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In 2016, England's National Institute for Health Research (NIHR) celebrated its tenth anniversary as an innovative national health research system with a focus on meeting patients' needs. This provides a good opportunity to reflect on how the creation of the NIHR has greatly enhanced important work, started in 1991, to develop a health research system in England that is embedded in the National Health Service.In 2004, WHO identified a range of functions that a national health research system should undertake to improve the health of populations. Health Research Policy and Systems (HRPS) has taken particular interest in the pioneering developments in the English health research system, where the comprehensive approach has covered most, if not all, of the functions identified by WHO. Furthermore, several significant recent developments in thinking about health research are relevant for the NIHR and have informed accounts of its achievements. These include recognition of the need to combat waste in health research, which had been identified as a global problem in successive papers in the Lancet, and an increasing emphasis on demonstrating impact. Here, pioneering evaluation of United Kingdom research, conducted through the impact case studies of the Research Excellence Framework, is particularly important. Analyses informed by these and other approaches identified many aspects of NIHR's progress in combating waste, building and sustaining research capacity, creating centres of research excellence linked to leading healthcare institutions, developing research networks, involving patients and others in identifying research needs, and producing and adopting research findings that are improving health outcomes.The NIHR's overall success, and an analysis of the remaining problems, might have lessons for other systems, notwithstanding important advances in many countries, as described in papers in HRPS and elsewhere. WHO's recently established Global Observatory for Health Research and Development provides an opportunity to promote some of these lessons. To inform its work, the Observatory is sponsoring a thematic series of papers in HRPS focusing on health research issues such as funding flows, priority setting, capacity building, utilisation and equity. While important papers on these have been published, this series is still open to new submissions. [ABSTRACT FROM AUTHOR]

Background: Co‐production is predicated on equal power‐sharing and responsibility in research partnerships. However, relatively few accounts exist that explore the subjective experience of how co‐researchers achieve such equality, from the perspectives of public contributors and researchers. Aim: This paper aims to provide a unique insight into the process of co‐production, by weaving personal reflections with principles to evaluate the impact arising from co‐produced knowledge. It is based upon participatory research that was initiated by a 'lay' person, on behalf of a community organization, seeking support for Somali families who are affected by autism. The paper explores the evolving partnerships that began with community theatre and qualitative research and leading to extensive dissemination and impact, all of which has been jointly owned and negotiated by the co‐researchers and community organizations. Discussion: Initially, this paper reflects on the process, drawing on principles defined for co‐production in health research and combining it with the co‐researcher's personal reflections of their experiences as insiders and outsiders, stepping in and out of each other's worlds. The value of reciprocity, flexibility and continuous reflection is illustrated. The latter part of the paper explores the impact of this co‐produced knowledge using a theoretical framework, to assess the specific impacts and its broader transformative potential. It demonstrates how (1) opportunities for all partners to be equitably involved to the maximum degree possible throughout the research process can affect social change and (2) co‐produced research can become a catalyst that is dynamic and complex, achieving multi‐layered impact. [ABSTRACT FROM AUTHOR]

Background: Engaging with the public is a key element of health research; however, little work has examined experiences of public involvement in research dissemination. The aim of this paper was to assess the extent of public involvement, experiences of public advisers and resulting changes in the dissemination of the North West Coast Household Health Survey (HHS). Methods: Three writing groups allowed public advisers to contribute to the dissemination of the HHS. A public workshop was set up to aid the co‐production of the research evidence and discuss the experiences of public advisers involved with the survey in March 2018. A focus group with public advisers was conducted in August 2018 to understand their experiences of involvement. Data were analysed using thematic analysis and coded by two researchers. Writing groups are still on‐going. Results: Fourteen public advisers contributed via three face‐to‐face writing groups, by actively interpreting findings and helping in the write‐up of research articles and by presenting talks at the public workshop. At the workshop, seven public advisors contributed to setting priorities for data analysis from the HHS. Five public advisers took part in the focus group, which highlighted that whilst public advisers were generally satisfied with their involvement, they would like to be involved in more activities. Conclusions: Members of the public shaped the dissemination of evidence and provided guidance for future steps. Public advisers were mostly positive about their involvement in the dissemination of the HHS, but highlighted the need for more transparency and support from researchers. [ABSTRACT FROM AUTHOR]

