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Background COVID-19 brought additional challenges to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision-making, which was already a contentious issue. In the UK, reports of poor DNACPR decision-making and communication emerged in 2020, including from the regulator, the Care Quality Commission. This paper explores the experiences of people who discussed DNACPR with a healthcare professional on behalf of a relative during the coronavirus pandemic, with the aim of identifying areas of good practice and what needs to be improved. Methods a total of 39 people participated in semi-structured interviews via video conferencing software or telephone. Data were evaluated using Framework Analysis. Findings results are presented around three main themes: understanding, communication and impact. Participants' understanding about DNACPR was important, as those with better understanding tended to reflect more positively on their discussions with clinicians. The role of relatives in the decision-making process was a frequent source of misunderstanding. Healthcare professionals' communication skills were important. Where discussions went well, relatives were given clear explanations and the opportunity to ask questions. However many relatives felt that conversations were rushed. DNACPR discussions can have a lasting impact—relatives reported them to be significant moments in care journeys. Many relatives perceived that they were asked to decide whether their relative should receive CPR and described enduring emotional consequences, including guilt. Conclusion the pandemic has illuminated deficiencies in current practice around DNACPR discussion, which can have difficult to anticipate and lasting negative consequences for relatives. This research raises questions about the current approach to DNACPR decision-making. [ABSTRACT FROM AUTHOR]

Background vaccination uptake in the UK and increased care home testing are likely affecting care home visitation. With scant scientific evidence to date, the aim of this longitudinal qualitative study was to explore the impact of both (vaccination and testing) on the conduct and experiences of care home visits. Methods family carers of care home residents with dementia and care home staff from across the UK took part in baseline (October/November 2020) and follow-up interviews (March 2021). Public advisers were involved in all elements of the research. Data were analysed using thematic analysis. Results across 62 baseline and follow-up interviews with family carers (n  = 26; 11) and care home staff (n  = 16; 9), five core themes were developed: delayed and inconsistent offers of face-to-face visits; procedures and facilitation of visits; variable uptake of the COVID-19 vaccine; misinformation, education and free choice; frustration and anger among family carers. The variable uptake in staff, compared to family carers, was a key factor seemingly influencing visitation, with a lack of clear guidance leading care homes to implement infection control measures and visitation rights differently. Conclusions we make five recommendations in this paper to enable improved care home visitation in the ongoing, and in future, pandemics. Visits need to be enabled and any changes to visiting rights must be used as a last resort, reviewed regularly in consultation with residents and carers and restored as soon as possible as a top priority, whilst more education needs to be provided surrounding vaccination for care home staff. [ABSTRACT FROM AUTHOR]

Background Despite insistent calls for more and better evidence to inform action to reduce health inequities, applied health research sensitive to these inequalities is rare. Recognising this problem, the Collaboration for Leadership in Applied Research and Care in the North West Coast (England) developed the Health Inequalities Assessment Toolkit (HIAT) to support those involved in health research to integrate equity into their work. Objective This paper reports on an evaluation of the extent to which HIAT enhances the equity focus of the work of users. Methods The evaluation used semi-structured interviews, focus groups and workshops (n  = 131 respondents including Public Advisers, university, NHS and local government partners). Routine data included HIAT feedback forms. Findings HIAT can help to strengthen the equity focus of applied health research by: increasing understanding of how socioeconomic inequities impact on health; building capacity for integrating equity into all aspects of research, implementation and capacity building; stimulating thinking on action to address local structural drivers of health inequalities; and increasing understanding of the positive contribution public involvement can make to research. Conclusion If we are to advance health equity goals delivering research and training needs to be combined with political commitment to create more equal societies. [ABSTRACT FROM AUTHOR]

