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Background: This paper identifies differences in all-cancer incidence and mortality between Pakistani-born (PB), Bangladeshi-born (BB), their descendants, and the White British (WB) in England and Wales. Pakistanis and Bangladeshis are the most marginalised and disadvantaged groups in England and Wales yet, are found to have low cancer mortality and low all-cause mortality. Previous studies though have not looked at generational differences, applied individual-level data nor separated Pakistanis and Bangladeshis from each other and other Asian groups. Methods: We use the Office for National Statistics Longitudinal Study of England and Wales which is a 1% representative sample of the population. We apply event history analysis on a study period from 1971 to 2016, following individuals from age 20 until a first cancer incidence, censoring at emigration or death. We observe 10,885,500 person-years and 71,926 cancer incidences for WB; 125,700 person-years and 295 events for PB; 53,900 person-years and 113 events for BB and 26,900 person-years and 24 events for descendants. Following incidence, we study a maximum of ten years until a death from cancer, or censoring. In this second analysis on mortality our sample has 329,700 person-years and 31,689 cancer deaths for WB; 1,200 person-years and 104 events for PB; 400 person-years and 50 events for BB and 100 person-years and 10 events for descendants. Results: Results from the fully adjusted models show that the risk of cancer incidence is lower for PB, BB and descendants compared to the WB native group. Estimated hazard ratio (HR) equals 0.42 for PB (95% confidence interval (CI): 0.38–0.47), for BB HR is 0.38 (CI: 0.32–0.46) and, for descendants HR is 0.36 (CI: 0.24–0.54). Results for cancer mortality after incidence show HR for PB is 0.93 (CI: 0.76–1.12), for BB it is 0.95 (CI: 0.72–1.25) and for descendants HR equals 1.62 (CI: 0.87–3.02 - significant at 90%). Conclusions: Using high quality representative data, we show that lower incidence of cancer and not better survival is the driver of the low cancer mortality previously found. This advantage persists across immigrant generations, but all-cancer mortality following incidence may be elevated for descendants. [ABSTRACT FROM AUTHOR]

Background: This paper evaluates the introduction of ten Community Health and Well-being Workers (CHWW) in four pilot sites across Cornwall. The period evaluated was from the initial start in June 2022 until June 2023, covering the project setup and implementation across a range of Primary Care Networks (PCNs) and Voluntary sector partners (VSCO). Methods: All ten CHWWs and their managers at each site were interviewed (n = 16) to understand the barriers and enablers to implementation and wider learning that could be captured around the project setup. Qualitative methods were used for data collection, including semi-structured interviews and focus groups. Transcripts were thematically analysed for cross-cutting themes, as well as site-specific effects. Results: In terms of learning, we cover the following key areas, which were of most importance to the successful implementation of the pilot: The CHWWs were introduced into an already established, successful social prescribing (SP) system by the time the CHWW project began. CHWWs can access some of the same training and office space as SPs, with overlapping meeting schedules allowing them joint input on some topics. It seemed that all the pre-work in terms of relationships and learning about a similar role helped a rapid implementation. Each site's CHWW management structure uses the same line management as the SPs. Roles were clustered together to remove duplication, maximise coverage and triaging of residents. The largest barrier to overcome was integrating VSCO staff into NHS systems. Conversely, hosting CHWWs within an NHS organisation has pros and cons, namely better access to NHS data and staff, but longer lead-in time for registration on systems, and more bureaucracy for procurement/spend. Conclusions: Looking to the future, the pilot's success has spread the programme to other integrated care areas in the country, with ongoing plans for further rollout and evaluation in the coming years. [ABSTRACT FROM AUTHOR]

Background: Deaths related to suicide, drug misuse, and alcohol-specific causes, known collectively as "deaths of despair" are of growing interest to researchers in England. Rates of death from these causes are highest in deprived northern communities and are closely tied to the social determinants of health and the policy decisions that have shaped them. The aim of this paper is to explore how stakeholders and community members living in Middlesbrough and South Tyneside, two Northern towns with above average rates of deaths of despair, understood the relationship between austerity policies and rates of deaths from these causes in their areas. Methods: I conducted interviews and one focus group with a total of 54 stakeholders and community members in Middlesbrough and South Tyneside. Data were analysed using the iterative categorisation technique and the findings were interpreted through thematic analysis. Results: The findings highlight four primary ways through which austerity exacerbated rates of deaths of despair in Middlesbrough and South Tyneside: reduced access to mental health services, diminished substance abuse treatment capacity, loss of youth services, and the closure of community institutions. Participants linked these cuts to rising social isolation, declining mental health, and increased substance misuse, which collectively deepened geographic inequalities in deaths of despair. Conclusions: This study underscores the urgent need for reinvestment in local services to reduce inequalities and prevent further unnecessary deaths due to drug, suicide, and alcohol-specific causes. Prioritising the restoration and enhancement of services lost to austerity is critical. Such reinvestment will not only help to alleviate some of the most immediate need but also form a foundation for addressing the wider structural inequalities that perpetuate deaths of despair. [ABSTRACT FROM AUTHOR]

Background: This paper outlines a pilot of a new memory aide for breastfeeding conducted in the Northeast of England and North Cumbria between April and August 2023. The United Kingdom has some of the lowest rates of breastfeeding, particularly in the Northeast of England, and as such more needs to be done to support mothers to breastfeed for as long as they would like to. Good support from health professionals can be effective in influencing decisions to breastfeed as well as helping to ensure initiation and continuation of breastfeeding but there is evidence to suggest that professionals and students do not always feel adequately trained and it is here, where memory aides may have value. Methods: Key breastfeeding practitioners and educators were brought together to select one of two memory aides for principles of attachment for effective breastfeeding. The selected memory aide, LATCHS, was piloted with 57 participants with a key role in promotion and support of breastfeeding in the Northeast of England and North Cumbria. Results: Participants conveyed mixed views about the proposed memory aide with more experienced staff reporting more favourable opinions than student midwives and early years practitioners. Experienced staff felt the new memory aide would complement an early memory aide, CHINS, which focused on principles of positioning. Discussion: Findings of the pilot indicate there is a role for a mnemonic to help practitioners understand, recall, and retain theory around attachment for effective breastfeeding and that memory aides can play an important role in complementing existing approaches to education and practice. The participants felt the proposed memory aide had some limitations and suggested important ways for it to be improved, particularly in adding an E to reflect the expecting wording. This produced the final memory aide: LATCHES. Conclusion: Using data from the pilot, the memory aide was refined, and the final version LATCHES agreed for wider dissemination. Future research is needed to understand the value of LATCHES on the wider breastfeeding workforce and whether any future improvements can be made to enhance its utility. [ABSTRACT FROM AUTHOR]

Background: The National Health Service (NHS) and general practice are increasingly adopting digital services. These services can impact both positively and negatively upon patient experiences, and access to digital services is not equal amongst all groups. Within a wider project examining digital facilitation (the Di-Facto study) our team conducted a patient survey amongst English primary care practices aiming to investigate patient views of what supports uptake and use of web-based services. This paper reports on the analysis of the free-text responses from the patient survey. Methods: The Di-Facto patient survey was distributed to practices in eight clinical commissioning groups (CCGs) in England between 2021–2022. We examined free-text responses to two questions relating to access to primary care web-based and support for web-based services. We used qualitative reflexive thematic analysis based on a six-stage process to analyse responses. Results: Of the 3051 patients who responded to the Di-Facto survey, 2246 provided a free-text response. We present our findings in two major themes: systems and structures and their impact on use of web-based services, and 'what works for me', a description of how respondents described what worked, or did not work in terms of their interactions with web-based services. Respondents described how the technology, such as poor practice website design, confusion over multiple digital apps, data security and concerns about eConsultation offerings impacted on use of web-based services. Respondents described practice level barriers, such as a lack of or inconsistent provision, which prevented optimal use of web-based services. Respondents described personal and technical barriers that impacted on their use of digital services, and described which web-based services worked well for them. Respondents felt that web-based services were not a replacement for face-to-face interactions with a doctor. Conclusions: This analysis of free-text responses from a large patient survey highlights the system, practice, and person level barriers and facilitators to use of digital services in primary care. With an increasing push towards digital solutions in NHS primary care, practices should consider the design, rollout and communication of their web-based services to support patient access. [ABSTRACT FROM AUTHOR]

Background: Given that AI-driven decision support systems (AI-DSS) are intended to assist in medical decision making, it is essential that clinicians are willing to incorporate AI-DSS into their practice. This study takes as a case study the use of AI-driven cardiotography (CTG), a type of AI-DSS, in the context of intrapartum care. Focusing on the perspectives of obstetricians and midwives regarding the ethical and trust-related issues of incorporating AI-driven tools in their practice, this paper explores the conditions that AI-driven CTG must fulfill for clinicians to feel justified in incorporating this assistive technology into their decision-making processes regarding interventions in labor. Methods: This study is based on semi-structured interviews conducted online with eight obstetricians and five midwives based in England. Participants were asked about their current decision-making processes about when to intervene in labor, how AI-driven CTG might enhance or disrupt this process, and what it would take for them to trust this kind of technology. Interviews were transcribed verbatim and analyzed with thematic analysis. NVivo software was used to organize thematic codes that recurred in interviews to identify the issues that mattered most to participants. Topics and themes that were repeated across interviews were identified to form the basis of the analysis and conclusions of this paper. Results: There were four major themes that emerged from our interviews with obstetricians and midwives regarding the conditions that AI-driven CTG must fulfill: (1) the importance of accurate and efficient risk assessments; (2) the capacity for personalization and individualized medicine; (3) the lack of significance regarding the type of institution that develops technology; and (4) the need for transparency in the development process. Conclusions: Accuracy, efficiency, personalization abilities, transparency, and clear evidence that it can improve outcomes are conditions that clinicians deem necessary for AI-DSS to meet in order to be considered reliable and therefore worthy of being incorporated into the decision-making process. Importantly, healthcare professionals considered themselves as the epistemic authorities in the clinical context and the bearers of responsibility for delivering appropriate care. Therefore, what mattered to them was being able to evaluate the reliability of AI-DSS on their own terms, and have confidence in implementing them in their practice. [ABSTRACT FROM AUTHOR]