Background: Prospective cohort studies of incident HIV and associated factors among gay, bisexual, and other men who have sex with men (GBMSM) in the United Kingdom are lacking. We report time trends in and factors associated with HIV incidence between 2013 and 2019 among a cohort of GBMSM: the AURAH2 prospective study.Methods and Findings: Participants were recruited through 1 of 3 sexual health clinics in London and Brighton (July 2013 to April 2016) and self-completed a baseline paper questionnaire and subsequent 4-monthly and annual online questionnaires (March 2015 to March 2018), including information on sociodemographics, lifestyle, health and well-being, HIV status, sexual/HIV-related behaviours, and preexposure prophylaxis and postexposure prophylaxis (PrEP/PEP). Incident HIV was ascertained by linkage with national HIV surveillance data from Public Health England (PHE). We investigated the associations of HIV incidence with (1) baseline factors using mixed-effects Weibull proportional hazard models, unadjusted and adjusted for age, country of birth and ethnicity, sexuality, and education level; and (2) time-updated factors, using mixed-effects Poisson regression models. In total, 1,162 men (mean age 34 years, 82% white, 94% gay, 74% university-educated) were enrolled in the study. Thirty-three HIV seroconversions occurred over 4,618.9 person-years (PY) of follow-up: an overall HIV incidence rate (IR) of 0.71 (95% confidence interval (CI) 0.51 to 1.00) per 100 PY. Incidence declined from 1.47 (95% CI 0.48 to 4.57) per 100 PY in 2013/2014 to 0.25 (95% CI 0.08 to 0.78) per 100 PY in 2018/2019; average annual decline was 0.85-fold (p < 0.001). Baseline factors associated with HIV acquisition included the following: injection drug use (6/38 men who reported injection drug-acquired HIV; unadjusted conditional hazard ratio (HR) 27.96, 95% CI 6.99 to 111.85, p < 0.001), noninjection chemsex-related drug use (13/321; HR 6.45, 95% CI 1.84 to 22.64, p < 0.001), condomless anal sex (CLS) (26/741; HR 3.75, 95% CI 1.31 to 10·74, p = 0.014); higher number of CLS partners (HRs >10 partners [7/57]; 5 to 10 partners [5/60]; and 2 to 4 partners [11/293]: 14.04, 95% CI 4.11 to 47.98; 9.60, 95% CI 2.58 to 35.76; and 4.05, 95% CI 1.29 to 12.72, respectively, p < 0.001); CLS with HIV-positive partners (14/147; HR 6.45, 95% CI 3.15 to 13.22, p < 0.001), versatile CLS role (21/362; HR 6.35, 95% CI 2.18 to 18.51, p < 0.001), group sex (64/500; HR 8.81, 95% CI 3.07 to 25.24, p < 0.001), sex for drugs/money (4/55, HR 3.27, 95% CI 1.14 to 9.38, p = 0.027) (all in previous 3 months); previous 12-month report of a bacterial sexually transmitted infection (STI) diagnoses (21/440; HR 3.95, 95% CI 1.81 to 8.63, p < 0.001), and more than 10 new sexual partners (21/471, HRs 11 to 49, 50 to 99, and >100 new partners: 3.17, 95% CI 1.39 to 7.26; 4.40, 95% CI 1.35 to 14.29; and 4.84, 95% CI 1.05 to 22.4, respectively, p < 0.001). Results were broadly consistent for time-updated analysis (n = 622 men). The study's main limitation is that men may not be representative of the broader GBMSM population in England.Conclusions: We observed a substantial decline in HIV incidence from 2013 to 2019 among GBMSM attending sexual health clinics. Injection drug use, chemsex use, and measures of high-risk sexual behaviour were strongly associated with incident HIV. Progress towards zero new infections could be achieved if combination HIV prevention including Test and Treat strategies and routine commissioning of a PrEP programme continues across the UK and reaches all at-risk populations. [ABSTRACT FROM AUTHOR]

Background: Two to 4% of emergency hospital admissions are caused by preventable adverse drug events. The estimated costs of such avoidable admissions in England were £530 million in 2015. The data-driven quality improvement in primary care (DQIP) intervention was designed to prompt review of patients vulnerable from currently prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and anti-platelets and was found to be effective at reducing this prescribing. A process evaluation was conducted parallel to the trial, and this paper reports the analysis which aimed to explore response to the intervention delivered to clusters in relation to participants' perceptions about which intervention elements were active in changing their practice.Methods: Data generation was by in-depth interview with key staff exploring participant's perceptions of the intervention components. Analysis was iterative using the framework technique and drawing on normalisation process theory.Results: All the primary components of the intervention were perceived as active, but at different stages of implementation: financial incentives primarily supported recruitment; education motivated the GPs to initiate implementation; the informatics tool facilitated sustained implementation. Participants perceived the primary components as interdependent. Intervention subcomponents also varied in whether and when they were active. For example, run charts providing feedback of change in prescribing over time were ignored in the informatics tool, but were motivating in some practices in the regular e-mailed newsletter. The high-risk NSAID and anti-platelet prescribing targeted was accepted as important by all interviewees, and this shared understanding was a key wider context underlying intervention effectiveness.Conclusions: This was a novel use of process evaluation data which examined whether and how the individual intervention components were effective from the perspective of the professionals delivering changed care to patients. These findings are important for reproducibility and roll-out of the intervention.Trial Registration: ClinicalTrials.gov, NCT01425502 . [ABSTRACT FROM AUTHOR]

Background: Active for Life Year 5 (AFLY5) is an educational programme for Year 5 children (aged 9-10) designed to increase children's physical activity, decrease sedentary behaviour and increase fruit and vegetable intake. This paper reports findings from a process evaluation embedded within a randomised controlled trial evaluating the programme's effectiveness. It considers the fidelity of implementation of AFLY5 with a focus on three research questions: 1. To what extent was the intervention delivered as planned? 2. In what ways, if any, did the teachers amend the programme? and 3. What were the reasons for any amendments? Methods: Mixed methods were used including data collection via observation of the intervention delivery, questionnaire, teacher's intervention delivery log and semi-structured interviews with teachers and parents. Qualitative data were analysed thematically and quantitative data were summarised using descriptive statistics. Results: Following training, 42 of the 43 intervention school teachers/teaching staff (98 %) were confident they could deliver the nutrition and physical activity lessons according to plan. The mean number of lessons taught was 12.3 (s.d. 3.7), equating to 77 % of the intervention. Reach was high with 95 % of children in intervention schools receiving lessons. A mean of 6.2 (s.d. 2.6) out of 10 homeworks were delivered. Median lesson preparation time was 10 min (IQR 10-20) and 28 % of lessons were reported as having been amended. Qualitative findings revealed that those who amended the lessons did so to differentiate for student ability, update them for use with new technologies and to enhance teacher and student engagement. Teachers endorsed the aims of the intervention, but some were frustrated with having to adapt the lesson materials. Teachers also a reported tendency to delegate the physical activity lessons to other staff not trained in the intervention. Conclusions: Fidelity of intervention implementation was good but teachers' enthusiasm for the AFLY5 programme was mixed despite them believing that the messages behind the lessons were important. This may have meant that the intervention messages were not delivered as anticipated and explain why the intervention was found not to be effective. Trial registration: ISRCTN50133740. [ABSTRACT FROM AUTHOR]