Background Children's second-hand smoke (SHS) exposure in the home is highest in socio-economically disadvantaged areas. Personalized household air-quality measurements can promote changes in smoking that reduce SHS exposure. The 'First Steps 2 Smoke-free' (FS2SF) intervention is the first to trial this approach delivered as part of health professionals' routine work. This paper reports the findings of qualitative interviews with participants that explored their experiences of the intervention and why outcomes varied. Methods 120 women were recruited from the NHS First Steps Programme, which supports disadvantaged mothers. They received either personalized feedback on their home air quality and advice on reducing SHS or standard SHS advice. Qualitative interviews with 15 mothers were analyzed thematically using the Capability, Opportunity, Motivation, Behaviour (COM-B) model. Results The intervention increased women's capability to change home-smoking behaviour, through increasing awareness and salience of SHS risks to their children, and motivation to act. However, taking effective action was constrained by their limited social and environmental opportunities, including others' smoking in the home. Conclusions The FS2SF intervention was ineffective as it was unable to fully address the precarious, complex life circumstances that make creating a smoke-free home particularly difficult for women experiencing intersecting dimensions of disadvantage. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to develop and externally validate multivariable prediction models for future pain intensity outcomes to inform targeted interventions for patients with neck or low back pain in primary care settings. Methods Model development data were obtained from a group of 679 adults with neck or low back pain who consulted a participating United Kingdom general practice. Predictors included self-report items regarding pain severity and impact from the STarT MSK Tool. Pain intensity at 2 and 6 months was modeled separately for continuous and dichotomized outcomes using linear and logistic regression, respectively. External validation of all models was conducted in a separate group of 586 patients recruited from a similar population with patients' predictor information collected both at point of consultation and 2 to 4 weeks later using self-report questionnaires. Calibration and discrimination of the models were assessed separately using STarT MSK Tool data from both time points to assess differences in predictive performance. Results Pain intensity and patients reporting their condition would last a long time contributed most to predictions of future pain intensity conditional on other variables. On external validation, models were reasonably well calibrated on average when using tool measurements taken 2 to 4 weeks after consultation (calibration slope = 0.848 [95% CI = 0.767 to 0.928] for 2-month pain intensity score), but performance was poor using point-of-consultation tool data (calibration slope for 2-month pain intensity score of 0.650 [95% CI = 0.549 to 0.750]). Conclusion Model predictive accuracy was good when predictors were measured 2 to 4 weeks after primary care consultation, but poor when measured at the point of consultation. Future research will explore whether additional, nonmodifiable predictors improve point-of-consultation predictive performance. Impact External validation demonstrated that these individualized prediction models were not sufficiently accurate to recommend their use in clinical practice. Further research is required to improve performance through inclusion of additional nonmodifiable risk factors. [ABSTRACT FROM AUTHOR]

Introduction The adult social care outcomes toolkit (ASCOT) measures social care-related quality of life (SCRQoL) using self-completion questionnaires and interviews. Many care home residents find such methods inaccessible, leading to a reliance on proxy-reporting. This study aimed to establish the psychometric properties of the mixed-methods toolkit [ASCOT-Care Homes, 4 outcome (CH4)] for measuring SCRQoL when residents cannot self-report. Methods Two cross-sectional, mixed-methods studies were undertaken in care homes for older people in England between 2015 and 2020. We used the ASCOT-CH4 (observation, and interviews with residents and proxies) to collect information about SCRQoL and collected additional data on residents' needs and characteristics, and variables hypothesised to be related to SCRQoL. Hypothesis testing was applied to establish construct validity, Cronbach's alpha for internal consistency and exploratory factor analysis for structural validity. Results The combined dataset included 475 residents from 54 care homes (34 nursing, 20 residential). Half had a diagnosis of dementia. Less than a third of residents were able to complete an ASCOT interview. Observations and proxy interviews informed researcher ratings, meaning there were no missing ASCOT-CH4 scores. ASCOT-CH4 was found to be a weak unidimensional scale, consistent with other ASCOT measures, with acceptable internal consistency (α  = 0.77, 8 items). Construct validity was supported by the findings. Conclusions The ASCOT-CH4 is an alternative to conventional proxy-questionnaires for measuring the SCRQoL of care home residents, with good psychometric properties. A limitation is that users need a range of data collection skills. Future research should explore whether findings are replicable when data are collected by other researchers. [ABSTRACT FROM AUTHOR]

The use of 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) recommendations has come under scrutiny during the COVID-19 pandemic, and the Care Quality Commission (CQC) has issued a call for new standards, guidance and training. One group for whom new training is required is 'capacity professionals' working in and with residential care facilities. These professionals (including Independent Mental Capacity Advocates and Best Interests Assessors) typically have a social work background and have specialist training regarding the 2005 Mental Capacity Act , the provisions of which have a direct relevance to DNACPR recommendations. We report on a survey and focus groups that probed the experiences of this professional group during the pandemic. We recruited 262 participants by approaching civil society organisations in which capacity professionals are well represented; twenty-two participated in follow-on focus groups. We used manifest content analysis and descriptive statistics to analyse the results. Our findings contribute to an emerging picture of what transpired in residential care homes during the first year of the pandemic and help to provide an empirical and normative basis for the development of the new guidance and training for which the CQC has called. [ABSTRACT FROM AUTHOR]

The value of co-produced research is increasingly recognised. This is a case study of a lay conducted, co-produced qualitative research study on the experiences of social workers and Disabled users of their services of using (or not) digital technologies when communicating with each other. We describe the co-production process from inception to dissemination and draw out lessons for future studies. Disabled lay researchers developed interview topic guides, conducted semi-structured interviews with social workers and Disabled users of social work services, analysed the data and led or contributed to study outputs. Several factors contributed to the success of this study. It was co-produced using service user, practitioner and academic knowledge. It is built on existing trusted relationships. Training and support were targeted and relevant, and delivered using a variety of learning methods, including peer support. Disabled lay researchers drew on their lived experiences to develop topic guides and interpret data. The study team was committed to inclusion, capacity building and an assets-based approach, and to carefully managing power relationships. Challenges were the time required to setup the study and to train and support lay researchers, and the bureaucratic and governance systems that were not ideally suited to root and branch co-production. [ABSTRACT FROM AUTHOR]