Background: The National Health Service Diabetes Prevention Programme (NHS DPP) was commissioned by NHS England in 2016 and rolled out in three 'waves' across the whole of England. It aims to help people with raised blood glucose levels reduce their risk of developing type 2 diabetes through behaviour change techniques (e.g., weight loss, dietary changes and exercise). An independent, longitudinal, mixed methods evaluation of the NHS DPP was undertaken. We report the findings from the implementation work package: a qualitative interview study with designated local leads, responsible for the local commissioning and implementation of the programme. The aim of the study was to explore how local implementation processes were enacted and adapted over time. Methods: We conducted a telephone interview study across two time-points. Twenty-four semi-structured interviews with local leads across 19 sampled case sites were undertaken between October 2019 and January 2020 and 13 interviews with local leads across 13 sampled case sites were conducted between July 2020 and August 2020. Interviews aimed to reflect on the experience of implementation and explore how things changed over time. Results: We identified four overarching themes to show how implementation was locally enacted and adapted across the sampled case sites: 1. Adapting to provider change; 2. Identification and referral; 3. Enhancing uptake in underserved populations; and 4. Digital and remote service options. Conclusion: This paper reports how designated local leads, responsible for local implementation of the NHS DPP, adapted implementation efforts over the course of a changing national diabetes prevention programme, including how local leads adapted implementation during the COVID-19 pandemic. This paper highlights three main factors that influence implementation: the importance of facilitation, the ability (or not) to tailor interventions to local needs and the role of context in implementation. [ABSTRACT FROM AUTHOR]

Background: The Brief Educational Workshops in Secondary Schools Trial (BESST) is an England-wide school-based cluster randomised controlled trial assessing the clinical and cost-effectiveness of an open-access psychological workshop programme (DISCOVER) for 16–18-year-olds. This baseline paper describes the self-referral and other recruitment processes used in this study and the baseline characteristics of the enrolled schools and participants. Method: We enrolled 900 participants from 57 Secondary schools across England from 4th October 2021 to 10th November 2022. Schools were randomised to receive either the DISCOVER day-long Stress workshop or treatment as usual which included signposting information. Participants will be followed up for 6 months with outcome data collection at baseline, 3-month, and 6-month post randomisation. Results: Schools were recruited from a geographically and ethnically diverse sample across England. To reduce stigma, students were invited to self-refer into the study if they wanted help for stress. Their mean age was 17.2 (SD = 0.6), 641 (71%) were female and 411 (45.6%) were from ethnic minority groups. The general wellbeing of our sample measured using the Mood and Feelings Questionnaire (MFQ) found 314 (35%) of students exhibited symptoms of depression at baseline. Eighty percent of students reported low wellbeing on the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) suggesting that although the overall sample mean is below the cut-off for depression, the self-referral approach used in this study supports distressed students in coming forward. Conclusion: The BESST study will continue to follow up participants to collect outcome data and results will be analysed once all the data have been collected. Trial registration: ISRCTN registry ISRCTN90912799. Registered on 28 May 2020. [ABSTRACT FROM AUTHOR]

It seems probable that some form of medically-assisted dying will become legal in England and Wales in the foreseeable future. Assisted dying Bills are at various stages of preparation in surrounding jurisdictions (Scotland, Republic of Ireland, Isle of Man, Jersey), and activists campaign unceasingly for a change in the law in England and Wales. There is generally uncritical supportive media coverage, and individual autonomy is seen as the unassailable trump card: 'my life, my death'. However, devising a law which is 'fit for purpose' is not an easy matter. The challenge is to achieve an appropriate balance between compassion and patient autonomy on the one hand, and respect for human life generally and medical autonomy on the other. More people should benefit from a change in the law than be harmed. In relation to medically-assisted dying, this may not be possible. Protecting the vulnerable is a key issue. Likewise, not impacting negatively on societal attitudes towards the disabled and frail elderly, particularly those with dementia. This paper compares three existing models of physician-assisted suicide: Switzerland, Oregon (USA), and Victoria (Australia). Vulnerability and autonomy are discussed, and concern expressed about the biased nature of much of the advocacy for assisted dying, tantamount to disinformation. A 'hidden' danger of assisted dying is noted, namely, increased suffering as more patients decline referral to palliative-hospice care because they fear they will be 'drugged to death'. Finally, suggestions are made for a possible 'least worse' way forward. One solution would seem to be for physician-assisted suicide to be the responsibility of a stand-alone Department for Assisted Dying overseen by lawyers or judges and operated by technicians. Doctors would be required only to confirm a patient's medical eligibility. Palliative-hospice care should definitely not be involved, and healthcare professionals must have an inviolable right to opt out of involvement. There is also an urgent need to improve the provision of care for all terminally ill patients. [ABSTRACT FROM AUTHOR]

Background: Many countries have introduced school food standards to improve the dietary intakes of school-aged children. England has school food standards (SFS) legislation in place but little is known about how well secondary schools comply with this. We aimed to assess compliance with the SFS legislation in English secondary schools and explore the impact of the SFS on pupils' nutritional intake. Methods: We conducted a cross-sectional study with English secondary schools from 2019 to 2022. We compared SFS compliance and pupil nutritional intake in schools mandated or not mandated to comply with the SFS legislation, and explored the association between school compliance and pupil nutritional intake. We assessed the percentage of SFS (%SFS) complied with by reviewing school food menus and observing food served in school canteens. We assessed pupil nutritional intake using a 24-hour dietary recall measure (Intake24) and estimated intakes of free sugar (primary outcome) and other nutrients/foods. We used adjusted multilevel models to compare pupil intakes in the SFS-mandated and SFS-non-mandated schools, and to explore the association between school SFS compliance and pupil intakes. Results: 36 schools (23 not mandated and 13 mandated to comply with the SFS) and 2,273 pupils participated. The median %SFS complied with was 63.9% (interquartile range 60.0–70.0%). This was similar for SFS-non-mandated (64.5%) and SFS-mandated schools (63.3%). Compliance was highest for standards applying to lunchtime (median = 81.3%) and lowest for those applying across the whole school day (median = 41.7%). It was also lower for standards restricting high fat, sugar and energy-dense items (median = 26.1%) than for standards aiming to increase dietary variety (median = 92.3%). Pupils from SFS-mandated schools had a lower mean lunchtime intake of free sugar (g) (adjusted mean difference: -2.78g; 95% CI: -4.66g to -0.90g). There were few significant associations between %SFS complied with and pupil nutritional intake. Conclusions: English secondary schools do not fully comply with SFS legislation regardless of whether they are mandated to comply. Schools and caterers may require monitoring and support to fully comply. There is little evidence that SFS compliance is associated with better pupil nutritional intake. Food environments outside of school also need to be considered. Study registration: ISRCTN68757496 (17-10-2019). [ABSTRACT FROM AUTHOR]

Background: Global demand for care during the last year of life (end-of-life) is rising and with shortfalls in community healthcare services, paramedics are increasingly called on to deliver this. Despite this growing demand on the paramedic workforce, little large-scale or detailed empirical research has evaluated current practice and paramedic experiences of attending this patient group. Therefore, as part of a wider study evaluating paramedic delivery of end-of-life care, a large-scale survey in England describing paramedics' current practice and experiences providing end-of-life care was undertaken. Methods: A cross-sectional online survey design. Quantitative data were analysed using descriptive statistics and qualitative free text responses using Framework Analysis. The survey link was distributed to registered paramedics employed by all 11 NHS Trusts employing paramedics in England, United Kingdom. Results: Nine hundred and twenty responses were received. They reported shortfalls in availability of healthcare professionals for advice and/or referral. Respondents often, always or sometimes: lacked patient medical history (91%, 839), access to existing advance care planning documentation (98%, 900) and specific medicines needed (80%, 737); encountered conflicting views (89%, 819); and reported lack of pre-registration training (81%, 743) or continuing professional development (77%, 708) influenced their ability to meet patient needs. Conclusions: This first national survey of paramedic practice and experiences in delivering end-of-life care provides new evidence and insight into the challenges faced by paramedics and the potential impact of these challenges on their perceived levels of competence and confidence. Respondents reported multiple challenges, which potentially impact their ability to provide good quality end-of-life care and increase the risk of hospital conveyance. Paramedic practice at end-of-life must be supported via improved access to: patient records; anticipatory medicines and authority to administer; 24/7 palliative care advice (for shared decision-making); and paramedic specific palliative and end-of-life care training and education (including via integrative ways of working between palliative care and ambulance services). Action is required to integrate paramedicine within the wider healthcare professional team, with robust education and training to support care delivery. [ABSTRACT FROM AUTHOR]

Background: Identifying locally relevant and agreed-upon priorities for improving young people's mental health, aligned with social and environmental factors, is essential for benefiting target communities. This paper describes a participatory approach to engage young people and professionals in identifying such priorities, whilst considering the social determinants related to them. Methods: We utilised a community-based participatory approach to support young people and professionals in identifying, reviewing, refining, and prioritising, locally relevant opportunity areas that are crucial for understanding and addressing social determinants of young people's mental health. We adopted a flexible five-stage process, which enabled greater reflection and adaptation in response to young people's and professionals' feedback and reflections. Results: Over seven months, we engaged with young people and professionals in Northern Devon, (a rural area in southwest England), involving over 290 individuals to identify locally relevant priorities for supporting young people's mental health. Three priorities were identified for subsequent exploration using co-design approaches: (1) identity and belonging; (2) mental health awareness and literacy; and (3) diverse opportunities (for education, employment and leisure). The engagements suggested that designing initiatives and strategies in these areas could contribute to improvements in young people's mental health. Conclusion: Young people in Northern Devon prioritised three themes for the next phase of the Kailo Programme—mental health literacy, access to diverse careers and employment opportunities, and identity and belonging within their communities. Rural communities face unique barriers associated with these issues, related to less diverse populations, lack of access to reliable and affordable transport and local industries, and seasonal working. The perceived neglect by authorities towards rural young people has resulted in a lack of activities and opportunities catering to their specific needs, compared to urban areas. Although the government has recognised the need to address these disparities, community members suggest that there is still more work to be done. Plain English summary: The Kailo project aims to help young people and their communities find local solutions for better mental health in the UK. This paper discusses our findings in Northern Devon, England. Through various conversations and workshops with young people and professionals, we identified three key themes: (1) identity and belonging; (2) mental health knowledge and awareness; and (3) a variety of career, education, and leisure opportunities. These themes will be of focus for Kailo's next phase where ideas and initiatives will be designed and developed with young people and community professionals with the aim to help address important mental health challenges young people are experiencing within Northern Devon. [ABSTRACT FROM AUTHOR]