Background: We assessed experiences of human papillomavirus (HPV) vaginal self‐sampling and future screening preferences in an ethnically and socio‐economically diverse group of women overdue for cervical screening. Setting and Participants: A postal questionnaire was embedded in the YouScreen self‐sampling trial in England: 32.5% (2712/8338) of kit completers returned the survey. Kit non‐completers were encouraged to return a questionnaire, but no responses were received. Participants were ethnically diverse (40.3% came from ethnic minority backgrounds), and 59.1% came from the two most deprived quintiles. Differences in confidence in kit completion, trust in the test results and intention to attend a follow‐up test if HPV‐positive were evaluated using Pearson's χ2 analyses. Binary logistic regression models explored predictors of a future screening choice and preferences for urine versus vaginal self‐sampling. Results: Most kit‐completers reported high confidence in self‐sampling (82.6%) and high trust in the results (79.9%), but experiences varied by ethnicity and screening status. Most free‐text comments were positive but some reported difficulties using the device, pain or discomfort. Most women would opt for self‐sampling in the future (71.3% vs. 10.4% for a clinician‐taken test) and it was more often preferred by ethnic minority groups, overdue screeners and never attenders. Urine self‐tests were preferred to vaginal tests (41.9% vs. 15.4%), especially among women from Asian, Black or Other Ethnic backgrounds. Conclusions: Kit‐completers were confident, found the test easy to complete, and trusted the self‐sample results. However, experiences varied by ethnic group and some women highlighted difficulties with the kit. Most women would prefer self‐sampling in the future, but it was not a universal preference, so offering a choice will be important. Patient or Public Contribution: We did not have direct patient and public involvement and engagement (PPIE) in the questionnaire design. However, patients and public representatives did input into the design of the YouScreen trial and reviewed the wider study materials (e.g. participant information sheet). Trial Registration: This questionnaire study was embedded in the YouScreen trial. The protocol for the YouScreen trial is available at https://www.isrctn.com/ISRCTN12759467. The National Institute for Health Research 43 Clinical Research Network (NIHR CRN) Central Portfolio Management System (CPMS) ID is 4441934. [ABSTRACT FROM AUTHOR]

Postwar migrants from the Caribbean and Indian subcontinent (Bangladesh, India, and Pakistan) to the UK are now experiencing the onset of age‐related diseases such as dementia. Our evidence base, both quantitative and qualitative, documenting the experiences of family caregivers of people with dementia is largely drawn from studies undertaken with white European, North American, and Australasian populations. Consequently, there is a need for research in the field of dementia caregiving to reflect the increasing diversity in ethnic identities of the older adult population of the UK. Using semistructured interviews, we investigated the experiences of 18 caregivers of people with dementia in Black Caribbean, Black African, and South Asian (Indian, Pakistani, and Bangladeshi) communities in England. Participants were recruited from the Join Dementia Research platform and were predominantly female intergenerational carers. We identified the following three themes: motivation to care (spending time with the care recipient and reciprocity), positive and negative consequences of caregiving (rewards and consequences), and the cultural context of caregiving (cultural norms and values supporting caregiving and negative attitudes towards dementia). Our findings develop existing literature by identifying (a) the importance of spending time with the person they care for, (b) the absence of faith as a caregiving driver, and (c) the challenge of watching the declining health of a parent. We highlight how the different motivations to care are intertwined and dynamic. This is illustrated by the linking of obligation and reciprocity in our dataset and positive and negative experiences of caregiving. [ABSTRACT FROM AUTHOR]

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Introduction: Healthcare professionals have development needs related to their consumption, use, and practice of clinical research. Little is known about these issues in mental health services specifically. Objectives: A survey of healthcare staff working in an NHS Mental Health and Disability Trust in England was conducted to describe research capacity and culture compared with previously reported samples, and to examine subgroup differences. Methods: An online questionnaire was utilized. The main measure was the Research Capacity and Culture tool comprising measures of individual's perceived research skills and of team and organizational research culture. Previous studies using the same measure were systematically identified, and pooled results, weighted by sample size, were calculated. Analyses were descriptive (current sample versus previous results) and inferential (comparisons between demographic and professional groups within the current sample). Results: N = 293 people completed the survey. The median item scores were poorer than those of pooled samples from studies reporting median item scores on 39/51 (76.5%) occasions and poorer than those pooled samples of studies reporting mean item scores on 51/51 (100.0%) occasions. Individual capability for research was in the 'less than adequate' range more than in previous samples (71.4% vs. 42.9%). For team culture items, the proportions were 84.2% vs. 78.9%, while most responses about organizational culture were in the 'adequate' range (55.6% vs. 66.7%). Staff >20 years employment had poorer perceptions of team and organizational culture. Conclusion: Perceptions of individual research capacity and team and organizational culture were poor compared with previous studies, most of which were conducted in non-mental health settings. There is need for development of research capacity and culture in mental health services including opportunities to develop basic research skills through to strategic developments to promote clinical academic careers. There is considerable room for improvement in the way organizations support research and signpost opportunities. [ABSTRACT FROM AUTHOR]

Background The need to make best use of limited resources in the English National Health Service is now greater than ever. This paper contributes to this endeavour by synthesizing data from cost-effectiveness evidence produced to support the development of public health guidance at the National Institute of Health and Clinical Excellence (NICE). No comprehensive list of cost-effectiveness estimates for public health interventions has previously been published in England. Methods Cost-effectiveness estimates using English cost data were collected and analysed from 21 (of 26) economic analyses underpinning public health guidance published by NICE between 2006 and 2010. Results Two hundred base-case cost-effectiveness estimates were analysed, 15% were cost saving (i.e. the intervention was more effective and cheaper than comparator). Eighty-five per cent were cost-effective at a threshold of £20 000 per quality-adjusted life year and 89% at the higher threshold of £30 000. A further 5.5% were above £30 000 and 5.5% of the interventions were dominated (i.e. the intervention was more costly and less effective than comparator). Conclusions The majority of public health interventions assessed are highly cost-effective. The next challenge is to provide commissioners with a framework that allows information from economic analyses to be combined with other criteria that supports making better investment decisions at a local level. [ABSTRACT FROM AUTHOR]

