patient-centric communication were witnessed in our findings. The absence of time constraints contributed to the ability of pharmacists to interact at this high level during consultations. It is unclear through our findings, however, whether any skillset of pharmacists (different from those of GPs) also had some role to play.Last but not least, our study offered insight into patients’ preferences with regards to feedback collection. To help action these insights, the patients could themselves be involved in determining what type of feedback is required, how it is collected and information disseminated. There is ample literature describing involvement of patients at various stages in research, such as in designing research priorities, questions, methods, protocols and study documentation as well as in data collection, analysis, interpretation and dissemination –60. PatiThe qualitative design used in the current study allowed for an in-depth understanding of patients’ experiences. The study was carried out at general practice settings diverse in terms of location and integration of pharmacists, hence the experiences captured are reflective of some different models of employing pharmacists in general practice and varied exposure of patients to pharmacists. Despite the limitations of ethnicity and age in the sample (see below), sufficient data saturation was achieved to offer findings a conceptual depth. We are confident, therefore, that findings synthesise a wide (if not the whole) range of potential experiences of patients at the specific recruitment points. Findings primarily apply to the UK reality, however, individual elements will still be useful for international attempts to integrate pharmacists into general practices.We did not set out to include a representative sample of the population in terms of age, ethnicity and region of domicile. Participants were recruited only from three practices in the south of England. As a result, findings might not be fully generalisable but can provide insights that could be extrapolated to other similar settings. Moreover, participants who volunteered for interviews mainly included white and older people, hence findings do not offer a good representation of younger age-groups and black and ethnic minorities who may have different experiences. It could be that older patients are most likely to face polypharmacy and other medication-related problems and so use pharmacists’ services, hence why younger patients were missing from our sample. The fact that interviews were carried out inside general practices might have introduced some biases in the responses of participants, due to a potential fear that pharmacists would learn about participants’ views. We believe, however, that the mutual trust established between the interviewer and participants and the reassurance about the confidentiality of the study encouraged the expression of honest views, hence making it very unlikely that findings would have significantly differed if interviews were carried out outside general practices. Although the research team followed a reflexive approach by ignoring personal experiences and collectively analysing data, because they are all pharmacists, some unavoidable instances of personal assumptions during data categorisation might still exist.Appropriately educate patients and the public about general practice-based pharmacists, including roles and responsibilities.Ensure pharmacists are present in the practice for an adequate amount of time each week, ideally on a daily basis, and explicitly communicate rotas to patients by also establishing an effective triage system to prevent exhaustion of pharmacists’ resources.Secure the prerequisites for efficient interactions with patients, for example, adequate appointment lengths.Design a formal, quick and attractive feedback mechanism for patients.The specific implications of the current study are that there is a need to:Future studies should employ maximum variation sampling to include experiences of patients from different ethnicities, ages, educational levels and regions of domicile in the UK. Future studies should also include developing additional measures to more thoroughly explore the added value pharmacists bring in general practice settings and co-designing pharmacists’ services with the public, including developing interventions to satisfy information needs with regards to pharmacists in general practice.The current study indicates that pharmacists’ integration into general practice has the potential to enhance the timely access to, and quality of, services in primary care. Practitioners, including pharmacists themselves, can use our findings to enhance their own practice by improving patient-centred interactions during consultations. More importantly, findings will inform delivery of the NHS Long Term Plan on how to make best use, from a patient perspective, of general practice-based pharmacists and will also assist practices when attempting to promote the benefits of having a pharmacist. Results will also guide international policy about integrating pharmacists into general practices, including how to design and evaluate patient-centric services.Additional file 1:. Interview schedule. This additional file consists of a table that presents the interview schedule developed and used in this study.