While much attention and emphasis have been given to the role and value of advisory groups in social science research, less has been published on the experiences of those involved in such collaborative efforts. This article reflects on the experiences of academics, collaborators and self-advocacy experts who formed an advisory group for a research project focused on people with learning disabilities' experiences of renting their own homes. Our paper describes the collaboration, how it changed because of Covid and because of changing relationships, and what worked well and what was challenging. This is in part because these more transparent accounts of working together are sometimes missing from research. We discuss issues relating to bureaucratic research systems which are largely inaccessible to people with learning disabilities and how we approached these. We also highlight the joys and benefits of the research approach that we adopted as well as the challenging and more difficult aspects. Plain English summary: This article tells the story of a research project about people with learning disabilities who rent their own homes in England. The article is not so much about the research findings but more about how the research team worked together. This group included self-advocacy experts with learning disabilities, research collaborators and academic researchers. At the start of the project, people with learning disabilities were invited to be part of an advisory group. But as the project went on, this group started to challenge the limits of the role and wanted to be more involved. This changed the course of the research—as well as the fact that it was happening at the same time as the Covid pandemic. The group had some difficult issues to deal with including complicated ethics processes, bureaucracy about getting people paid, and disagreements about language and terminology. We had some hard conversations about the words we use in academia and in real life and who gets to do research. We also had lots of fun wearing silly glasses at Christmas and talking about carrier pigeons. In the end we all felt that the way the research was carried out had improved the project overall. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the impact a novel education programme - to improve research engagement, awareness, understanding and confidence - had on a diverse health and social care workforce. Barriers and facilitators to engagement were explored together with research capacity-building opportunities and ways to embed a research culture. The programme is entitled 'Supporting The Advancement of Research Skills' (STARS programme); the paper reports findings from a health and social care setting in England, UK. Methods: A four-level outcome framework guided the approach to evaluation and was further informed by key principles of research capacity development and relevant theory. Quantitative data were collected from learners before and after engagement; these were analysed descriptively. Semi-structured online interviews were conducted with learners and analysed thematically. A purposive sample was achieved to include a diversity in age, gender, health and social care profession, and level of attendance (regular attendees, moderate attendees and non-attenders). Results: The evaluation spanned 18 half-day workshops and 11 seminars delivered by expert educators. 165 (2% of total staff at Midlands Partnership University NHS Foundation Trust (MPFT)) staffs booked one or more education sessions; 128 (77%) including Allied Health Professionals (AHPs), psychologists, nursing and midwifery, and social workers attended one or more session. Key themes of engagement with teaching sessions, relevance and impact of training and promoting a research active environment were identified with relevant sub-themes. Positive impacts of training were described in terms of research confidence, intentions, career planning and application of research skills as a direct result of training. Lack of dedicated time for research engagement, work pressures and time commitments required for the programme were key barriers. Facilitators that facilitated engagement are also described. Conclusions: Findings demonstrate the impact that a free, virtual and high-quality research education programme had at individual and organisational levels. The programme is the product of a successful collaboration between health and social care and academic organisations; this provides a useful framework for others to adapt and adopt. Key barriers to attendance and engagement spoke to system-wide challenges that an education programme could not address in the short-term. Potential solutions are discussed in relation to protecting staff time, achieving management buy-in, recognising research champions, and having a clear communication strategy. [ABSTRACT FROM AUTHOR]

Background: A lifelong gluten-free diet is the only treatment for coeliac disease. The cost and availability of gluten-free substitute food (GFSF) remain challenging. Some local areas in England have stopped gluten-free prescriptions for coeliac disease. The aim of this paper is to present the quantitative findings of the financial impact of prescription withdrawal on people with coeliac disease. Methods: A cross-sectional survey with adults in England who reported having been diagnosed with coeliac disease by a health professional. The postal survey was distributed by Coeliac UK to their members in 13 prescribing and 13 non-prescribing local areas that were matched for geographical location and level of deprivation. Additionally, an advertisement for the survey was placed on social media. The questionnaire contained items on the availability and use of prescriptions; the weekly amount spent on GFSF; amount of specific GFSF bought; affordability of GFSF; demographics and health-related variables. Data were analysed by descriptive statistics, analysis of variance and regression analysis. Results: Of the 1697 participants, 809 resided in areas that provided prescriptions and 888 in non-prescribing areas. Participants self-report of their prescription did not always match the local area prescription policy. There was no statistically significant difference between prescribing and non-prescribing areas in how easy or difficult participants found it to obtain GFSF (p = 0.644) and its availability in various locations. Participants in non-prescribing areas purchased most types of GFSF items in statistically significantly higher quantities and thereby spent an additional £11.32/month on GFSF items than participants in prescribing areas (p < 0.001). While taking into account the self-reported prescription status, the amount increased to £14.09/month (p < 0.001). Although affordability to buy GFSF did not differ based on local area prescription policy or self-reported prescription status, it was dependent on equivalised annual income. However, affordability did not influence spending on GFSF. Regression analysis indicated that males and households with additional members with coeliac disease spent more on GFSF. Conclusions: The study has highlighted that gluten-free prescription withdrawal can have financial implications for people with coeliac disease. Any future changes to the prescription policy of GFSF should consider the impact on the population, especially lower income households. [ABSTRACT FROM AUTHOR]

Background: Little is known about the effectiveness of, and implementation complexities associated with, service delivery models for children and young people (CYP) experiencing 'common' mental health problems such as anxiety, depression, behavioural difficulties and self-harm. This paper outlines how a model for high-quality service design for this population group was developed by identifying available services, their effectiveness, cost-effectiveness and acceptability, and the barriers and enablers to access. Methods: Sequential, mixed-methods design, combining evidence syntheses (scoping and integrative reviews of the international literature) with primary research (a collective case study in England and Wales). Data from these two elements were collaboratively synthesised in a subsequent model-building phase. Results: The scoping review yielded a service model typology. The integrative review found effectiveness evidence only for four models: collaborative care (the only service model to also have cost-effectiveness evidence), outreach approaches, brief intervention services and an organisational framework called 'Availability, Responsiveness and Continuity'. No service model seemed more acceptable than others. Three case study themes were identified: pathways to support; service engagement; and learning and understanding. The model-building phase identified rapid access, learning self-care skills, individualised support, clear information, compassionate and competent staff and aftercare planning as core characteristics of high-quality services. These characteristics were underpinned by four organisational qualities: values that respect confidentiality; engagement and involvement; collaborative relationships; and a learning culture. Conclusions: A consistent organisational evidence-base for service design and delivery in CYP's mental health spanning many years appears to have had little impact on service provision in England and Wales. Rather than impose – often inflexible and untested – specific local or national models or frameworks, those commissioning, designing and delivering mental health services for CYP should (re)focus on already known, fundamental components necessary for high-quality services. These fundamental components have been integrated into a collaboratively produced general model of service design for CYP with common mental health problems. While this general model is primarily focused on British service provision, it is broad enough to have utility for international audiences. [ABSTRACT FROM AUTHOR]

Background: Over 180,000 people use crack cocaine in England, yet provision of smoking equipment to support safer crack use is prohibited under UK law. Pipes used for crack cocaine smoking are often homemade and/or in short supply, leading to pipe sharing and injuries from use of unsafe materials. This increases risk of viral infection and respiratory harm among a marginalised underserved population. International evaluations suggest crack pipe supply leads to sustained reductions in pipe sharing and use of homemade equipment; increased health risk awareness; improved service access; reduction in injecting and crack-related health problems. In this paper, we introduce the protocol for the NIHR-funded SIPP (Safe inhalation pipe provision) project and discuss implications for impact. Methods: The SIPP study will develop, implement and evaluate a crack smoking equipment and training intervention to be distributed through peer networks and specialist drug services in England. Study components comprise: (1) peer-network capacity building and co-production; (2) a pre- and post-intervention survey at intervention and non-equivalent control sites; (3) a mixed-method process evaluation; and (4) an economic evaluation. Participant eligibility criteria are use of crack within the past 28 days, with a survey sample of ~ 740 for each impact evaluation survey point and ~ 40 for qualitative process evaluation interviews. Our primary outcome measure is pipe sharing within the past 28 days, with secondary outcomes pertaining to use of homemade pipes, service engagement, injecting practice and acute health harms. Anticipated impact: SIPP aims to reduce crack use risk practices and associated health harms; including through increasing crack harm reduction awareness among service providers and peers. Implementation has only been possible with local police approvals. Our goal is to generate an evidence base to inform review of the legislation prohibiting crack pipe supply in the UK. This holds potential to transform harm reduction service provision and engagement nationally. Conclusion: People who smoke crack cocaine in England currently have little reason to engage with harm reduction and drug services. Little is known about this growing population. This study will provide insight into population characteristics, unmet need and the case for legislative reform. Trial registration: ISRCTN12541454 https://doi.org/10.1186/ISRCTN12541454 [ABSTRACT FROM AUTHOR]

Introduction: This study characterized the extent to which (1) financial barriers and (2) abortion care-seeking within a person's country of residence were associated with delays in abortion access among those travelling to England and the Netherlands for abortion care from European countries where abortion is legal on broad grounds in the first trimester but where access past the first trimester is limited to specific circumstances. Methodology: We drew on cross-sectional survey data collected at five abortion clinics in England and the Netherlands from 2017 to 2019 (n = 164). We assessed the relationship between difficulty paying for the abortion/travel, acute financial insecurity, and in-country care seeking on delays to abortion using multivariable discrete-time hazards models. Results: Participants who reported facing both difficulty paying for the abortion procedure and/or travel and difficulty covering basic living costs in the last month reported longer delays in accessing care than those who had no financial difficulty (adjusted hazard odds ratio: 0.39 95% CI 0.21–0.74). This group delayed paying other expenses (39%) or sold something of value (13%) to fund their abortion, resulting in ~ 60% of those with financial difficulty reporting it took them over a week to raise the funds needed for their abortion. Having contacted or visited an abortion provider in the country of residence was associated with delays in presenting abroad for an abortion. Discussion: These findings point to inequities in access to timely abortion care based on socioeconomic status. Legal time limits on abortion may intersect with individuals' interactions with the health care system to delay care. Plain Language Summary: This paper explores delays in accessing abortion care associated with financial and medical system barriers. We focus on residents of countries in Europe where abortion is available on broad grounds in the first trimester seeking abortion care outside of their country of residence. This study demonstrates an association between difficulty covering abortion costs for people facing financial insecurity and in-country care seeking and delays in accessing abortion abroad. Policy barriers, medical system barriers, as well as financial barriers may interact to delay access to care for people in European countries with broad grounds for abortion access in the first trimester but restrictions thereafter, especially for people later in pregnancy. [ABSTRACT FROM AUTHOR]