Background: We have developed a healthy lifestyles programme (HeLP) for primary school aged children (9-10 years), currently being evaluated in a definitive cluster randomised controlled trial. This paper descriptively presents the baseline characteristics of trial children (BMI, waist circumference, % body fat, diet and physical activity) by gender, cluster level socio-economic status, school size and time of recruitment into the trial.Methods: Schools were recruited from across the South West of England and allocated 1:1 to either intervention (HeLP) or control (usual practice) stratified by the proportion of children eligible for free school meals (FSM, <19%, ≥19%) and school size (one Year 5 class, >1 Year 5 class). The primary outcome is change in body mass index standard deviation score (BMI sds) at 24 months post-randomisation. Secondary outcomes are BMI sds at 18 months, waist circumference and percentage body fat sds at 18 and 24 months, proportion of children classified as underweight, overweight and obese at 18 and 24 months, physical activity (for a sub-sample) and food intake at 18 months.Results: At baseline 11.4% and 13.6% of children were categorised as overweight or obese respectively. A higher percentage of girls than boys (25.3% vs 24.8%) and children from schools in FSM category 2 (28.2% vs 23.2%) were overweight or obese. Children were consuming a mean (range) of 4.15 (0-13) energy dense snacks (EDS) and 3.23 (0-9) healthy snacks (HS) per day with children from schools in FSM category 2 consuming more EDS and negative food markers and less HS and positive food markers. Children spent an average 53.6 min per day (11.9 to 124.8) in MVPA and thirteen hours (779.3 min) per day (11 h to 15 h) doing less than 'light' intensity activity. Less than 5% of children achieved the Departments of Health's recommendation of 60 min of MVPA every day.Conclusion: We have excellent completeness of baseline data for all measures and have achieved compliance to accelerometry not seen before in other large scale studies. Our anthropometric baseline data is representative of local and national data for children this age and reflects the gender and socio-economic variations expected of children this age in relation to physical activity and weight status.Trial Registration: ISRCTN15811706 (1/05/2012). [ABSTRACT FROM AUTHOR]

Background: Around a fifth of children starting school in England are now overweight/obese. There is a paucity of interventions with the aim of obesity prevention in preschool-age children in the UK. Previous research has demonstrated some positive results in changing specific health behaviours, however, positive trends in overall obesity rates are lacking. Preschool settings may provide valuable opportunities to access children and their families not only for promoting healthy lifestyles, but also to develop and evaluate behaviour-change interventions.Methods: This paper presents a cluster randomised feasibility study of a theory based behaviour-change preschool practitioner-led intervention tested in four preschool centres in the North East of England. The primary outcome measures were to test the acceptability and feasibility of the data collection measures and intervention. Secondary measures were collected and reported for extra information. At baseline and post intervention, children's anthropometric, dietary and physical activity measures as well as family 'active' time data were collected. The preschool practitioner-led intervention included family intervention tasks such as 'family goal-setting activities' and 'cooking challenges'. Preschool activities included increasing physical activity and providing activities with the potential to change behaviour with increased knowledge of and acceptance of healthy eating. The process evaluation was an on-going monthly process and was collected in multiple forms such as questionnaires, photographs and verbal feedback.Results: 'Gatekeeper' permission and lower-hierarchal adherence were initially a problem for recruitment and methods acceptance. However, at intervention end the preschool teachers and parents stated they found most intervention methods and activities acceptable, and some positive changes in family health behaviours were reported. However, the preschool centres appeared to have difficulties with enforcing everyday school healthy eating policies.Conclusions: The findings from the current study may have implications for nursery practitioners, nursery settings, Local Educational Authorities and policy makers, and contributes to the body of literature. However, further work with preschool practitioners is required to determine how personal attitudes and school policy application can be supported to implement successfully such an intervention.Trial Registration: ISRCTN12345678 (16/02/17) retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Lifestyle interventions targeting physical activity, sedentary time and dietary behaviours have the potential to initiate and support behavioural change and result in public health gain. Although men have often been reluctant to engage in such lifestyle programs, many are at high risk of several chronic conditions. We have developed an evidence and theory-based, gender sensitised, health and lifestyle program (European Fans in Training (EuroFIT)), which is designed to attract men through the loyalty they feel to the football club they support. This paper describes the study protocol to evaluate the effectiveness and cost-effectiveness of the EuroFIT program in supporting men to improve their level of physical activity and reduce sedentary behaviour over 12 months.Methods: The EuroFIT study is a pragmatic, two-arm, randomised controlled trial conducted in 15 football clubs in the Netherlands, Norway, Portugal and the UK (England). One-thousand men, aged 30 to 65 years, with a self-reported Body Mass Index (BMI) ≥27 kg/m(2) will be recruited and individually randomised. The primary outcomes are objectively-assessed changes in total physical activity (steps per day) and total sedentary time (minutes per day) at 12 months after baseline assessment. Secondary outcomes are weight, BMI, waist circumference, resting systolic and diastolic blood pressure, cardio-metabolic blood biomarkers, food intake, self-reported physical activity and sedentary time, wellbeing, self-esteem, vitality and quality of life. Cost-effectiveness will be assessed and a process evaluation conducted. The EuroFIT program will be delivered over 12 weekly, 90-minute sessions that combine classroom discussion with graded physical activity in the setting of the football club. Classroom sessions provide participants with a toolbox of behaviour change techniques to initiate and sustain long-term lifestyle changes. The coaches will receive two days of training to enable them to create a positive social environment that supports men in engaging in sustained behaviour change.Discussion: The EuroFIT trial will provide evidence on the effectiveness and cost-effectiveness of the EuroFIT program delivered by football clubs to their male fans, and will offer insight into factors associated with success in making sustained changes to physical activity, sedentary behaviour, and secondary outcomes, such as diet.Trial Registration: Isrctn: 81935608 . Registered 16 June 2015. [ABSTRACT FROM AUTHOR]