Background Public Health registrars (SpRs) were an important component of the workforce that contributed to the COVID-19 response. This study explores their contribution and the impact the early stages of the pandemic had on their learning and training. Methods Data were collected from SpRs in the London and Kent, Surrey, Sussex training programme between July and September 2020 through a mixture of questionnaires and semi-structured interviews. A thematic analysis of interview transcripts was undertaken to identify themes. Results 35/128 SpRs responded to the survey and 11 were interviewed. SpRs were placed across a range of organizations and made a significant contribution to the COVID-19 response. Overall, SpRs learned important skills but working on the response may for some have impacted negatively on training. A number of facilitators and barriers to learning were identified. Conclusion The study findings highlight the opportunities for learning created by the pandemic. However, changing projects and the desire of SpRs to contribute to the response meant the impacts on training were mixed. Future deployment of SpRs should consider the balance of responsibility and pace when delegating work, as well as the need to supervise effectively and support remote working to maintain good mental wellbeing. [ABSTRACT FROM AUTHOR]

Background In Europe, more than 15 million people live with heart failure (HF). It imposes an enormous social, organizational and economic burden. As a reaction to impending impact on healthcare provision, different country-specific structures for HF-care have been established. The aim of this report is to provide an overview and compare the HF-care approaches of Germany, Ireland, the Netherlands and the UK, and to open the possibility of learning from each other's experience. Methods A mixed methods approach was implemented that included a literature analysis, interviews and questionnaires with HF-patients and caregivers, and expert interviews with representatives from healthcare, health service research and medical informatics. Results The models of HF-care in all countries analyzed are based on the European Society of Cardiology guidelines for diagnosis and treatment of HF. Even though the HF-models differed in design and implementation in practice, key challenges were similar: (i) unequal distribution of care between urban and rural areas, (ii) long waiting times, (iii) unequal access to and provision of healthcare services, (iv) information and communication gaps and (v) inadequate implementation and financing of digital applications. Conclusion Although promising approaches exist to structure and improve HF-care, across the four countries, implementation was reluctant to embrace novel methods. A lack of financial resources and insufficient digitalization making it difficult to adopt new concepts. Integration of HF-nurses seems to be an effective way of improving current models of HF-care. Digital solutions offer further opportunities to overcome communication and coordination gaps and to strengthen self-management skills. [ABSTRACT FROM AUTHOR]

Background and Objectives Existing research reveals that single men living alone are at a heightened risk of isolation and precarity. This study traced the impact of the pandemic on the daily lives of a group of single men over three waves of the COVID-19 pandemic in the United Kingdom. Research Design and Methods A qualitative longitudinal study with older people aged 50 and older (n = 102), interviewed by telephone in 2020–2021. This analysis focuses on a subsample comprising single men (n = 16) who lived alone and were interviewed three times (n = 48). The men were White British, Black, and Asian, aged 58–88 years, and were identified as facing difficulties in their lives arising from long-term health problems and or/social isolation. Participants were asked about the impact of, and response to, three lockdowns. Data were analyzed using themes identified in the secondary literature using thematic and longitudinal analysis. Results For single men living alone, precarity intensified during the pandemic due to worsening physical and/or mental health combined with restricted access to relationships and activities. Key moments in the life course influenced how these men experienced and viewed the impact of COVID-19. Discussion and Implications This analysis sheds light on the deepening precarity of older men living alone during the pandemic, highlighting the emergence of new vulnerabilities for some. The findings emphasize the need, given the likelihood of future waves of the pandemic, to target support at those living alone, particularly in relation to the provision of community health services, social infrastructure, and combating digital exclusion. [ABSTRACT FROM AUTHOR]

The article provides a novel look at the links between salutogenesis, health promotion, and urban design supported by the findings of recent research on local high streets and their benefits for the well-being of older people. Salutogenesis and the related explanatory concept of sense of coherence (SOC) have provided a theoretical framework for developing healthy settings interventions, shifting the focus from exploring barriers and deficits to assets and resources in promoting people's health and well-being. While these concepts have informed policies and programmes at the level of regions and cities, no attempt has been made to establish more direct links with the disciplines devoted to the organization and design of the built environment at the scale of public spaces and streets. This article advances the idea that the main categories of SOC—comprehensibility, manageability and meaningfulness—have found application in urban design theory. Linking these categories with urban design concepts in a comprehensive framework, it is possible to guide interventions aimed at strenghtening well-being resources available in the public realm. This is corroborated by the findings resulting from a study of the well-being experiences of older people (n = 84) across a range of local high streets in the city of Edinburgh (UK) applying an innovative multi-methods approach. The discussion establishes the links between well-being benefits, SOC constructs and urban design concepts, and underscores the potential of the proposed framework to guide a design-oriented salutogenic approach to the built environment. [ABSTRACT FROM AUTHOR]