Background: Community-based volunteering supports outbreak management by extending reach into at-risk communities. This paper examines the application of a 'community champions' model in England, UK, during the COVID-19 pandemic. Evidence pre-pandemic shows that community champion interventions tap into social networks to strengthen connections with disadvantaged communities. During the pandemic, the UK government set up a COVID community champions funding award scheme for local authorities to develop local programmes that addressed emerging inequalities. The study aim was to identify transferable learning on community engagement in the pandemic by undertaking a secondary qualitative synthesis of practice-based case studies of local COVID community champion programmes. Methods: A systematic staged approach for synthesis of practice-based case studies was used. In total, 16 COVID community champion case studies, which were written by practitioners involved in local programme implementation and published by the Local Government Association, were included. Case studies covered aims, programme development and delivery, examples of activities and a discussion of learning. Framework qualitative analysis methods were used to code and organise data prior to cross case analysis. The final stage produced an overarching thematic framework that best represented descriptive and interpretive themes. Results: The results provide an overview of common features of COVID community champion programmes and emergent learning. All local programmes aimed to reduce health inequalities by involving at-risk communities in local prevention efforts, adapting the approach to local priorities. Two levels of community engagement were volunteer mobilisation and subsequent community-based outreach activities. Elements of capacity building, such as training and creation of networks, were common. The synthesis of practice-based learning found that stronger relationships with communities were regarded as a key mechanism to support more equitable prevention strategies. Other learning themes related to champion roles, community engagement strategies and programme implementation. Conclusions: By focusing on how community champion approaches were applied by local authorities in England during the COVID-19 pandemic, this study contributes to knowledge on volunteer mobilisation as a mechanism to improve public health communication and outreach. Notwithstanding the limitations of experiential evidence, the synthesis of practice-based learning highlights potentially transferable community engagement strategies for health protection and health improvement. [ABSTRACT FROM AUTHOR]

Background: The Live Well with Parkinson's Self-Management Toolkit is designed for use in the NHS to support people with Parkinson's, their carers and health professionals in managing motor and non-motor symptoms and promoting well-being. The Toolkit was developed based on theory-based behaviour change and self-management techniques in consultation with people living with Parkinson's and health and social care practitioners. There are digital (e-Toolkit) and paper (manual) versions. Methods: Single-blind two-arm randomised controlled trial RCT of clinical effectiveness and cost-effectiveness of the Toolkit, facilitated by up to six sessions with a trained non-specialist supporter, in improving quality of life. People with Parkinson's will be assessed at baseline, 6 and 12 months. Assessors will be blind to the treatment group. The primary outcome measure is the Parkinson's Disease Questionnaire (PDQ-39, Parkinson's related quality of life) score at 12 months. Secondary outcome measures include the MDS Unified Parkinson's Disease Rating Scale (Part I, II, III, IV), EQ-5D, and a Client Service Receipt Inventory shortened, adapted for Parkinson's. Carer outcomes include the Zarit Carer Burden Inventory and Carer Quality of Life Questionnaire for Parkinsonism. A total of 338 people with Parkinson's, and their carers if appropriate, will be recruited from diverse settings across England. Those with advanced dementia, at end-of-life or with atypical Parkinsonism will be excluded. A parallel mixed methods process evaluation will explore the factors promoting or inhibiting implementation, uptake, use, effectiveness and cost-effectiveness of the Toolkit and sessions. Discussion: If successful, the Live Well with Parkinson's Toolkit could be used as a model for other complex long-term disorders, including dementia. This would bridge existing gaps in the NHS (as shown by the national Parkinson's audit data), by enabling patients and carers to access personalised information, advice and support on symptom management and 'living well' with Parkinson's. Trial registration: ISRCTN92831552. Registered on 26th Oct 2021. [ABSTRACT FROM AUTHOR]

Background: Implementation evaluation should focus on implementation success, guided by theories and frameworks. With high staff vacancies in the health services, it is important to consider pragmatic methods of data collection for implementation evaluation. This paper presents a cross-sectional rapid evaluation of a handheld medical device designed for remote examinations, piloted in Northern England. By using downloaded device data and administrative records mapped to domains from the implementation outcomes framework, this evaluation offers a pragmatic example of assessing implementation success. Methods: The pilot design was pragmatic: sites volunteered, decided which services to use the device in, and launched when ready. The pilot and evaluation together lasted 1 year. Data was downloaded from the devices, and administrative records for the pilot accessed. Variables were mapped to five of the implementation outcomes, after reviewing with the device manufacturer and pilot team to assess robustness. Results: N=352 care episodes were recorded using the device with 223 patients. Out of 19 sites 'signed up' to the pilot, 5 launched and delivered 10 of 35 proposed projects: a site and project adoption rate of 26 and 29%, respectively. Six sites signed up to an extension period; three had launched and three had not during the original timelines, indicating some sustainability. Feasibility was high, with only one in seven care episodes needing to be repeated due to poor device quality or error (sound/audio/internet). Fidelity of device usage was low for two of the eight available device examinations. Device and staffing costs were high but potential cost savings were attributable to fewer in-person appointments. Conclusions: Through using device and administrative data, this evaluation minimised burden on busy healthcare staff yet was still guided by an evaluation framework. Five out of the eight implementation outcomes were measured, including sustainability and costs. The findings give insight into implementation challenges, particularly around adoption. For future research, it is recommended to engage with staff to prioritise outcome measurements and to focus on meaningful interpretation of indicators. [ABSTRACT FROM AUTHOR]

Background: Existing estimates of palliative care need in the UK were produced before the COVID-19 pandemic. We sought to produce updated, population-level estimates of palliative care need for each of the four UK nations and explore how these changed during the pandemic. Methods: We conducted a descriptive analysis of routine data. We used a well-established, diagnosis-based methodology which produced minimal estimates of palliative care need based on underlying causes of death; intermediate estimates based on underlying and contributory causes of death; and maximal estimates based on excluding unexpected causes of death. Additional estimates incorporated deaths involving COVID-19. All methods were applied to official mortality statistics from England, Wales, Scotland, and Northern Ireland for the years 2017 to 2021. Results: From 2017 to 2019 for the UK in total, palliative care need was estimated at ~ 74% (minimal), ~ 90% (intermediate) and ~ 96% (maximal) of total deaths, which was broadly consistent with previous studies. Results were similar across all nations. In the pandemic years, 2020-21, the minimal estimates remained stable in terms of the number of people in need but dropped significantly in terms of the proportion of deaths associated with palliative care need (to ~ 66%) due to the overall increase in mortality and large number of deaths from COVID-19. The intermediate (~ 90%) and maximal (~ 96%) estimates showed an increase in the number of people in need but remained stable in proportion of deaths. When deaths involving COVID-19 were treated as deaths associated with palliative need, the minimal estimates increased to ~ 77% and intermediate estimates increased to ~ 92%. Conclusions: In each of the UK's nations, most people who die will have palliative care needs. Excluding deaths from COVID-19 in population-level estimates of palliative care need risks under-estimating true levels of need. Future studies which estimate population-level palliative care need should consider factoring in deaths from COVID-19. [ABSTRACT FROM AUTHOR]

Background: The Universal Infant Free School Meal (UIFSM) policy was introduced in 2014/15 in England and Scotland for schoolchildren aged 4–7 years, leading to an increase in school meal uptake. UK school meals are known to be healthier and less industrially processed than food brought from home (packed lunches). However, the impact of the UIFSM policy on the quantity of ultra-processed food (UPF) consumed at school during lunchtime is unknown. This study aimed to evaluate the impact of the UIFSM policy on lunchtime intakes of UPF in English and Scottish schoolchildren. Methods: Data from the UK National Diet and Nutrition Survey (2008–2019) were used to conduct a difference-in-difference (DID) natural experiment. Outcomes included school meal uptake and the average intake of UPF (% of total lunch in grams (%g) and % total lunch in Kcal (%Kcal)) during school lunchtime. The change in the outcomes before and after the introduction of UIFSM (September 2014 in England, January 2015 in Scotland) in the intervention group (4–7 years, n = 835) was compared to the change in an unexposed control group (8–11 years, n = 783), using linear regression. Inverse probability weights were used to balance characteristics between intervention and control groups. Results: Before UIFSM, school meal uptake and consumption of UPFs were similar in the intervention and control groups. The DID model showed that after UIFSM, school meal uptake rose by 25%-points (pp) (95% CI 14.2, 35.9) and consumption of UPFs (%g) decreased by 6.8pp (95% CI -12.5,-1.0). Analyses indicated this was driven by increases in minimally processed dairy and eggs, and starchy foods, and decreases in ultra-processed salty snacks, bread and drinks. The differences were larger in the lowest-income children (-19.3 UPF(%g); 95% CI -30.4,-8.2) compared to middle- and high-income children. Analyses using UPF %Kcal had similar conclusions. Conclusions: This study builds on previous evidence suggesting that UIFSM had a positive impact on dietary patterns, showing that it reduced consumption of UPFs at school lunchtime, with the greatest impact for children from the lowest-income households. Universal free school meals could be an important policy for long term equitable improvements in children's diet. [ABSTRACT FROM AUTHOR]

Introduction: Depression and alcohol use disorder (AUD) in people living with Type 2 diabetes mellitus (T2DM) are associated with worse health outcomes. AUD is strongly associated with depression and anxiety, but it is not known how these conditions cluster in people with T2DM. We investigated rates of new episodes of depression and anxiety following T2DM diagnosis in people with and without prior AUD among an English primary care population. Methods: The study population was people diagnosed with T2DM between 2004 and 2019. We used the Clinical Practice Research Datalink (CPRD) Aurum database and linked Hospital Episode Statistics Admitted Patient Care (HES APC) and Office for National Statistics (ONS) mortality data. We examined incidence of new episodes of anxiety or depression in people with T2DM with and without AUD. AUD was defined as any of i) clinical diagnosis; ii) alcohol withdrawal; or iii) chronic alcohol-related harm (physical or mental) using SNOMED-CT or ICD-10 codes. People were excluded if they had codes for depression/anxiety 12 months prior to T2DM diagnosis. Poisson regression models were fitted adjusting sequentially for a) age, gender, calendar time; b) region, Index of Multiple Deprivation, ethnicity, body mass index, smoking status, Charlson co-morbidity index; and c) history of a mental health condition. Results: Our study population was 479,447 people of whom 10,983 (2.3%) had an AUD code prior to T2DM diagnosis. After adjusting for all measured confounders except history of a mental health condition, IRR for depression was 2.00 (95% CI 1.93, 2.06) for people with AUD compared to without AUD. This reduced to 1.45 (95% CI 1.41, 1.50) after further adjustment for history of a mental health condition. Findings for anxiety were substantially similar to those for depression (adjusted for all measured confounders except history of a mental health condition, IRR 2.08 95% CI 1.99, 2.18 fully adjusted IRR 1.48 95% CI 1.41, 1.55). Conclusions: People with AUD have over double the rates of depression and anxiety following T2DM diagnosis than those without AUD. This was only partially explained by pre-existing diagnoses of mental health conditions. A holistic approach incorporating mental health support is needed to improve health outcomes for people with AUD who develop T2DM. Trial registration: Not applicable. [ABSTRACT FROM AUTHOR]