Background: Increasingly, it is being suggested that translational gaps might be eradicated or narrowed by bringing research users and producers closer together, a theory that is largely untested. This paper reports a national study to fill a gap in the evidence about the conditions, processes and outcomes related to collaboration and implementation.Methods: A longitudinal realist evaluation using multiple qualitative methods case studies was conducted with three Collaborations for Leadership in Applied Health Research in Care (England). Data were collected over four rounds of theory development, refinement and testing. Over 200 participants were involved in semi-structured interviews, non-participant observations of events and meetings, and stakeholder engagement. A combined inductive and deductive data analysis process was focused on proposition refinement and testing iteratively over data collection rounds.Results: The quality of existing relationships between higher education and local health service, and views about whether implementation was a collaborative act, created a path dependency. Where implementation was perceived to be removed from service and there was a lack of organisational connections, this resulted in a focus on knowledge production and transfer, rather than co-production. The collaborations' architectures were counterproductive because they did not facilitate connectivity and had emphasised professional and epistemic boundaries. More distributed leadership was associated with greater potential for engagement. The creation of boundary spanning roles was the most visible investment in implementation, and credible individuals in these roles resulted in cross-boundary work, in facilitation and in direct impacts. The academic-practice divide played out strongly as a context for motivation to engage, in that 'what's in it for me' resulted in variable levels of engagement along a co-operation-collaboration continuum. Learning within and across collaborations was patchy depending on attention to evaluation.Conclusions: These collaborations did not emerge from a vacuum, and they needed time to learn and develop. Their life cycle started with their position on collaboration, knowledge and implementation. More impactful attempts at collective action in implementation might be determined by the deliberate alignment of a number of features, including foundational relationships, vision, values, structures and processes and views about the nature of the collaboration and implementation. [ABSTRACT FROM AUTHOR]

Background: Screening with the guaiac faecal occult blood test (gFOBt) is associated with improved colorectal cancer (CRC) survival, and is offered biennially to men and women aged 60-74 years in England's national Bowel Cancer Screening Programme (BCSP). Uptake of the gFOBt is low, with only 54 % of the eligible population completing the test. Text-message reminders could improve uptake of gFOBt.Methods/design: This paper describes the protocol for a randomised controlled trial, which will examine the effectiveness of a text-message reminder to promote uptake of gFOBt screening in the BCSP. Individual mobile telephone data from 180 general practices in London with existing mobile-health services will be linked to the national BCSP information system via a secure on-line network. All screening-eligible adults registered with a participating practice will be randomised, to receive either usual care (N = 1600) or usual care plus a text-message reminder to self-complete and return their kit eight weeks after their initial invitation (N = 1600). The primary outcome will be the proportion of individuals who return an adequately completed gFOBt kit within 18 weeks of the initial invitation. Differences in uptake between groups will be evaluated using a logistic regression analysis, adjusting for individual-level and area-level socio-demographic variables.Discussion: This will be the first large-scale randomised trial of a text-message reminder in a national screening programme for CRC. If effective, this study provides a cost-effective means to promote uptake of CRC screening in an organised programme.Trial Registration: Current Controlled Trials ISRCTN70904476 (18/09/2015). [ABSTRACT FROM AUTHOR]

Background: Social prescribing is a way of addressing the 'non-medical' needs (e.g. loneliness, debt, housing problems) that can affect people's health and well-being. Connector schemes (e.g. delivered by care navigators or link workers) have become a key component to social prescribing's delivery. Those in this role support patients by either (a) signposting them to relevant local assets (e.g. groups, organisations, charities, activities, events) or (b) taking time to assist them in identifying and prioritising their 'non-medical' needs and connecting them to relevant local assets. To understand how such connector schemes work, for whom, why and in what circumstances, we conducted a realist review.Method: A search of electronic databases was supplemented with Google alerts and reference checking to locate grey literature. In addition, we sent a Freedom of Information request to all Clinical Commissioning Groups in England to identify any further evaluations of social prescribing connector schemes. Included studies were from the UK and focused on connector schemes for adult patients (18+ years) related to primary care.Results: Our searches resulted in 118 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs). These CMOCs underpinned our emerging programme theory that centred on the essential role of 'buy-in' and connections. This was refined further by turning to existing theories on (a) social capital and (b) patient activation.Conclusion: Our realist review highlights how connector roles, especially link workers, represent a vehicle for accruing social capital (e.g. trust, sense of belonging, practical support). We propose that this then gives patients the confidence, motivation, connections, knowledge and skills to manage their own well-being, thereby reducing their reliance on GPs. We also emphasise within the programme theory situations that could result in unintended consequences (e.g. increased demand on GPs). [ABSTRACT FROM AUTHOR]

Internet usage is a salient developmental factor in adolescents' lives. Although relevant correlates of Internet use have been documented earlier, there is a lack of information on lower socioeconomic status groups. This is important, as these adolescents have increased risk of negative online experiences. The current survey aimed to explore Internet use and parental involvement amongst adolescents from areas of socio-economic disadvantage in 30 urban schools across five European countries. A total of 2594 students participated, of whom 90% were 14–16 years. Virtually all adolescents of socioeconomic disadvantage had Internet access, with 88.5% reporting spending more than two hours per day online, often on apps such as Instagram, Snapchat, and YouTube. Almost one-third of adolescents did not talk with their parents about their Internet use and almost two-thirds indicated that their parents were only a little or not interested in their Internet use. A consistent finding across countries was that girls more often talked with their parents about their Internet use and more often reported that their parents were interested in their Internet use than boys. The results suggest that parents have an important task in explicitly showing interest in their adolescents' Internet use, with special attention needed for boys. [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]

Background: As integrated care systems are embedded across England there are regions where the integration process has been evaluated and continues to evolve. Evaluation of these integrated systems contributes to our understanding of the challenges and facilitators to this ongoing process. This can support integrated care systems nationwide as they continue to develop. We describe how two integrated care partnerships in different localities, at differing stages of integration with contrasting approaches experienced challenges specifically when integrating with primary care services. The aim of this analysis was to focus on primary care services and how their existing structures impacted on the development of integrated care systems. Methods: We carried out an exploratory approach to re-analysing our previously conducted 51 interviews as part of our prior evaluations of integrated health and care services which included primary care services. The interview data were thematically analysed, focussing on the role and engagement of primary care services with the integrated care systems in these two localities. Results: Four key themes from the data are discussed: (i) Workforce engagement (engagement with integration), (ii) Organisational communication (information sharing), (iii) Financial issues, (iv) Managerial information systems (data sharing, IT systems and quality improvement data). We report on the challenges of ensuring the workforce feel engaged and informed. Communication is a factor in workforce relationships and trust which impacts on the success of integrated working. Financial issues highlight the conflict between budget decisions made by the integrated care systems when primary care services are set up as individual businesses. The incompatibility of information technology systems hinders integration of care systems with primary care. Conclusions: Integrated care systems are national policy. Their alignment with primary care services, long considered to be the cornerstone of the NHS, is more crucial than ever. The two localities we evaluated as integration developed both described different challenges and facilitators between primary care and integrated care systems. Differences between the two localities allow us to explore where progress has been made and why. [ABSTRACT FROM AUTHOR]