Background sexuality, intimacy and relationship needs are often a neglected aspect of the care of older adults in residential care facilities. Improving awareness, knowledge and improving attitudes about these needs among care staff could enhance quality of care and lead to better outcomes for residents. Objective to evaluate the feasibility and acceptability of a co-designed education and training e-resource to help care staff support their residents' sexuality, intimacy and relationship needs. Methods we delivered the education and training e-resource to five UK care homes over a 6-month period in a pre-post mixed methods study using surveys, focus groups and individual interviews. Results fifty-nine members of staff from participating care homes undertook the education and training e-resource. 18/59 (31%) of participants completed all six modules and the pre-post surveys. Eleven participants participated in focus groups/interviews to explore experiences of using the e-resource. The e-resource was successfully implemented in the study homes and found to be acceptable. We found preliminary evidence of positive changes in staff attitudes. Factors that facilitated implementation included support from the care home manager. Barriers identified included IT infrastructure and technology. Conclusions the findings provide initial evidence that a co-designed education and training e-resource raised awareness of, and improved attitudes towards, older adults' sexuality and intimacy needs. This work provides the foundation for a next phase to establish the effectiveness of the e-resource on staff practice and resident outcomes. [ABSTRACT FROM AUTHOR]

This article explores the impact of online Irish traditional singing sessions on health and well-being during the COVID-19 pandemic. Singing sessions are unique facets of Ireland's music tradition that saw dramatic closure, interruption and digital transition in response to COVID-19 social distancing measures. This study highlights a gap in health promotion literature with regard to traditional singing sessions as a group singing activity and examines the potential for online group singing activities to have positive impacts on the health and well-being of participants. While traditional singing sessions foreground solo performances, they are quintessentially group activities, and include community engagement and active participation from singers and listeners alike. Through an online survey (n  = 108), and ethnographic interviews (n  = 3), this study explores potential health and well-being implications of online traditional singing sessions, and reveals four main areas of impact: social connection, enjoyment, cognitive motivation and timekeeping. The study suggests that online traditional singing sessions can promote health and well-being in participants, particularly during times of isolation. [ABSTRACT FROM AUTHOR]

To explore how Experts by Experience (EbyE) conceptualize key priorities for preventing and reducing gambling-related harm in the United Kingdom (UK). To identify barriers and facilitators to EbyE engagement in decisions for gambling research, education, treatment (RET) and policy development. Qualitative study utilizing semi-structured interviews with 20 participants from the UK between March and July 2020. Gamblers aged 29–60 years who self-reported that they had experienced gambling-related harm, and who actively used their experiences to inform strategies to prevent and reduce gambling-related harm in the UK. Participants were motivated to: advocate for gambling reform, and raise awareness of their experiences of gambling addiction or disorder. Gambling regulation was described as not adequately keeping pace with gambling industry practices, with initiatives needed to prevent the harms associated with product design, how individuals engaged with products and marketing practices. The reliance on voluntary contributions by the gambling industry for RET was perceived as a potential barrier to reform. Participants recommended new independent structures which engaged EbyE in meaningful ways in contributing to decision-making. An independent body run by and for EbyE was one mechanism that participants perceived could represent the voices of those impacted by gambling-related harm. Individuals with a lived experience of gambling-related harm, including affected social network members, bring a range of unique experiences and perspectives, and should be seen as valuable stakeholders in co-producing strategies to prevent and reduce gambling-related harm. [ABSTRACT FROM AUTHOR]

Objectives Medication adherence is critical in the successful management of lupus. There is very limited existing literature on reasons why non-adherence is not reported. This study explores the impact of current and previous medical experiences on patient satisfaction, adherence and reporting of non-adherence. Methods Mixed methodology involved thematic analysis of in-depth interviews (n  = 23) to further explore the statistically analysed quantitative survey findings (n  = 186). Results This study identified five themes: (i) physician-patient discordance and a 'hierarchy of evidence' in medication decisions; (ii) the association of adherence with satisfaction with care; (iii) the persisting impact of past adverse medical experiences (AMEs); (iv) the dynamic balance of patient-physician control; and (v) holistic care, beyond a purely medication-based focus. Improving quality of life (43% of participants) and a supportive medical relationship (24%) were the main reasons for adherence. Patient-priorities and self-reported symptoms were perceived as less important to physicians than organ-protection and blood results. Non-reporters of non-adherence, non-adherers and those with past AMEs (e.g. psychosomatic misdiagnoses) had statistically significant lower satisfaction with care. The importance of listening to patients was a key component of every theme, and associated with patient satisfaction and adherence. The mean rating for rheumatologist's listening skills was 2.88 for non-adherers compared with 3.53 for other participants (mean difference 0.65, P = 0.003). Conclusion Patients would like more weight and discussion given to self-reported symptoms and quality of life in medication decisions. Greater understanding and interventions are required to alleviate the persisting impact of past AMEs on some patients' wellbeing, behaviour and current medical relationships. [ABSTRACT FROM AUTHOR]