Background: Many countries have introduced school food standards to improve the dietary intakes of school-aged children. England has school food standards (SFS) legislation in place but little is known about how well secondary schools comply with this. We aimed to assess compliance with the SFS legislation in English secondary schools and explore the impact of the SFS on pupils' nutritional intake. Methods: We conducted a cross-sectional study with English secondary schools from 2019 to 2022. We compared SFS compliance and pupil nutritional intake in schools mandated or not mandated to comply with the SFS legislation, and explored the association between school compliance and pupil nutritional intake. We assessed the percentage of SFS (%SFS) complied with by reviewing school food menus and observing food served in school canteens. We assessed pupil nutritional intake using a 24-hour dietary recall measure (Intake24) and estimated intakes of free sugar (primary outcome) and other nutrients/foods. We used adjusted multilevel models to compare pupil intakes in the SFS-mandated and SFS-non-mandated schools, and to explore the association between school SFS compliance and pupil intakes. Results: 36 schools (23 not mandated and 13 mandated to comply with the SFS) and 2,273 pupils participated. The median %SFS complied with was 63.9% (interquartile range 60.0–70.0%). This was similar for SFS-non-mandated (64.5%) and SFS-mandated schools (63.3%). Compliance was highest for standards applying to lunchtime (median = 81.3%) and lowest for those applying across the whole school day (median = 41.7%). It was also lower for standards restricting high fat, sugar and energy-dense items (median = 26.1%) than for standards aiming to increase dietary variety (median = 92.3%). Pupils from SFS-mandated schools had a lower mean lunchtime intake of free sugar (g) (adjusted mean difference: -2.78g; 95% CI: -4.66g to -0.90g). There were few significant associations between %SFS complied with and pupil nutritional intake. Conclusions: English secondary schools do not fully comply with SFS legislation regardless of whether they are mandated to comply. Schools and caterers may require monitoring and support to fully comply. There is little evidence that SFS compliance is associated with better pupil nutritional intake. Food environments outside of school also need to be considered. Study registration: ISRCTN68757496 (17-10-2019). [ABSTRACT FROM AUTHOR]

Background: Heroin-Assisted Treatment (HAT) is well evidenced internationally to improve health and social outcomes for people dependent on opioids who have not been helped by traditional treatment options. Despite this evidence base, England has been slow to implement HAT. The first service outside of a trial setting opened in 2019, providing twice-daily supervised injections of medical-grade heroin (diamorphine) to a select sample of high-risk heroin users in Middlesbrough. This paper explores their experiences, including the negotiation of the strict regularly controls required of a novel intervention in the UK context. Methods: We conducted in-depth interviews with service providers and users of the Middlesbrough HAT service between September and November 2021. Data from each group were thematically analysed and reported separately. This paper details the experiences of the twelve heroin dependent men and women accessing HAT. Results: Participants' accounts of HAT treatment evidenced a tension between the regulatory constraints and uncertainty of treatment provision, and the positive outcomes experienced through supportive service provision and an injectable treatment option. Limited confidence was held in treatment efficacy, longevity of funding, and personal capacity for treatment success. This was counteracted by a strong motivation to cease engagement with the illicit drug market. While attendance requirements placed restrictions on daily activities, participants also experienced benefits from strong, supportive bonds built with the service providers through their continued engagement. Conclusions: The Middlesbrough HAT programme provided benefits to a high-risk population of opioid dependent people who were unable or disinclined to participate in conventional opioid substitution treatments. The findings in this paper highlight the potential for service modifications to further enhance engagement. The closure of this programme in 2022 prohibits this opportunity for the Middlesbrough community, but holds potential to inform advocacy and innovation for future HAT interventions in England. [ABSTRACT FROM AUTHOR]

Background: Long-acting injectable buprenorphine (LAIB) is a new treatment for opioid use disorder that has been introduced against an international policy backdrop of recovery and person-centred care. This paper explores the goals that people want to achieve from LAIB to identify potential implications for policy and practice. Methods: Data derive from longitudinal qualitative interviews conducted with 26 people (18 male; 8 female) initiating LAIB in England and Wales, UK (June 2021-March 2022). Participants were interviewed up to five times by telephone over six months (107 interviews in total). Transcribed interview data relating to each participant's treatment goals were coded, summarised in Excel, and then analysed via a process of Iterative Categorization. Results: Participants often articulated a desire to be abstinent without defining exactly what they meant by this. Most intended to reduce their dosage of LAIB but did not want to rush. Although participants seldom used the term 'recovery', almost all identified objectives consistent with current definitions of this concept. Participants articulated broadly consistent goals over time, although some extended the timeframes for achieving treatment-related goals at later interviews. At their last interview, most participants remained on LAIB, and there were reports that the medication was enabling positive outcomes. Despite this, participants were aware of the complex personal, service-level, and situational factors that hindered their treatment progress, understood the additional support they needed to achieve their goals, and voiced frustrations when services failed them. Conclusions: There is a need for wider debate regarding the goals people initiating LAIB are seeking and the diverse range of positive treatment outcomes LAIB could potentially generate. Those providing LAIB should offer regular on-going contact and other forms of non-medical support so that patients have the best opportunity to succeed. Policies relating to recovery and person-centred care have previously been criticised for responsibilising patients and service users to take better care of themselves and to change their own lives. In contrast, our findings suggest that these policies may, in fact, be empowering people to expect a greater range of support as part of the package of care they receive from service providers. [ABSTRACT FROM AUTHOR]

Background: Youth alcohol consumption has fallen markedly over the last twenty years in England. This paper explores the drivers of the decline from the perspectives of young people. Methods: The study used two methods in a convergent triangulation design. We undertook 38 individual or group qualitative interviews with 96 participants in various educational contexts in England. An online survey of 547 young people in England, was also conducted. Participants were aged between 12–19 years. For both data sources, participants were asked why they thought youth alcohol drinking might be in decline. Analysis of interview data was both deductive and inductive, guided by a thematic approach. Content analysis of survey responses further refined these themes and indicated their prevalence within a larger sample. Results: The research identified eight key themes that young people used to explain the decline in youth drinking: The potential for alcohol-related harm; Contemporary youth cultures and places of socialisation; The affordability of alcohol; Displacement of alcohol by other substances; Access and the regulatory environment; Disputing the decline; Future Orientations; and Parenting and the home environment. Heterogeneity in the experiences and perspectives of different groups of young people was evident, particularly in relation to age, gender, and socio-economic position. Conclusions: Young people's explanations for the decline in youth drinking in England aligned well with those generated by researchers and commentators in prior literature. Our findings suggest that changing practices of socialisation, decreased alcohol affordability and changed attitudes toward risk and self-governance may be key explanations. [ABSTRACT FROM AUTHOR]

Background: Dental caries is common in young people and has wide-ranging ramifications for health and quality of life. Text messaging interventions show promise as a means to promote oral health behaviour change among young people. This paper reports the internal pilot of the Brushing RemInder 4 Good oral HealTh (BRIGHT) trial, which is evaluating an intervention comprising an oral health classroom lesson and text messages about toothbrushing, on caries in young people. Pilot trial objectives were to evaluate the feasibility and appropriateness of recruitment and data collection methods, the randomisation strategy, and intervention delivery against progression criteria for the main trial. Methods: This is an internal pilot trial embedded within an assessor-blinded, two-arm, cluster randomised controlled trial. Participants were pupils aged 11–13 years (in year 7/S1 or year 8/S2) in secondary schools in England, Scotland, and Wales with above average pupil eligibility for free school meals. Following completion of pupil baseline questionnaires and dental assessments, year groups within schools were randomised to the intervention or control arm. Approximately 12 weeks later, participants completed a follow-up questionnaire, which included questions about sources of oral health advice to assess intervention contamination between year groups. At the end of the pilot phase, trial conduct was reviewed against pre-specified progression criteria. Results: Ten schools were recruited for the pilot, with 20 year groups and 1073 pupils randomised (average of 54 pupils per year group). Data collection methods and intervention delivery were considered feasible, the response rate to the follow-up questionnaire was over 80%, there was an indication of a positive effect on self-reported toothbrushing, and interest was obtained from 80% of the schools required for the main trial. Despite partial intervention contamination between year groups, within-school randomisation at the level of the year-group was considered appropriate for the main trial, and the sample size was revised to account for partial contamination. Facilitators and barriers to recruitment and data collection were identified and strategies refined for the main trial. Conclusions: Progression to the main trial of BRIGHT, with some design refinements, was concluded. The internal pilot was an efficient way to determine trial feasibility and optimise trial processes. Trial registration: ISRCTN registry, ISRCTN12139369, registered 10/05/2017 [ABSTRACT FROM AUTHOR]

Background: In the context of substantial financial disinvestment from alcohol and drug treatment services in England, our aim was to review the existing evidence of how such disinvestments have impacted service delivery, uptake, outcomes and broader health and social implications.Methods: We conducted a systematic review of quantitative and qualitative evidence (PROSPERO CRD42020187295), searching bibliographic databases and grey literature. Given that an initial scoping search highlighted a scarcity of evidence specific to substance use treatment, evidence of disinvestment from publicly funded sexual health and smoking cessation services was also included. Data on disinvestment, political contexts and impacts were extracted, analysed, and synthesized thematically.Results: We found 20 eligible papers varying in design and quality including 10 related to alcohol and drugs services, and 10 to broader public health services. The literature provides evidence of sustained disinvestment from alcohol and drug treatment in several countries and a concurrent decline in the quantity and quality of treatment provision, but there was a lack of methodologically rigorous studies investigating the impact of disinvestment.Conclusions: This review identified a paucity of scientific evidence quantifying the impacts of disinvestment on alcohol and drug treatment service delivery and outcomes. As the global economy faces new challenges, a stronger evidence base would enable informed policy decisions that consider the likely public health impacts of continued disinvestment. [ABSTRACT FROM AUTHOR]