Background: Child maltreatment is a significant public health problem. Group Family Nurse Partnership (gFNP) is a new intervention for young, expectant mothers implemented successfully in pilot studies. This study was designed to determine the effectiveness and cost-effectiveness of gFNP in reducing risk factors for maltreatment with a potentially vulnerable population.Methods: A multi-site, randomized controlled, parallel-arm trial and prospective economic evaluation was conducted, with allocation via remote randomization (minimization by site, maternal age group) to gFNP or usual care. Participants were expectant mothers aged below 20 years with at least one live birth, or aged 20-24 years with no live births and with low educational qualifications. Data from maternal interviews at baseline and when infants were 2, 6 and 12 months, and video-recording at 12 months, were collected by researchers blind to allocation. Cost information came from weekly logs completed by gFNP family nurses and other service delivery data reported by participants. Primary outcomes measured at 12 months were parenting attitudes (Adult-Adolescent Parenting Index, AAPI-2) and maternal sensitivity (CARE Index). The economic evaluation was conducted from a UK NHS and personal social services perspective with cost-effectiveness expressed in terms of incremental cost per quality-adjusted life year (QALY) gained. The main analyses were intention-to-treat with additional complier average causal effects (CACE) analyses.Results: Between August 2013 and September 2014, 492 names of potential participants were received of whom 319 were eligible and 166 agreed to take part, 99 randomly assigned to receive gFNP and 67 to usual care. There were no between-arm differences in AAPI-2 total (7 · 5/10 in both, SE 0.1), difference adjusted for baseline, site and maternal age group 0 · 06 (95% CI - 0 · 15 to 0 · 28, p = 0 · 59) or CARE Index (intervention 4 · 0 (SE 0 · 3); control 4 · 7 (SE 0 · 4); difference adjusted for site and maternal age group - 0 · 68 (95% CI - 1 · 62 to 0 · 16, p = 0 · 25) scores. The probability that gFNP is cost-effective based on the QALY measure did not exceed 3%.Conclusions: The trial did not support gFNP as a means of reducing the risk of child maltreatment in this population but slow recruitment adversely affected group size and consequently delivery of the intervention.Trial Registration: ISRCTN78814904 . Registered on 17 May 2013. [ABSTRACT FROM AUTHOR]

Breastfeeding is the most accessible and cost‐effective activity available to public health and has been shown to be one of the most effective preventive measures mothers can take to protect their children's health. Despite the well‐documented benefits, the UK has one of the lowest breastfeeding rates in the world. The Becoming Breastfeeding Friendly (BBF) toolkit was developed through highly structured technical and academic collaboration, led by Yale University. It provides an evidence‐based process to help countries assess their breastfeeding status and readiness to scale up, and identifies concrete measures countries can take to sustainably increase breastfeeding rates, based on data‐driven recommendations. BBF is grounded in the Breastfeeding Gear Model complex adaptive systems framework which is made up of eight simultaneous conditions that sustain breastfeeding. In 2018, a committee of multi‐agency stakeholders implemented the BBF process in England, collecting evidence to score the 'gear' components of England's breastfeeding environment against 54 benchmarks. The Training and Programme Delivery gear received the highest score, attributable to existing learning outcomes for health professionals and practitioners, peer supporters and specialist services, although there is a need for greater coordination and integration. The lowest scores were given for Promotion and Coordination, Goals and Monitoring due to the lack of a dedicated national strategy for breastfeeding and poor sharing of localised strategies and programmes. The process generated clear recommendations highlighting the need for more robust routine infant feeding data collection and reporting, and the necessity for strengthening leadership, monitoring and oversight to scale up and sustain breastfeeding. Key messages: England's overall weighted Becoming Breastfeeding Friendly (BBF) Index score was 1.1 (range 0–3) representing a moderate scaling up environment (range 1.1–2.0). Five gears: Political Will, Legislation and Policies, Funding and Resources; Training and Programme Delivery and Research and Evaluation scored at a moderate gear strength, while the remaining three gears—Advocacy, Promotion and Coordination Goals and Monitoring—were weak.The BBF process for England highlighted substantial gaps in the current breastfeeding practice data and recommended that more robust routine, population‐level infant feeding data collection and reporting is initiated that goes beyond 6–8 weeks and up to 2 years.The process identified that the lack of a national infant feeding co‐ordinator role or national breastfeeding committee had resulted in no dedicated workplan and a lack of advocacy for breastfeeding programmes. The need for greater future coordination, strategic goal setting and consistent monitoring was recommended to strengthen the breastfeeding environment. [ABSTRACT FROM AUTHOR]

Background: The nursing associate role was first deployed in England in 2019 to fill a perceived skills gap in the nursing workforce between healthcare assistants and registered nurses and to offer an alternative route into registered nursing. Initially, trainee nursing associates were predominantly based in hospital settings; however, more recently, there has been an increase in trainees based in primary care settings. Early research has focussed on experiences of the role across a range of settings, particularly secondary care; therefore, little is known about the experiences and unique support needs of trainees based in primary care. Aim: To explore the experiences and career development opportunities for trainee nursing associates based in primary care. Methods: This study used a qualitative exploratory design. Semi-structured interviews were undertaken with 11 trainee nursing associates based in primary care from across England. Data were collected between October and November 2021, transcribed and analysed thematically. Findings: Four key themes relating to primary care trainee experiences of training and development were identified. Firstly, nursing associate training provided a 'valuable opportunity for career progression'. Trainees were frustrated by the 'emphasis on secondary care' in both academic content and placement portfolio requirements. They also experienced 'inconsistency in support' from their managers and assessors and noted a number of 'constraints to their learning opportunities', including the opportunity to progress to become registered nurses. Conclusion: This study raises important issues for trainee nursing associates, which may influence the recruitment and retention of the nursing associate workforce in primary care. Educators should consider adjustments to how the curriculum is delivered, including primary care skills and relevant assessments. Employers need to recognise the resource requirements for the programme, in relation to time and support, to avoid undue stress for trainees. Protected learning time should enable trainees to meet the required proficiencies. [ABSTRACT FROM AUTHOR]