Introduction advance care planning (ACP) in care homes has high acceptance, increases the proportion of residents dying in place and reduces hospital admissions in research. We investigated whether ACP had similar outcomes when introduced during real-world service implementation. Methods a service undertaking ACP in Lincoln, UK care homes was evaluated using routine data. Outcomes were proportion of care homes and residents participating in ACP; characteristics of residents choosing/declining ACP and place of death for those with/without ACP. Hospital admissions were analysed using mixed-effects Poisson regression for number of admissions, and a mixed-effects negative binomial model for number of occupied hospital bed days. Results About 15/24 (63%) eligible homes supported the service, in which 404/508 (79.5%) participants chose ACP. Residents choosing ACP were older, frailer, more cognitively impaired and malnourished; 384/404 (95%) residents choosing ACP recorded their care home as their preferred place of death: 380/404 (94%) declined cardiopulmonary resuscitation. Among deceased residents, 219/248 (88%) and 33/49 (67%) with and without advance care plan respectively died in their care home (relative risk 1.35, 95% confidence interval [CI] 1.1–1.6, P  < 0.001). Hospital admission rates and bed occupancy did not differ after implementation. Discussion About 79.5% participants chose ACP. Those doing so were more likely to die at home. Many homes were unwilling or unable to support the service. Hospital admissions were not reduced. Further research should consider how to enlist the support of all homes and to explore why hospital admissions were not reduced. [ABSTRACT FROM AUTHOR]

Background: Against a background of declining blood donor numbers, recruiting new donors is critical for the effective operations of healthcare providers. Thus, interventions are needed to recruit new blood donors.Purpose: We provide initial evidence for Voluntary Reciprocal Altruism (VRA) to enhance nondonors' willingness to become blood donors. VRA interventions involve asking two questions: one on accepting a blood transfusion if needed and one on willingness to donate. As early trials often use self-reports of willingness to perform blood donation behavior, we derive a correction factor to better estimate actual behavior. Finally, we explore the effect of VRA interventions on two prosocial emotions: gratitude and guilt.Methods: Across three experiments (two in the UK and one in Australia: Total N = 1,208 nondonors) we manipulate VRA messages and explore how they affect both reported willingness to make a one-off or repeat blood donation and influence click through to blood donation, organ donation and volunteering registration sites (behavioral proxies). We report data from a longitudinal cohort (N = 809) that enables us to derive a correction for self-reported behavioral willingness.Results: Across the three experiments, we show that exposure to a question that asks about accepting a transfusion if needed increased willingness to donate blood with some spillover to organ donor registration. We also show that gratitude has an independent effect on donation and report a behavioral correction factor of .10.Conclusions: Asking nondonors about accepting a transfusion if needed is likely to be an effective strategy to increase new donor numbers. [ABSTRACT FROM AUTHOR]

The constituency work of British Members of Parliament (MPs) has long been referred to in political circles as a form of social work. This article reports on a qualitative study using semi-structured interviews with thirteen MPs. The aim of the research was to find out what characterises their constituency work to understand why it apparently bears comparison with social work. The article draws on the concepts of proximity and place from the mobilities paradigm to articulate the idea of 'politics as social work'. MPs in the study engaged in face-to-face emotional labour in which they formed and sustained empathic relationships with people and places to represent them. They practised judgement under uncertainty and risk work, and they were embedded in local organisational networks of risk and trust with local authorities and other agencies. The article argues that this analysis of politics as social work provides a deeper understanding of the politics of social work. In the era of the COVID-19 pandemic and its severe socio-economic impact, the importance for social work of the concept of emplaced empathy and the need for our reorientation to place is thrown into particularly sharp focus. [ABSTRACT FROM AUTHOR]

Background Gypsies, Roma and Travellers are at risk of low uptake of routine immunizations. Interventions to improve uptake in these communities are seldom evaluated. As part of a qualitative study exploring barriers and facilitators to immunization uptake in Travellers, we report service provider (SP) perspectives. Methods We interviewed immunization SPs working with six Traveller communities across four UK cities. Participants included frontline staff and those with strategic or commissioning roles. Semi-structured interviews explored perceived attitudes of Travellers to vaccinations, local service delivery, and opportunities and challenges to improving uptake. Audio-recordings were transcribed, analyzed thematically and mapped to a socio-ecological model of health. Results 39 SPs participated. Four overarching themes were identified: building trusting relationships between SPs and Travellers; facilitating attendance at appointments; improving record keeping and monitoring and responding to local and national policy change. Travellers were perceived as largely supportive of immunizations, though system and organizational processes were recognized barriers to accessing services. Conclusions Findings were broadly consistent across Traveller groups and settings. The barriers identified could often be addressed within existing infrastructure, though require system or policy change. Development of a culturally competent system appears important to enable equity in access to immunizations for Travellers. [ABSTRACT FROM AUTHOR]