Background: Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial. Overview of paper: This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people. Plain English summary: Eating disorders are among the most serious mental health problems affecting children and young people. There has been accumulating clinical and research evidence that early expert outpatient treatment is effective and can also significantly reduce the need for costly inpatient care, indicating that investing in community-based eating disorder services is likely to be both clinically and economically beneficial. This paper describes a large-scale service transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in new services for eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community eating disorders services for children and young people. [ABSTRACT FROM AUTHOR]

Introduction: Primary total elbow replacement (TER) services in England are being restructured with the goal of centralising care to specialised centres. It is important to monitor the impact of this service redesign. This protocol outlines an intended analysis to provide detailed descriptions of the patients who are receiving primary TER, where and by whom TER is being performed, and what the current surgical practices for TER are in England before the reconfiguration. Methods: This analysis will use the National Joint Registry (NJR) elbow dataset and link it with NHS England Hospital Episode Statistics-Admitted Patient Care (HES-APC). It will include eligible patients from the start of the NJR elbow dataset in April 2012 to December 2022. The main objective is to determine the incidence of TER in England. Age-sex standardised rates will be calculated for groups including different ethnicities, and socioeconomic backgrounds, using the mid-year population data provided by the Office for National Statistics. This planned analysis will summarise patient characteristics such as age, sex, body mass index (BMI), hand dominance, American Society of Anaesthesiologists (ASA) grade, indication for TER, socioeconomic status, and patient co-morbidities. It will also examine implant fixation type, classification, brand/type, and changes over time in implant types used in England. Additionally, it will explore the characteristics and volume of the surgeons and hospitals providing primary TER services, including the grade of the primary surgeons, funding source for surgery, and admission type. The analysis will cover the number of procedures performed by surgeons and hospitals annually in England and in each region of England. Finally, the planned analysis will summarise the elective wait time, postoperative length of stay, and any serious adverse events or re-admissions within 30 and 90 days after the TER. Discussion: This protocol describes the first deep dive analysis into the NJR elbow dataset to describe the incidence of TER surgery in England and the characteristics of patients who are receiving it. This analysis will summarise current primary TER practices in England before service reconfigurations. The impact of reconfiguration can be monitored by comparing future practice to the outcomes from this study. Trial registration ClinicalTrials.gov, NCT06355011. Registered 02 April 2024, https://clinicaltrials.gov/ct2/show/NCT06355011. [ABSTRACT FROM AUTHOR]

Background: Children in care and care leavers have worse health outcomes than their peers without care experience. This study addresses an evidence gap in exploring care-experienced young people's views and experiences of accessing general practice and dental services and attending health reviews in England. Methods: We conducted a qualitative study using podcasting as a creative medium. We recruited young people from two sites: one in South England (A) and one in greater London (B). We held two paired discussions in site A and two focus groups in site B, with 14 participants in total. Participants were aged between 13 and 22 years and were diverse in gender, ethnicity, and care experiences. Data were analysed thematically using candidacy theory as a theoretical framework. Results: Mental health was a prevailing concern for participants, but general practice was not considered a place to discuss it. Most participants reported distant relationships with primary healthcare professionals and considered opening-up to a professional to be risky, for example, it could result in an unknown/unwanted outcome. A lack of time and personal connection in appointments, and experiences of feeling judged, dismissed, or misunderstood, hindered young people's ability to disclose mental health or relationship concerns. Participants reported variation in the timeliness and location of services, with salient examples of extensive waiting periods for braces. Participants perceived annual health reviews to be largely inconsequential. Conclusions: Any primary care presentation by a care-experienced young person should trigger additional professional curiosity. To build rapport and trust, professionals should not underestimate the power of active listening, being reliable and honest, and small acts of thoughtfulness, for example, ensuring medical letters are provided promptly. Carers and other trusted professionals should help care-experienced young people to understand the role of primary care and support them with access. Health reviews may not be of value to all young people in care. Further research is needed to examine primary healthcare access for care-experienced young people with significant safeguarding and healthcare needs. [ABSTRACT FROM AUTHOR]

Background: Improving the public's understanding of how regional and socioeconomic inequalities create and perpetuate inequalities in health, is argued to be necessary for building support for policies geared towards creating a more equal society. However, research exploring public perceptions of health inequalities, and how they are generated, is limited. This is particularly so for young people. Our study sought to explore young people's lived experiences and understandings of health inequalities. Methods: We carried out focus group discussions (n = 18) with 42 young people, aged 13–21, recruited from six youth organisations in England in 2021. The organisations were located in areas of high deprivation in South Yorkshire, the North East and London. Young people from each organisation took part in three interlinked focus group discussions designed to explore their (i) perceptions of factors impacting their health in their local area, (ii) understandings of health inequalities and (iii) priorities for change. Due to the Covid-19 pandemic, most discussions took place online (n = 15). However, with one group in the North East, we carried out discussions face-to-face (n = 3). Data were analysed thematically and we used NVivo-12 software to facilitate data management. Results: Young people from all groups demonstrated an awareness of a North-South divide in England, UK. They described how disparities in local economies and employment landscapes between the North and the South led to tangible differences in everyday living and working conditions. They clearly articulated how these differences ultimately led to inequalities in people's health and wellbeing, such as linking poverty and employment precarity to chronic stress. Young people did not believe these inequalities were inevitable. They described the Conservative government as prioritising the South and thus perpetuating inequalities through uneven investment. Conclusions: Our study affords important insights into young people's perceptions of how wider determinants can help explain the North-South health divide in England. It demonstrates young people's contextualised understandings of the interplay between spatial, social and health inequalities. Our findings support calls for pro-equity policies to address the structural causes of regional divides in health. Further research, engaging young people in deliberative policy analysis, could build on this work. [ABSTRACT FROM AUTHOR]

Background: Healthcare professionals (HCPs) can play an important role in encouraging patients and their caregivers to be vaccinated. The objective of this qualitative study was to investigate HCPs' perspectives on challenges in vaccine communication and unmet training needs in this domain. Methods: Semi-structured interviews were conducted with 41 HCPs (mainly nurses and physicians) with vaccination roles (23 in England; 18 in France), gathering information on: (1) HCPs' approach to vaccine conversations with patients; (2) Challenges of communicating about vaccines; (3) Vaccine-related training and learning resources available to HCPs, and; (4) HCPs' training needs around vaccine communication. Results: HCPs described a range of communication experiences that indicated insufficient time, information, and skills to confidently navigate difficult conversations with vaccine-hesitant patients. Communication skills were especially important to avoid conflict that could potentially damage the patient-provider relationship. Some HCPs interviewed had received communication training, but for most, this training was not specific to vaccination. Although general communication skills were transferable to vaccine conversations, most HCPs welcomed specific training and informational resources to support countering patients' misconceptions or misinformation about vaccines. Conclusions: HCPs would benefit from training tailored to address vaccine communication with patients, and this should be part of a systemic approach that also provides time and space to have effective vaccine conversations. [ABSTRACT FROM AUTHOR]

Background: Interventions promoting social activity may reduce behavioural psychological symptoms and improve quality of life in people living with dementia. This study aimed to identify social benefits for participants living with dementia in the context of Promoting Activity, Independence and Stability in Early Dementia (PrAISED), an exercise intervention programme promoting physical activity and independence in participants living with dementia in England. Methods: This was a multi-method realist evaluation undertaking secondary analysis of data collected during the PrAISED process evaluation, including qualitative interviews with participants with dementia, caregivers and therapists, personal notes of researchers, and video recordings of therapy sessions. The study consisted of four phases: (1) Setting operational definition of social outcomes in PrAISED; (2) Developing Context, Mechanisms, Outcome (CMO) configurations; (3) Testing and refining CMOs; and (4) Synthesising definitive CMOs into a middle range theory. Results: Two CMOs were identified. (1) When therapists were able to make therapy sessions engaging and had the caregivers' support, the participants experienced therapy sessions as an opportunity to achieve goals in areas they were interested in. They also found the sessions enjoyable. This all led to the participants being highly engaged in their social interactions with the therapists. (2) When the participants realised that they were gaining benefits and progress through the PrAISED intervention, such as increased balance, this boosted their confidence in physical ability. It might also reduce caregivers' risk-aversion/gatekeeping attitude, which in turn would lead to participants' increased participation in social activities. Conclusion: The PrAISED intervention supported social participation in participants living with dementia. Under certain circumstances, home-based therapy interventions can be beneficial for social health (regardless of physical health gains). Given the limitations of currently available outcome measures to assess social participation, qualitative methods should be used to explore social health outcomes. [ABSTRACT FROM AUTHOR]

Background: Ethnicity is known to be an important correlate of health outcomes, particularly during the COVID-19 pandemic, where some ethnic groups were shown to be at higher risk of infection and adverse outcomes. The recording of patients' ethnic groups in primary care can support research and efforts to achieve equity in service provision and outcomes; however, the coding of ethnicity is known to present complex challenges. We therefore set out to describe ethnicity coding in detail with a view to supporting the use of this data in a wide range of settings, as part of wider efforts to robustly describe and define methods of using administrative data. Methods: We describe the completeness and consistency of primary care ethnicity recording in the OpenSAFELY-TPP database, containing linked primary care and hospital records in > 25 million patients in England. We also compared the ethnic breakdown in OpenSAFELY-TPP with that of the 2021 UK census. Results: 78.2% of patients registered in OpenSAFELY-TPP on 1 January 2022 had their ethnicity recorded in primary care records, rising to 92.5% when supplemented with hospital data. The completeness of ethnicity recording was higher for women than for men. The rate of primary care ethnicity recording ranged from 77% in the South East of England to 82.2% in the West Midlands. Ethnicity recording rates were higher in patients with chronic or other serious health conditions. For each of the five broad ethnicity groups, primary care recorded ethnicity was within 2.9 percentage points of the population rate as recorded in the 2021 Census for England as a whole. For patients with multiple ethnicity records, 98.7% of the latest recorded ethnicities matched the most frequently coded ethnicity. Patients whose latest recorded ethnicity was categorised as Other were most likely to have a discordant ethnicity recording (32.2%). Conclusions: Primary care ethnicity data in OpenSAFELY is present for over three quarters of all patients, and combined with data from other sources can achieve a high level of completeness. The overall distribution of ethnicities across all English OpenSAFELY-TPP practices was similar to the 2021 Census, with some regional variation. This report identifies the best available codelist for use in OpenSAFELY and similar electronic health record data. [ABSTRACT FROM AUTHOR]