Objective: The current paper describes Diet In Nutrients Out (DINO), an integrated dietary assessment system incorporating dietary data entry and nutritional analysis within one platform for use in dietary assessment in small-scale intervention studies to national surveys. Design: DINO contains >6000 food items, mostly aggregated composites of branded foods, across thirty-one main food groups divided into 151 subsidiary groups for detailed reporting requirements, with fifty-three core nutrient fields. Setting: MRC Human Nutrition Research (HNR), Cambridge, UK and MRC Keneba, Gambia. Subjects: DINO is used across dietary assessment projects at HNR and MRC Keneba. Results: DINO contains macro- and micronutrients as well as additional variables of current research and policy interest, such as caffeine, whole grains, vitamin K and added sugars. Disaggregated data are available for fruit, vegetables, meat, fish and cheese in composite foods, enabling greater accuracy when reporting food consumption or assessing adherence to dietary recommendations. Portion sizes are categorised in metric and imperial weights, with standardised portion sizes for each age group. Regular reviews are undertaken for portion sizes and food composition to ensure contemporary relevance. A training programme and a checking schedule are adhered to for quality assurance purposes, covering users and data. Eating context questions are integrated to record where and with whom the respondent is eating, allowing examination between these factors and the foods consumed. Conclusions: An up-to-date quality-assured system for dietary assessment is crucial for nutritional surveillance and research, but needs to have the flexibility to be tailored to address specific research questions. [ABSTRACT FROM AUTHOR]

Background: January 2016 saw the publication of proposed revisions to the UK's lower risk drinking guidelines but no sustained promotional activity. This paper aims to explore the impact of publishing guidelines without sustained promotional activity on reported guideline exposure and determinants of behaviour (capability, opportunity and motivation) proposed by the COM-B model.Methods: Data were collected by a monthly repeat cross-sectional survey of adults (18+) resident in England over 15 months between November 2015 and January 2017 from a total of 16,779 drinkers, as part of the Alcohol Toolkit Study. Trends and associated 95% confidence intervals were described in the proportion of reported exposure to guidelines in the past month and measures of the capability, opportunity and motivation to consume alcohol within drinking guidelines.Results: There was a rise in reported exposure to drinking guidelines in January 2016 (57.6-80.6%) which did not reoccur in January 2017. Following the increase in January 2016, reported exposure reduced slowly but remained significantly higher than in December 2015. In February 2016, there was an increase in measures of capability (31.1% reported tracking units of alcohol consumption and 87.8% considered it easier to drink safely) and opportunity (84.0% perceived their lifestyle as conducive to drinking within guidelines). This change was not maintained in subsequent months. Other measures showed marginal changes between January and February 2016 with no evidence of change in subsequent months.Conclusions: Following the publication of revised drinking guideline in January 2016, there was a transient increase in exposure to guidelines, and capability and opportunity to drink within the guidelines that diminished over time. The transience and size of the changes indicate that behaviour change is unlikely. Well-designed, theory-based promotional campaigns may be required for drinking guidelines to be an effective public health intervention. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Chief Medical Officer for England recommending that young people remaining alcohol free until 18 years of age. Topics include highest levels of drinking among adolescents and the North East England being one of the highest levels of adolescent alcohol consumption in the UK; and exploring the relationship between alcohol use during adolescence and negative consequences in adulthood.

Background: The objective of this work to calculate prescribed quantity of an active pharmaceutical ingredient (API) in prescription medications for human use, to facilitate research on the prediction of amount of API released to the environment and create an open-data tool to facilitate spatiotemporal and long-term prescription trends for wider usage.Design: We have developed an R package, PrAna to calculate the prescribed quantity (in kg) of an APIs by postcode using England's national level prescription data provided by National Health Service, for the years 2015-2018. Datasets generated using PrAna can be visualized in a real-time interactive web-based tool, PrAnaViz to explore spatiotemporal and long-term trends. The visualisations can be customised by selecting month, year, API, and region.Results: PrAnaViz's targeted API approach is demonstrated with the visualisation of prescribed quantities of 14 APIs in the Bath and North East Somerset (BANES) region during 2018. Once the APIs list is loaded, the back end retrieves relevant data and populates the graphs based on user-defined data features in real-time. These plots include the prescribed quantity of APIs over a year, by month, and individual API by month, general practice, postcode, and medicinal form. The non-targeted API approach is demonstrated with the visualisation of clarithromycin prescribed quantities at different postcodes in the BANES region.Conclusion: PrAna and PrAnaViz enables the analysis of spatio-temporal and long-term trends with prescribed quantities of different APIs by postcode. This can be used as a support tool for policymakers, academics and researchers in public healthcare, and environmental scientist to monitor different group of pharmaceuticals emitted to the environment and for prospective risk assessment of pharmaceuticals in the environment. [ABSTRACT FROM AUTHOR]

Background: Systematic reviews have identified effective strategies for increasing postal response rates to questionnaires; however, most studies have isolated single techniques, testing the effect of each one individually. Despite providing insight into explanatory mechanisms, this approach lacks ecological validity, given that multiple techniques are often combined in routine practice.Methods: We used a two-armed parallel randomised controlled trial (n = 2702), nested within a cross-sectional health survey study, to evaluate whether using a pragmatic combination of behavioural science and evidenced-based techniques (e.g., personalisation, social norms messaging) in a study invitation letter increased response to the survey, when compared with a standard invitation letter. Participants and outcome assessors were blinded to group assignment. We tested this in a sample of women testing positive for human papillomavirus (HPV) at cervical cancer screening in England.Results: Overall, 646 participants responded to the survey (response rate [RR] = 23.9%). Logistic regression revealed higher odds of response in the intervention arm (n = 357/1353, RR = 26.4%) compared with the control arm (n = 289/1349, RR = 21.4%), while adjusting for age, deprivation, clinical site, and clinical test result (aOR = 1.30, 95% CI: 1.09-1.55).Conclusion: Applying easy-to-implement behavioural science and evidence-based methods to routine invitation letters improved postal response to a health-related survey, whilst adjusting for demographic characteristics. Our findings provide support for the pragmatic adoption of combined techniques in routine research to increase response to postal surveys.Trial Registration: ISRCTN, ISRCTN15113095 . Registered 7 May 2019 - retrospectively registered. [ABSTRACT FROM AUTHOR]

