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Objectives: e-coachER was a web-based intervention designed to support uptake and maintenance of physical activity for people attending exercise referral schemes (ERS) for weight loss, diabetes, hypertension, osteoarthritis or a history of depression/low mood. The aim of this study was to explore the mechanisms of impact of the e-coachER intervention, specifically how participants interacted with e-coachER and the key mediators of increased physical activity., Design: This was a qualitative one-on-one interview study. Interviews were audio-recorded and transcribed and analysed using thematic analysis., Setting: UK primary care ERS., Participants: A purposive sample of adult patients randomised to the intervention arm of the e-coachER randomised controlled trial., Results: Twenty-six participants (20 female), who had logged on to e-coachER at least once were recruited, resulting in a total of 38 interviews (mean duration 48 min). Four broad, inter-related themes were generated from the data (1) catalyst for change, (2) goals and aspirations, (3) support and (4) engagement with the e-coachER programme. Most participants who took part in e-coachER were already motivated to improve their health and perceived e-coachER as an additional source of motivation and accountability. Many felt that the opportunity to set goals and self-monitor supported participant's competence and autonomy by enabling them to progress at their own pace. Many participants reported on how e-coachER helped them to foster a sense of relatedness by encouraging them to seek support from others. Finally, e-coachER was regarded as being generally accessible and engaging. Despite this, some found it too simplistic, and others found it hard to maintain engagement over time., Conclusions: The e-coachER intervention seemed to be generally motivating in the early stages of initiating behaviour change, but engagement waned over time. Our findings highlight how important an online package might be in supporting behaviour change while also highlighting the challenges of achieving sustained physical activity changes., Trial Registration Number: ISRCTN15644451., Competing Interests: Competing interests: All authors declare support from National Institute for Health Research (NIHR), Health Technology Assessment (grant 13/20/25) for the submitted work. SGD's position is supported by NIHR Applied Research Collaboration, Southwest (PenARC). CG was supported in part by a NIHR Career Development Fellowship (CDF-2012-05-259). All other authors have no financial relationships with any organisations that might have an interest in the submitted work since initiation of the study and have no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: There is modest evidence that exercise referral schemes increase physical activity in inactive individuals with chronic health conditions. There is a need to identify additional ways to improve the effects of exercise referral schemes on long-term physical activity., Objectives: To determine if adding the e-coachER intervention to exercise referral schemes is more clinically effective and cost-effective in increasing physical activity after 1 year than usual exercise referral schemes., Design: A pragmatic, multicentre, two-arm randomised controlled trial, with a mixed-methods process evaluation and health economic analysis. Participants were allocated in a 1 : 1 ratio to either exercise referral schemes plus e-coachER (intervention) or exercise referral schemes alone (control)., Setting: Patients were referred to exercise referral schemes in Plymouth, Birmingham and Glasgow., Participants: There were 450 participants aged 16-74 years, with a body mass index of 30-40 kg/m 2 , with hypertension, prediabetes, type 2 diabetes, lower limb osteoarthritis or a current/recent history of treatment for depression, who were also inactive, contactable via e-mail and internet users., Intervention: e-coachER was designed to augment exercise referral schemes. Participants received a pedometer and fridge magnet with physical activity recording sheets, and a user guide to access the web-based support in the form of seven 'steps to health'. e-coachER aimed to build the use of behavioural skills (e.g. self-monitoring) while strengthening favourable beliefs in the importance of physical activity, competence, autonomy in physical activity choices and relatedness. All participants were referred to a standard exercise referral scheme., Primary Outcome Measure: Minutes of moderate and vigorous physical activity in ≥ 10-minute bouts measured by an accelerometer over 1 week at 12 months, worn ≥ 16 hours per day for ≥ 4 days including ≥ 1 weekend day., Secondary Outcomes: Other accelerometer-derived physical activity measures, self-reported physical activity, exercise referral scheme attendance and EuroQol-5 Dimensions, five-level version, and Hospital Anxiety and Depression Scale scores were collected at 4 and 12 months post randomisation., Results: Participants had a mean body mass index of 32.6 (standard deviation) 4.4 kg/m 2 , were referred primarily for weight loss and were mostly confident self-rated information technology users. Primary outcome analysis involving those with usable data showed a weak indicative effect in favour of the intervention group ( n  = 108) compared with the control group ( n  = 124); 11.8 weekly minutes of moderate and vigorous physical activity (95% confidence interval -2.1 to 26.0 minutes; p  = 0.10). Sixty-four per cent of intervention participants logged on at least once; they gave generally positive feedback on the web-based support. The intervention had no effect on other physical activity outcomes, exercise referral scheme attendance (78% in the control group vs. 75% in the intervention group) or EuroQol-5 Dimensions, five-level version, or Hospital Anxiety and Depression Scale scores, but did enhance a number of process outcomes (i.e. confidence, importance and competence) compared with the control group at 4 months, but not at 12 months. At 12 months, the intervention group incurred an additional mean cost of £439 (95% confidence interval -£182 to £1060) compared with the control group, but generated more quality-adjusted life-years (mean 0.026, 95% confidence interval 0.013 to 0.040), with an incremental cost-effectiveness ratio of an additional £16,885 per quality-adjusted life-year., Limitations: A significant proportion (46%) of participants were not included in the primary analysis because of study withdrawal and insufficient device wear-time, so the results must be interpreted with caution. The regression model fit for the primary outcome was poor because of the considerable proportion of participants [142/243 (58%)] who recorded no instances of ≥ 10-minute bouts of moderate and vigorous physical activity at 12 months post randomisation., Future Work: The design and rigorous evaluation of cost-effective and scalable ways to increase exercise referral scheme uptake and maintenance of moderate and vigorous physical activity are needed among patients with chronic conditions., Conclusions: Adding e-coachER to usual exercise referral schemes had only a weak indicative effect on long-term rigorously defined, objectively assessed moderate and vigorous physical activity. The provision of the e-coachER support package led to an additional cost and has a 63% probability of being cost-effective based on the UK threshold of £30,000 per quality-adjusted life-year. The intervention did improve some process outcomes as specified in our logic model., Trial Registration: Current Controlled Trials ISRCTN15644451., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 24, No. 63. See the NIHR Journals Library website for further project information.