Background: In recognition of the burden of Perinatal Mental Health problems, NHS England invested £365 million to transform women's access to mental health care, including investment in Community Perinatal Mental Health Services. This study examined how elements of provider care affected women's engagement with these services. Methods: Semi-structured interviews were conducted with 139 women and explored their experiences of care from 10 different Community Perinatal Mental Health Teams; including which service components participants believed made a difference to their initial and continued engagement. Realist analysis was used to create context-mechanism-outcome configurations (CMOCs) across interviews, since not all parts of the configurations were always articulated within singular interviews. Results: Four key pillars for engagement were identified: perinatal competence, relationship building, accurate reassurance, and reliability. The way perinatal competencies were relayed to women mattered; compassion, understanding and consistency were critical interactional styles. The extent to which these factors affected women's engagement varied by their context and personal characteristics. Conclusions: As mental health problems increase, disproportionately affecting vulnerable populations, it is critical to continue to ensure support is not only available, but appropriately meets the needs of those individuals. Our findings suggest that key staff behaviours applied at the right time can support women's engagement and potentially contribute to better treatment outcomes. [ABSTRACT FROM AUTHOR]

Background: Alcohol-related mortality and morbidity increased during the COVID-19 pandemic in England, with people from lower-socioeconomic groups disproportionately affected. The North East and North Cumbria (NENC) region has high levels of deprivation and the highest rates of alcohol-related harm in England. Consequently, there is an urgent need for the implementation of evidence-based preventative approaches such as identifying people at risk of alcohol harm and providing them with appropriate support. Non-alcohol specialist secondary care clinicians could play a key role in delivering these interventions, but current implementation remains limited. In this study we aimed to explore current practices and challenges around identifying, supporting, and signposting patients with Alcohol Use Disorder (AUD) in secondary care hospitals in the NENC through the accounts of staff in the post COVID-19 context. Methods: Semi-structured qualitative interviews were conducted with 30 non-alcohol specialist staff (10 doctors, 20 nurses) in eight secondary care hospitals across the NENC between June and October 2021. Data were analysed inductively and deductively to identify key codes and themes, with Normalisation Process Theory (NPT) then used to structure the findings. Results: Findings were grouped using the NPT domains 'implementation contexts' and 'implementation mechanisms'. The following implementation contexts were identified as key factors limiting the implementation of alcohol prevention work: poverty which has been exacerbated by COVID-19 and the prioritisation of acute presentations (negotiating capacity); structural stigma (strategic intentions); and relational stigma (reframing organisational logics). Implementation mechanisms identified as barriers were: workforce knowledge and skills (cognitive participation); the perception that other departments and roles were better placed to deliver this preventative work than their own (collective action); and the perceived futility and negative feedback cycle (reflexive monitoring). Conclusions: COVID-19, has generated additional challenges to identifying, supporting, and signposting patients with AUD in secondary care hospitals in the NENC. Our interpretation suggests that implementation contexts, in particular structural stigma and growing economic disparity, are the greatest barriers to implementation of evidence-based care in this area. Thus, while some implementation mechanisms can be addressed at a local policy and practice level via improved training and support, system-wide action is needed to enable sustained delivery of preventative alcohol work in these settings. [ABSTRACT FROM AUTHOR]

Background: Clustering and co-occurring of family adversities, including mental health problems, substance use, domestic violence and abuse, as well as poverty can increase health and behavioural risks for children, which persist throughout the life course. Yet, interventions that acknowledge and account for the complex interactive nature of such risks are limited. This study aimed to develop intervention principles based on reflections from mothers, fathers, and young people who experience multiple and interacting adversities. These principles will show how family members perceive an intervention may bring about positive change and highlight key insights into design and delivery. Methods: A series of six co-design workshops with mothers, fathers, and young people who experienced multiple and interacting adversities (n = 41) were iteratively conducted across two regions in England (London and North-East) by four researchers. Workshop content and co-design activities were informed by advisory groups. Data from facilitator notes and activities were analysed thematically, resulting in a set of intervention principles. Results: The intervention principles highlighted that: (1) to reduce isolation and loneliness parents and young people wanted to be connected to services, resources, and peer support networks within their local community, particularly by a knowledgeable and friendly community worker; (2) to address feelings of being misunderstood, parents and young people wanted the development of specialised trauma informed training for practitioners and to have the space to build trusting, gradual, and non-stigmatising relationships with practitioners; and (3) to address the needs and strengths of individual family members, mothers, fathers, and young people wanted separate, tailored, and confidential support. Conclusions: The current study has important implications for practice in supporting families that experience multiple and interacting adversities. The intervention principles from this study share common characteristics with other intervention models currently on offer in the United Kingdom, including social prescribing, but go beyond these to holistically consider the whole families' needs, environments, and circumstances. There should be particular focus on the child's as well as the mothers' and fathers' needs, independently of the family unit. Further refinement and piloting of the developing intervention are needed. Plain English summary: Families can experience multiple difficulties. These difficulties include parental mental health problems, alcohol and drug use, domestic violence, and poverty. These difficulties can impact the wellbeing of both parents and children. Currently, support that is provided to families rarely accounts for these complex and multiple difficulties. This study aimed to gather insights from mothers, fathers, and young people about how to best support families who experience multiple difficulties at the same time. We ran six workshops with community groups of mothers, fathers, and young people from London and North East England. We learned that: (1) Parents and young people wanted to be connected to services, resources and peer support networks within their local community. (2) Parents and young people wanted to build trusting, gradual, and non-stigmatising relationships with practitioners. (3) Parents and young people wanted support that was personalised to their own needs and that focused on their strengths. This research contributes key ideas for supporting families, which will be used alongside other studies to develop new ways of supporting families. The next steps will be to complete and test the developing support model, by delivering it to families and measuring how well it works. [ABSTRACT FROM AUTHOR]

Background: Current research suggests that people with attention deficit hyperactivity disorder (ADHD) are at higher risk of physical and mental health disorders. This study aimed to explore these health risks in ADHD from the perspectives of multiple stakeholders. Methods: This study forms part of the 'Managing young people with ADHD in Primary care (MAP) study'. A survey developed by the study team was distributed to over 16 year olds with ADHD, their supporters, primary healthcare professionals and health commissioners across England, via social media and through patient/clinical networks (September—October 2022). This survey contained two questions on health risks. Question one asked about views on health risks in ADHD (free text). Question two asked about advice given (options list and free text). Descriptive statistics summarised responses to questions one and two, and qualitative analysis (reflexive thematic analysis) was used to explore free text responses from question one. Results: 782 participants responded to the MAP survey. Of these, 206 healthcare professionals, 157 people with ADHD and 88 supporters answered question one. The most mentioned perceived risks were substance misuse, sleep disorders, weight management and smoking. More people with ADHD reported disordered eating as a health risk (n = 32) than healthcare professionals (n = 5). Generated themes included perceived health risks, impact of living with ADHD, lack of adequate healthcare, and need for ADHD awareness. In respect to advice given (question two), based on responses from 258 professionals, 162 people with ADHD and 100 supporters, the most common advice discussed in consultation was mental health (n = 149, n = 50 and n = 17 respectively). High numbers of respondents reported not giving/receiving advice on wider health (n = 38, n = 88 and n = 61 respectively). Conclusions: Findings demonstrate that respondents perceived a range of physical and mental health risks posed by ADHD. These related to difficulties with activities of daily living, as well as healthcare interactions and the impact of core features of ADHD (e.g. impulsivity, emotional dysregulation). These risks are not currently explicitly addressed in United Kingdom national guidance on ADHD. More work is needed to examine and address the broader health outcomes of people with ADHD. [ABSTRACT FROM AUTHOR]

Background: The Ambitions for Palliative and End of Life Care is a national framework for local action in England co-produced by over 30 partners; little research has been conducted on how the Framework is received and used. This study sought to examine and support how people understand, interpret, and implement the Framework. Methods: A multi-stage qualitative methodology involving four stages of data collection: (1) case study interviews, (2) focus groups, (3) interactive workshops, and (4) Evidence Cafés. From initial interviews, ongoing thematic data analysis informed the design and focus of subsequent stages as part of a process of knowledge transfer. Results: A practical resource to support service provision and development was produced; a grab-and-go guide called "Small Steps, Big Visions". It focuses on the eight foundations in the Ambitions Framework, with additional guidance on collaboration and partnership working, and sharing learning. Each foundation is presented with a 'what' (definition), 'ask' (prompt questions), and 'examples in action' (drawn from case studies). Conclusions: Research can contribute to policy implementation to advance palliative and end of life care. The engagement and input of those responsible for implementation is key. [ABSTRACT FROM AUTHOR]

Background: A quality improvement strategy (PReCePT) was used in a standard and enhanced format to scale up a clinical intervention (administering magnesium sulphate to women in preterm labour) across all maternity units in England to protect prematurely born infants from neurodevelopmental disabilities. Formal evaluations reported the effectiveness of the standard package alone in increasing the administration of magnesium sulphate. In this paper, we focus on the findings of the process evaluations, using normalisation process theory to explain how different implementation contexts generated the observed outcomes relating to normative and relational restructuring and sustainment. Methods: Interviews were conducted with key individuals in implementation of leadership positions nationally and locally. Interviews were analysed initially using the framework method. We then engaged recursively with NPT constructs to generate generalisable insights with pragmatic applicability in other settings. Results: In total, 72 interviews were conducted with good representation from units across England and staff from the National Academic Health Science Network. We found that all units irrespective of whether they received a standard or enhanced QI package were successful in the 'normative restructuring' of their setting to enable magnesium sulphate to be administered. This suggests that this implementation outcome is necessary to achieve improvements. However, it may not be sufficient to sustain the changes once additional resources have been withdrawn. Sustainment, our findings suggest, required 'relational restructuring' to accommodate altered workflows and facilitate the sharing of responsibilities and tasks in daily practice. Relational restructuring was more likely to have been achieved units receiving enhanced QI support but also happened in units with standard QI support, especially in those where perinatal team working was already well established. Conclusion: Unlike other large QI-focused spread-and-scale programmes which failed to show any impact on outcomes, the PReCePT programme in both the enhanced and standard support packages led to improvements in the uptake of magnesium sulphate. The findings suggest that QI programmes interact with the enabling factors, such as strong interprofessional team working, already present in the setting. A standard package with minimal support was therefore sufficient in settings with enabling factors, but enhanced support was required in units where these were absent. [ABSTRACT FROM AUTHOR]