Introduction: The advertising of e-cigarettes in the UK is regulated through the revised EU Tobacco Products Directive and the Tobacco and Related Products Regulations, with further rules set out in the Advertising Standards Authority (ASA) Committees of Advertising (CAP) Code. Focusing on the ASA CAP Code Rules, we examined e-cigarette advertising regulation compliance in traditional advertising channels and on social media.Methods: We conducted a content analysis of UK e-cigarette and related product advertising using a randomly selected sample (n = 130) of advertising in traditional channels and on Instagram which appeared between January and December 2019. All ads were independently double-coded to assess compliance with each CAP Code Rule.Results: In traditional channels, our sample of advertising had largely good compliance. Only very small numbers of these ads appeared to be clearly in breach of any of the ASA rules (5% were in breach of Rule 22.7; 2% of Rule 22.9; and 1% of Rule 22.10). In contrast, we judged that all of the Instagram sample (n = 30) was in breach of Rule 22.12. For some rules, it was not possible to make definitive judgments about compliance, given uncertainty regarding how a rule should be interpreted and applied.Conclusions: We found overall good compliance for advertising in traditional channels, but assessed all of our social media advertising samples was in breach of regulations. Current guidance on e-cigarette advertising could be improved to facilitate e-cigarette advertising assessment and regulation. It would be beneficial to bring consumer perspectives into the assessment of regulation compliance.Implications: The regulation of e-cigarette advertising is a global concern. The UK Government has a statutory obligation to review the Tobacco and Related Products Regulations by May 2021. This study assessed compliance with current UK e-cigarette advertising regulations on placement and content. We identified areas where greater clarity is needed and outlined implications for future regulation. [ABSTRACT FROM AUTHOR]

Introduction the aim of this study was to develop a programme theory to inform the design of loneliness interventions and guide any future evaluations. Methods we undertook a mixed-method evaluation, informed by the realist approach, of different approaches to loneliness in one health and social care system in the East Midlands, UK. We used a combination of documentary analysis, interviews/focus groups with service providers and users and quantitative analysis to develop an initial programme theory. Results common aims of local interventions included enhancing social connectivity, providing emotional support and advice/information; recurring interventions included social activities, emotional support, advice and information, lunch clubs, learning new skills and practical support. None were robustly evaluated. Fifty-six service user or providers were involved in interviews or focus groups, which highlighted the causes of loneliness, preferred services, access to services, thoughts about intervention configuration and desired outcomes from services. The themes emerging from the interviews/focus groups from both service provider and service user perspectives were combined with all of the previous emerging data to create an overarching programme theory. Statements were constructed to allow service providers to think about which interventions might be useful to achieve specific outcomes in different contexts. Conclusion the causes and consequences of loneliness vary widely between individuals, so a personalised approach is required to identify the causes and potential solutions. This study provides some high-level principles that can help commissioners and providers to tailor interventions to the individual needs of service users. [ABSTRACT FROM AUTHOR]

Introduction Care homes have been severely affected by the SARS-CoV-2 pandemic. Rapid antigen testing could identify most SARS-CoV-2 infected staff and visitors before they enter homes. We explored implementation of staff and visitor testing protocols using lateral flow devices (LFDs). Methods An evaluation of a SARS-CoV-2 LFD-based testing protocol in 11 care homes in Liverpool, UK, including staff and visitor testing, plus a qualitative exploratory study in nine of these homes. The proportion of pilot homes with outbreaks, and outbreak size, were compared to non-pilot homes in Liverpool. Adherence to testing protocols was evaluated. Fifteen staff were interviewed, and transcript data were thematically coded using an iterative analysis to identify and categorize factors influencing testing implementation. Results In total, 1,638 LFD rapid tests were performed on 407 staff. Protocol adherence was poor with 8.6% of staff achieving >75% protocol adherence, and 25.3% achieving |$\ge$| 50%. Six care homes had outbreaks during the study. Compared to non-pilot care homes, there was no evidence of significant difference in the proportion of homes with outbreaks, or the size of outbreaks. Qualitative data showed difficulty implementing testing strategies due to excessive work burden. Factors influencing adherence related to test integration and procedural factors, socio-economic factors, cognitive overload and the emotional value of testing. Conclusion Implementation of staff and visitor care home LFD testing protocols was poorly adhered to and consequently did not reduce the number or scale of COVID-19 outbreaks. More focus is needed on the contextual and behavioural factors that influence protocol adherence. [ABSTRACT FROM AUTHOR]

Background informal carers provide the majority of the support for persons with dementia living at home. Restrictions imposed due to COVID-19 have had a profound impact on the daily life of the entire population. This study provides insight into the impact of these restrictions on carers of people with dementia living at home. Design qualitative semi-structured interviews. Participants purposive sample of carers who provide at least 10 hours of care a week for the person with dementia living at home. Setting UK. Results twenty-three carers were interviewed, and thematic analysis identified three main themes—Changes to daily life, impact on carer health and wellbeing and reduced support from health and social support networks. The results highlight the impact of restrictions imposed on daily life and routines due to the pandemic, wellbeing of carers, reduced social support, lack of access to health and care professionals and respite for carers. The restrictions have had negative consequences on carers' wellbeing, and they have experienced difficulties in accessing formal care services and respite care. Conclusion carers attempt to continue to provide physical, emotional and practical support for persons with dementia in the community throughout the COVID-19 restrictions. To prevent a future carer crisis, carers need better support systems including formal carer services, telecare solutions that work for them and additional support for respite, as the restrictions from this pandemic continue. [ABSTRACT FROM AUTHOR]