Background: Excessive alcohol consumption is commonly reported in university/college students, and contributes to emerging peer-group relations., Purpose: This study aimed to provide up-to-date longitudinal data on students' alcohol consumption patterns, and predictors of this, across a single academic year., Methods: A 3-wave study was conducted at a university in the UK. Participants reported their alcohol consumption patterns, along with perceptions of the social norms and behavioral expectations associated with attending licensed venues where alcohol is sold (the "night time economy"). Participants also reported their social identification with this environment., Results: Around half of participants overall fell into the three higher alcohol-risk categories (moderate, high or hazardous drinking). A modest reduction in consumption was observed across the study. At each assessment point, males reported greater alcohol consumption in the preceding two months than females, while Year 4 students and those on graduate-entry programs reported the lowest consumption. Excessive alcohol consumption was regarded as largely normative within the night time economy, both descriptively ("what others do") and injunctively ("what others approve of"). Social identification and norm perceptions, along with gender, year group, and intoxication and socialising expectations, were significantly associated with higher alcohol consumption at baseline. However, baseline consumption was the only variable significantly associated with alcohol use at the end of the academic year., Conclusions: Many students drink alcohol at potentially harmful levels, and norms and expectations supporting this consumption are prominent and stable. The findings support a targeted approach to intervention that accounts for heterogeneity in the student population., (Crown Copyright © 2019. Published by Elsevier B.V. All rights reserved.)