Background: Involving communities in research priority setting can increase the relevance and efficiency of research, leading to better health outcomes. However these exercises often lack clarity in how communities are involved and the extent to which priorities are acted upon is unclear. Seldom-heard groups, for example ethnic minorities may experience barriers to participation. We report methods and outcomes of an inclusive co-produced community research priority setting exercise within the multicultural and deprived city of Bradford, UK. The aim was to identify priorities for keeping children happy and healthy and was undertaken by the Born in Bradford (BiB) research programme to inform future research agendas. Methods: A 12 member multi-disciplinary, multi-ethnic community steering group led the process using a modified James Lind Alliance approach between December 2018-March 2020. Research priorities were collected through a widely distributed paper and online survey. Respondents were asked to list three important things to keep children i) happy, ii) healthy and what needs to change to improve either health or happiness. Free text data were coded iteratively by community researchers, and shared priorities were co-produced in a series of workshops and meetings with the community steering group and community members. Results: Five hundred eighty-eight respondents to the survey identified 5748 priorities, which were coded into 22 themes. These covered a range of individual, social and wider socioeconomic, environmental and cultural priorities. Diet/nutrition and exercise were most commonly identified as important for health, including what needs to change to improve health. For happiness, home life and family relationships, listening to children, and education/activities were the most commonly identified. Community assets were identified as important to change for both health and happiness. From the survey response the steering group developed 27 research questions. There were mapped onto existing and planned research agendas within BiB. Conclusions: Communities identified both structural and individual factors as important priorities for health and happiness. We demonstrate how communities can be involved in priority setting using a co-productive approach in the hope this can be used as a model for others. The resulting shared research agenda will shape future research to improve the health of families living in Bradford. [ABSTRACT FROM AUTHOR]

Background: Children and young people's (CYP) mental health is a major public health concern internationally and the recent Covid-19 pandemic has amplified these concerns. However, only a minority of CYP receive support from mental health services due to the attitudinal and structural barriers they and their families encounter. For over 20 years, report after report has consistently highlighted the shortcomings of mental health services for CYP in the United Kingdom and attempts to improve services have been largely unsuccessful. The findings reported in this paper are from a multi-stage study that aimed to develop a model of effective, high-quality service design for CYP experiencing common mental health problems. The aim of the stage reported here was to identify CYP's, parents' and service providers' perceptions of the effectiveness, acceptability and accessibility of services. Methods: Case studies were conducted of nine different services for CYP with common mental health problems in England and Wales. Data were collected using semi-structured interviews with 41 young people, 26 parents and 41 practitioners and were analysed using the Framework approach. Patient and Public Involvement was integrated throughout the study with a group of young co-researchers participating in data collection and analysis. Results: Four key themes defined participants' perceptions of service effectiveness, acceptability and accessibility. Firstly, open access to support with participants highlighting the importance of self-referral, support at the point of need and service availability to CYP/parents. Secondly, the development of therapeutic relationships to promote service engagement which was based on assessment of practitioner's personal qualities, interpersonal skills and mental health expertise and underpinned by relational continuity. Thirdly, personalisation was viewed as promoting service appropriateness and effectiveness by ensuring support was tailored to the individual. Fourthly, the development of self-care skills and mental health literacy helped CYP/parents manage and improve their/their child's mental health problems. Conclusions: This study contributes to knowledge by identifying four components that are perceived to be central to providing effective, acceptable and accessible mental health services for CYP with common mental health problems irrespective of service model or provider. These components could be used as the foundations for designing and improving services. [ABSTRACT FROM AUTHOR]

Background: In the English NHS, integrated care is seen as an opportunity to deliver joined-up care for children and families. This paper examines the lessons learnt by professional stakeholders in the process of developing different examples of integrated models of care/frameworks for children's services. Methods: Initial desk research was undertaken to identify different examples of integrated care models and systems/frameworks for children's services. This identified forty-three examples in England. Of these, twelve examples were shortlisted after consultation with the senior managers within the Health and Care Partnership that had commissioned the research, and a more detailed online search for published documents was undertaken. Semi-structured qualitative interviews were then conducted with sixteen professional stakeholders in eight of these examples, ranging from one to four interviewees per example. Interviews focused on the lessons learnt from integrating and transforming services. Data were analysed using framework analysis. Results: The eight examples vary in their design but have several broad commonalities. A number of common themes and learning have emerged, of which two were identified within all eight examples: the first is about focusing on children and young people; the second is about focusing on partner engagement and collaboration and the importance of building trust and relationships between partners. A number of other important themes also emerged together with several challenges. Conclusions: A number of common factors were identified that are essential to success in integrating health and care systems. Common across all localities were being child-centric and focusing on child outcomes plus the importance of building trust, engagement and relationships with partners. The findings can help health and care system leaders transform services to ensure efficiency, improvement in services and integration. [ABSTRACT FROM AUTHOR]

Women experiencing three or more co-occurring issues (homelessness, substance misuse, mental health) are a highly vulnerable population associated with multimorbidity. Taking women's life stories of trajectories into social exclusion in the north of England as its focus, this paper aims to explore the complexity of social contexts in which women navigate extreme health inequalities. Of the few studies that have examined women's experiences of homelessness through the lens of social capital, most have focused on network size, rather than the quality and influence of the relationships which precipitate or contextualise experiences of social exclusion. We utilise case studies to offer a theoretically-grounded analysis which illustrates the relationship between social capital and homelessness within this population. Our results illustrate how structural contexts, and specifically social capital accrual and social bonding processes particularly pertinent to women can act to both ameliorate and perpetuate social exclusion. We conclude by arguing that health inequalities cannot be tackled as single-issue processes but instead are multi-layered and complex. [ABSTRACT FROM AUTHOR]

In their letter to the Editor in this issue, Kolstoe and Carpenter challenge a core aspect of our recently published case study of research approvals [BMC Medical Ethics 20:7] by arguing that we conflate research ethics with governance and funding processes. Amongst the key concerns of the authors are: 1) that our paper exemplifies a typical conflation of concepts such as governance, integrity and ethics, with significant consequences for claims around the responsibility and accountability of the organisations involved; 2) that, as a consequence of this conflation, we misrepresent the ethics review process, including in fundamental aspects such as the ethics approval-opinion distinction; 3) that it is difficult to see scope for greater integration of processes such as applying for funding, research approvals, Patient and Public Involvement, etc., as suggested by us. Here we present an alternative point of view towards the concerns raised. [ABSTRACT FROM AUTHOR]

Background: People with intellectual disabilities are a marginalized group whose health experiences and outcomes are poor. Lack of skill and knowledge in the healthcare workforce is a contributing factor. In England, there is a new legislative requirement for mandatory intellectual disability training to be given to the existing healthcare workforce, including doctors. There is a lack of evidence about effective models of educational delivery of such training in medical schools. We undertook a scoping review to assess the range of intellectual disabilities educational interventions and their effectiveness. Methods: We included any study from 1980 onwards which reported an educational intervention on intellectual disability, or intellectual disability and autism, for medical students from any year group. Databases searched included PUBMED, ERIC, Scopus and Web of Science as well as searches of grey literature and hand searching two journals (Medical Education and Journal of Learning Disabilities). 2,020 records were extracted, with 1,992 excluded from initial screening, and a further 12 excluded from full-text review, leaving 16 studies for inclusion. Data was extracted, quality assessed, and findings collated using narrative analysis. Results: We found a variety of intervention types: classroom-based teaching, simulation, placement, home visits, and panel discussions. There was substantial variation in content. Most studies involved lived experience input. Across studies, interventions had different learning outcomes which made it difficult to assess effectiveness. Overall study quality was poor, with high use of non-validated measures, making further assessment of effectiveness problematic. Conclusions: There is a need for more consistency in intervention design, and higher quality evaluation of teaching in this area. Our review has drawn attention to the variety in teaching on this topic area and further research should focus on updating this review as curriculum changes are implemented over time. [ABSTRACT FROM AUTHOR]

Patient and public involvement in health research is important to ensure that research remains relevant to the patient groups it intends to benefit. The UK NIHR funded Blueprint study aimed to develop a 'model' of effective service design for children and young people with common mental health problems. To ensure Blueprint's findings were rooted in lived experience and informed by different perspectives, six young adults with lived experience of mental health issues were recruited, trained and employed as co-researchers to work alongside academic researchers. Blueprint collaborated with a third sector partner (McPin) to recruit, employ and mentor the co-researchers and deliver a bespoke training and mentoring package to support their development. Since Blueprint's scheduled work plan was significantly impacted by the Covid-19 pandemic, planned co-researcher activities had to be adapted to accommodate distance learning and remote fieldwork and analysis. Blueprint's co-researchers, academic researchers and a representative of McPin collaboratively used a process of reflexivity and thematic analysis to capture Blueprint's involvement journey. We identified numerous benefits but also challenges to involvement, some of which were exacerbated by the pandemic. Navigating and overcoming these challenges also allowed us to collectively identify key guidelines for involvement for the wider research community which focus on enabling access to involvement, supporting co-researchers and optimising involvement for the benefit of co-researchers and research teams. This paper presents an overview of the Blueprint involvement journey from co-researcher, academic researcher and McPin perspectives, sharing our learning from the recruitment, training, fieldwork and analysis phases in order to inform the knowledge base on lived experience involvement and provide guidance to other researchers who seek to emulate this approach. Plain English summary: The Blueprint study worked with young co-researchers with lived experience to explore services in England and Wales for children and young people with common mental health problems like depression, anxiety and self-harm. Blueprint aimed to find out what services exist, how children, young people and their families find out about and access these services, what the services actually do, and whether they are helpful and offer value for money. Blueprint worked closely with McPin, a charity that works to support young people with lived experience get involved in research. Together we developed a training and mentoring package to support the co-researcher's development and their preparation for the role which included research interviews with service users, parents/carers and service providers and data analysis. The co-researchers, research team and McPin worked together to reflect on the successes and challenges of this approach to research and the challenges of carrying out this work during a global pandemic. We have summarised what we have learnt about how best to enable and support co-researcher involvement to provide guidance to other researchers. [ABSTRACT FROM AUTHOR]