Objective to explore physiotherapists' perceptions of mechanisms to explain observed variation in early postoperative practice after hip fracture surgery demonstrated in a national audit. Methods a qualitative semi-structured interview study of 21 physiotherapists working on orthopaedic wards at seven hospitals with different durations of physiotherapy during a recent audit. Thematic analysis of interviews drawing on Normalisation Process Theory to aid interpretation of findings. Results four themes were identified: achieving protocolised and personalised care; patient and carer engagement; multidisciplinary team engagement across the care continuum and strategies for service improvement. Most expressed variation from protocol was legitimate when driven by what is deemed clinically appropriate for a given patient. This tailored approach was deemed essential to optimise patient and carer engagement. Participants reported inconsistent degrees of engagement from the multidisciplinary team attributing this to competing workload priorities, interpreting 'postoperative physiotherapy' as a single professional activity rather than a care delivery approach, plus lack of integration between hospital and community care. All participants recognised changes needed at both structural and process levels to improve their services. Conclusion physiotherapists highlighted an inherent conflict between their intention to deliver protocolised care and allowing for an individual patient-tailored approach. This conflict has implications for how audit results should be interpreted, how future clinical guidelines are written and how physiotherapists are trained. Physiotherapists also described additional factors explaining variation in practice, which may be addressed through increased engagement of the multidisciplinary team and resources for additional staffing and advanced clinical roles. [ABSTRACT FROM AUTHOR]

Objectives GCA is a large vessel vasculitis (LVV) presenting with headache, jaw claudication, musculoskeletal and visual involvement. Current treatment is glucocorticoids and anti-IL-6 tocilizumab in refractory disease. The objective of this study was to explore the impact of GCA and its treatment on people's health-related quality of life (HRQoL), to inform the development of a disease-specific patient-reported outcome measure (PROM) for use in clinical trials and practice. Methods Participants from the UK and Australia, with biopsy- or imaging-confirmed GCA, were interviewed to identify salient aspects of HRQoL in relation to GCA and its treatment. Purposive sampling included a range of demographic and disease features (cranial, LVV-GCA and visual involvement). Inductive analysis identified individual themes of importance, then domains. Candidate questionnaire items were developed from the individual themes, refined by piloting, cognitive interviews and a linguistic translatability assessment. Results Thirty-six interviews were conducted to saturation with participants with GCA from the UK (25) and Australia (11). Mean age was 74 years, 23 (63.9%) were female, 13 (36.1%) had visual loss and 5 (13.9%) had LVV-GCA. Thirty-nine individual themes within five domains were identified: physical symptoms; activity of daily living and function; participation; psychological impact; and impact on sense of self and perception of health. Sixty-nine candidate items were developed from individual themes; piloting and refinement resulted in a 40-item draft questionnaire. Conclusion This international qualitative study underpins the development of candidate items for a disease-specific PROM for GCA. The draft questionnaire is now ready for psychometric testing. [ABSTRACT FROM AUTHOR]

Background: With genome-wide association data for many exposures and outcomes now available from large biobanks, one-sample Mendelian randomization (MR) is increasingly used to investigate causal relationships. Many robust MR methods are available to address pleiotropy, but these assume independence between the gene-exposure and gene-outcome association estimates. Unlike in two-sample MR, in one-sample MR the two estimates are obtained from the same individuals, and the assumption of independence does not hold in the presence of confounding.Methods: With simulations mimicking a typical study in UK Biobank, we assessed the performance, in terms of bias and precision of the MR estimate, of the fixed-effect and (multiplicative) random-effects meta-analysis method, weighted median estimator, weighted mode estimator and MR-Egger regression, used in both one-sample and two-sample data. We considered scenarios differing by the: presence/absence of a true causal effect; amount of confounding; and presence and type of pleiotropy (none, balanced or directional).Results: Even in the presence of substantial correlation due to confounding, all two-sample methods used in one-sample MR performed similarly to when used in two-sample MR, except for MR-Egger which resulted in bias reflecting direction and magnitude of the confounding. Such bias was much reduced in the presence of very high variability in instrument strength across variants (IGX2 of 97%).Conclusions: Two-sample MR methods can be safely used for one-sample MR performed within large biobanks, expect for MR-Egger. MR-Egger is not recommended for one-sample MR unless the correlation between the gene-exposure and gene-outcome estimates due to confounding can be kept low, or the variability in instrument strength is very high. [ABSTRACT FROM AUTHOR]