Introduction: Physical activity is recommended for improving health among people with common chronic conditions such as obesity, diabetes, hypertension, osteoarthritis and low mood. One approach to promote physical activity is via primary care exercise referral schemes (ERS). However, there is limited support for the effectiveness of ERS for increasing long-term physical activity and additional interventions are needed to help patients overcome barriers to ERS uptake and adherence.This study aims to determine whether augmenting usual ERS with web-based behavioural support, based on the LifeGuide platform, will increase long-term physical activity for patients with chronic physical and mental health conditions, and is cost-effective., Methods and Analysis: A multicentre parallel two-group randomised controlled trial with 1:1 individual allocation to usual ERS alone (control) or usual ERS plus web-based behavioural support (intervention) with parallel economic and mixed methods process evaluations. Participants are low active adults with obesity, diabetes, hypertension, osteoarthritis or a history of depression, referred to an ERS from primary care in the UK.The primary outcome measure is the number of minutes of moderate-to-vigorous physical activity (MVPA) in ≥10 min bouts measured by accelerometer over 1 week at 12 months.We plan to recruit 413 participants, with 88% power at a two-sided alpha of 5%, assuming 20% attrition, to demonstrate a between-group difference of 36-39 min of MVPA per week at 12 months. An improvement of this magnitude represents an important change in physical activity, particularly for inactive participants with chronic conditions., Ethics and Dissemination: Approved by North West Preston NHS Research Ethics Committee (15/NW/0347). Dissemination will include publication of findings for the stated outcomes, parallel process evaluation and economic evaluation in peer-reviewed journals.Results will be disseminated to ERS services, primary healthcare providers and trial participants., Trial Registration Number: ISRCTN15644451; Pre-results., Competing Interests: Competing interests: SGD reports personal fees from University College London outside the submitted work. CM reports grants from NIHR during the conduct of the study; grants from ESRC Impact Acceleration Award outside the submitted work; is an employee of the Health Improvement Team (NHS Greater Glasgow & Clyde) who fund and manage the Service Level Agreement for the Exercise Referral Scheme. NM reports grants from various research funders including NIHR during the conduct of the study. LY reports grants from NIHR during the conduct of the study., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Significant others can play a key role in suicide prevention, but little attention has been given to the resources they may need in order to do so effectively. Based on previous qualitative research and working in partnership with suicide prevention charities, we developed a simple educational leaflet to help family members and friends recognise and respond to a possible suicidal crisis. We disseminated 15,000 copies through a wide range of community agencies within one English local authority. This paper describes the development, distribution and evaluation of the leaflet. The aim of the evaluation was to assess how the distribution strategy was working, whether the leaflet was regarded as useful and acceptable, how it was being used and whether there were any concerns about its content., Design: Interview study., Methods: We conducted two rounds of semi-structured telephone interviews with every agency on the distribution list and in-depth qualitative interviews with a purposefully selected sub-sample., Results: The leaflet was seen as filling an important gap. It was eagerly embraced by staff in frontline agencies, who passed it on to clients, used it for their own personal/professional development and to support clients or colleagues, or used it as a teaching aid. No concerns were raised about its content., Conclusion: Findings reveal a deep-seated fear of talking about suicide among frontline staff. They were using the leaflet in ways we had not anticipated, demonstrating lateral thinking and a real commitment to suicide prevention in agencies that are not typically associated with it.

Background: There are few interventions that directly address self-harming behaviour among adolescents. At the request of clinicians in Child and Adolescent Mental Health Services (CAMHS) in England and working with them, we redeveloped an adult SMS text-messaging intervention to meet the needs of adolescents under the care of CAMHS who self-harm., Methods: We used normalisation process theory (NPT) to assess the feasibility of delivering it through CAMHS. We planned to recruit 27 young people who self-harm and their clinicians, working as dyads and using the intervention (TeenTEXT) for 6 months., Results: Despite strong engagement in principle from CAMHS teams, in practice we were able to recruit only three clinician/client dyads. Of these, two dropped out because the clients were too unwell. We identified a number of barriers to implementation. These included: a context of CAMHS in crisis, with heavy workloads and high stress levels; organisational gatekeeping practices, which limited the extent to which clinicians could engage with the intervention; perceived burdensomeness and technophobia on the part of clinicians, and a belief by many clinicians that CAMHS may be the wrong delivery setting and that the intervention may have better fit with schools and universal youth services., Conclusions: User-centred design principles and the use of participatory methods in intervention development are no guarantee of implementability. Barriers to implementation cannot always be foreseen, and early clinical champions may overestimate the readiness of colleagues to embrace new ideas and technologies. NPT studies have an important role to play in identifying whether or not interventions are likely to receive widespread clinical support. This study of a text-messaging intervention to support adolescents who self-harm (TeenTEXT) showed that further work is needed to identify the right delivery setting, before testing the efficacy of the intervention.

Background: The direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services., Methods: A single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the "Livewell project". 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative., Results: The main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory)., Conclusions: The study has surfaced issues around innovation adoption in the healthcare context. The case identifies 'negotiated order', managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system.

Background: In quasi-markets governance over healthcare providers is mediated by commissioners. Different commissioners apply different combinations of six methods of control ('media of power') for exercising governance: managerial performance, negotiation, discursive control, incentives, competition and juridical control. This paper compares how English and German healthcare commissioners do so., Methods: Systematic comparison of observational national-level case studies in terms of six media of power, using data from multiple sources., Results: The comparison exposes and contrasts two basic generic modes of commissioning: 1. Surrogate planning (English NHS), in which a negotiated order involving micro-commissioning, provider competition, financial incentives and penalties are the dominant media of commissioner power over providers. 2. Case-mix commissioning (Germany), in which managerial performance, an 'episode based' negotiated order and juridical controls appear the dominant media of commissioner power., Conclusions: Governments do not necessarily maximise commissioners' power over providers by implementing as many media of power as possible because these media interact, some complementing and others inhibiting each other. In particular, patient choice of provider inhibits commissioners' use of provider competition as a means of control.