Background: Two-sample Mendelian randomization (MR) allows the use of freely accessible summary association results from genome-wide association studies (GWAS) to estimate causal effects of modifiable exposures on outcomes. Some GWAS adjust for heritable covariables in an attempt to estimate direct effects of genetic variants on the trait of interest. One, both or neither of the exposure GWAS and outcome GWAS may have been adjusted for covariables.Methods: We performed a simulation study comprising different scenarios that could motivate covariable adjustment in a GWAS and analysed real data to assess the influence of using covariable-adjusted summary association results in two-sample MR.Results: In the absence of residual confounding between exposure and covariable, between exposure and outcome, and between covariable and outcome, using covariable-adjusted summary associations for two-sample MR eliminated bias due to horizontal pleiotropy. However, covariable adjustment led to bias in the presence of residual confounding (especially between the covariable and the outcome), even in the absence of horizontal pleiotropy (when the genetic variants would be valid instruments without covariable adjustment). In an analysis using real data from the Genetic Investigation of ANthropometric Traits (GIANT) consortium and UK Biobank, the causal effect estimate of waist circumference on blood pressure changed direction upon adjustment of waist circumference for body mass index.Conclusions: Our findings indicate that using covariable-adjusted summary associations in MR should generally be avoided. When that is not possible, careful consideration of the causal relationships underlying the data (including potentially unmeasured confounders) is required to direct sensitivity analyses and interpret results with appropriate caution. [ABSTRACT FROM AUTHOR]

Introduction: We examined the mediating role of friends smoking in the association between depressive symptoms and daily/weekly cigarette smoking from adolescence into adulthood.Methods: Data were drawn from the Nicotine Dependence In Teens study (NDIT, Canada) and the Avon Longitudinal Study of Parents and Children (ALSPAC, UK) studies. Three age groups were investigated in NDIT: age 13-14 (n = 1189), 15-16 (n = 1107), and 17-18 (n = 1075), and one in ALSPAC (n = 4482, age 18-21). Multivariable mediation models decomposed the total effect (TE) of depressive symptoms on smoking into a natural direct effect (NDE) and natural indirect effect (NIE) through friends smoking.Results: The odds ratios (ORs) for the TE were relatively constant over time with estimates ranging from 1.12 to 1.35. Friends smoking mediated the association between depressive symptoms and smoking in the two youngest samples (OR [95% confidence interval [CI] 1.09 [1.01,1.17] in 13- to 14-year-olds; 1.10 [1.03,1.18] in 15- to 16-year-olds). In the two older samples, NDE of depressive symptoms was close to the TE, suggestive that mediation was absent or too small to detect.Conclusion: Friends smoking mediates the association between depressive symptoms and daily/weekly cigarette smoking in young adolescents.Implications: If young adolescents use cigarettes to self-medicate depressive symptoms, then interventions targeting smoking that ignore depressive symptoms may be ineffective. Our results also underscore the importance of the influence of friends in younger adolescents, suggestive that preventive intervention should target the social environment, including social relationships. [ABSTRACT FROM AUTHOR]

Introduction: Standardized packaging was phased in between May 2016 and May 2017 in the United Kingdom and July 2017 and July 2018 in Norway. In both countries, the health warnings on packs prior to standardized packaging being implemented were from the former Tobacco Products Directive library of warnings (text warnings covering 43% of the pack front and pictorial warnings covering 53% of the pack reverse). The warnings on packs, postimplementation, were from the current Tobacco Products Directive library of warnings (novel pictorial warnings covering 65% of the pack front and reverse) for the United Kingdom but unchanged in Norway.Aims and Methods: Longitudinal online surveys were conducted prior to standardized packaging (United Kingdom: April-May 2016; Norway: May-June 2017) and postimplementation (United Kingdom: September-November 2017 and May-July 2019; Norway: August-September 2018). We explored smokers' response to the on-pack warnings (salience, cognitive reactions, and behavioral reactions).Results: In the United Kingdom, noticing warnings on packs, reading or looking closely at them, thinking about them, thinking about the health risks, avoidant behaviors, forgoing cigarettes, and being more likely to quit due to the warnings significantly increased from waves 1 to 2, and then decreased from waves 2 to 3, but remained higher than at wave 1. In Norway, noticing warnings, reading or looking closely at them, thinking about them, thinking about the health risks, and being more likely to quit due to the warnings significantly decreased from waves 1 to 2; avoidant behaviors and forgoing cigarettes remained unchanged.Conclusions: The inclusion of large novel pictorial warnings on standardized packs increases warning salience and effectiveness.Implications: Two longitudinal online surveys in the United Kingdom and Norway explored the impact of standardized packaging on warning salience and effectiveness. That warning salience and effectiveness only increased in the UK postimplementation, where standardized packaging was implemented alongside new larger pictorial warnings on the pack front and reverse, and not in Norway, where standardized packaging was introduced but older smaller text warnings (pack front) and pictorial warnings (pack reverse) were retained, highlights the importance of removing full branding and introducing stronger warnings simultaneously. [ABSTRACT FROM AUTHOR]