Background This study explored barriers and facilitators to integrating health evidence into spatial planning at local authority levels and examined the awareness and use of the Public Health England 'Spatial Planning for Health' resource. Methods A sequential exploratory mixed-methods design utilized in-depth semi-structured interviews followed by an online survey of public health, planning and other built environment professionals in England. Results Views from 19 individuals and 162 survey responses revealed high awareness and use of the Spatial Planning for Health resource, although public health professionals reported greater awareness and use than other professionals. Key barriers to evidence implementation included differences in interpretation and the use of 'evidence' between public health and planning professionals, lack of practical evidence to apply locally and lack of resource and staff capacity in local authorities. Key facilitators included integrating health into the design of local plans, articulating wider benefits to multiple stakeholders and simplifying presenting evidence (regarding language and accessibility). Conclusion The Spatial Planning for Health resource is a useful resource at local authority level. Further work is needed to maximize its use by built environment professionals. Public health teams need support, capacity and skills to ensure that local health and well-being priorities are integrated into local planning documents and decisions. [ABSTRACT FROM AUTHOR]

Background: Previous research has shown the benefits of arts and cultural engagement for physical, mental and social wellbeing. This engagement is socially and geographically patterned. Yet it remains unclear whether place-based attributes are associated with engagement behaviour independent of individual factors. Therefore, the aim of this cross-sectional study was to robustly disentangle associations between geographical deprivation and arts engagement from the individual socio-demographic factors that tend to correlate with residential locations.Methods: Two different samples drawn from two representative surveys of adults living in England were compared - Understanding Society Wave 2 (2010/12) (N = 14,782) and Taking Part survey (2010/11) (N = 4575). Propensity score matching (PSM) was applied to investigate the association between neighbourhood deprivation (20% most deprived vs 20% least deprived) and arts engagement (arts participation, cultural attendance and museums and heritage engagement).Results: Higher levels of neighbourhood deprivation were associated with lower arts, culture and heritage engagement independent of individuals' demographic backgrounds, socio-economic characteristics and regional locations. When exploring subcategories of deprivation, similar results were obtained across deprivation domains. Results were also consistent when using more distinct categories of deprivation (i.e. 10% most deprived vs 10% least deprived) and when comparing people living in the 20% most deprived neighbourhoods with those living in the 40% medium-deprived areas.Conclusion: This study is the first to apply a robust PSM technique to examine the association between neighbourhood deprivation and arts engagement using two nationally-representative samples. Results show that neighbourhood deprivation may act as a barrier that could prevent people from engaging in the arts, which in turn may exacerbate social and health inequalities. This highlights the importance of place-based schemes that focus on increasing individual motivation and capacity to engage in arts and cultural activities, especially in areas of high deprivation. [ABSTRACT FROM AUTHOR]

Objective: To analyse differences in the prevalence of prediabetes (PD), undiagnosed diabetes (UDD) and diagnosed diabetes (DD) and associated factors between Brazilian and English older adults.Design: Cross-sectional study.Setting: England and Brazil.Participants: 5301 participants of the English Longitudinal Study of Ageing study and 1947 participants of the Brazilian Longitudinal Study of Aging study classified as non-diabetics, PD, UDD and DD.Results: The prevalence of PD, UDD and DD was 48·6, 3 and 9·6 % in England and 33, 6 and 20 % in Brazil. In England, the increase in age, non-white skin colour, smoking, general obesity and abdominal obesity were associated with PD, UDD and DD, whereas hypertriglyceridaemia, low HDL levels, hypertension and stroke were associated with UDD and DD. In Brazil, the increase in age was associated with DD and UDD, non-white skin colour and smoking were associated with UDD and abdominal obesity and hypertriglyceridaemia were associated with all three conditions. CVD in England and schooling in Brazil were associated with PD and DD. A sedentary lifestyle was associated with DD in both samples.Conclusions: The prevalence of diabetes was higher in the Brazilian sample. Different associated factors were found in the two samples, which may be related to differences in nutritional transition, access to healthcare services and the use of such services. [ABSTRACT FROM AUTHOR]

Background This study explored barriers and facilitators to integrating health evidence into spatial planning at local authority levels and examined the awareness and use of the Public Health England 'Spatial Planning for Health' resource. Methods A sequential exploratory mixed-methods design utilized in-depth semi-structured interviews followed by an online survey of public health, planning and other built environment professionals in England. Results Views from 19 individuals and 162 survey responses revealed high awareness and use of the Spatial Planning for Health resource, although public health professionals reported greater awareness and use than other professionals. Key barriers to evidence implementation included differences in interpretation and the use of 'evidence' between public health and planning professionals, lack of practical evidence to apply locally and lack of resource and staff capacity in local authorities. Key facilitators included integrating health into the design of local plans, articulating wider benefits to multiple stakeholders and simplifying presenting evidence (regarding language and accessibility). Conclusion The Spatial Planning for Health resource is a useful resource at local authority level. Further work is needed to maximize its use by built environment professionals. Public health teams need support, capacity and skills to ensure that local health and well-being priorities are integrated into local planning documents and decisions. [ABSTRACT FROM AUTHOR]

Objective: To consider the principal effect of an interaction between year (pre- and post-Universal Infant Free School Meals (UIFSM)) and school on pupil's dietary intakes.Design: A repeated cross-sectional survey using dietary data from 2008 to 2009 (pre-) and 2017 to 2018 (post-UIFSM).Setting: Two primary schools, NE England.Participants: Pupils aged 4-7 years (2008-2009 n 121; 2017-2018 n 87).Results: At lunchtime, there was a statistically significant decrease in pupils non-milk extrinsic sugars intake (%E NMEs) pre- to post-UIFSM (mean change -4·6 %; 95 % CI -6·3, -2·9); this was reflected in total diet (-3·8 %; -5·2, -2·7 %). A year and school interaction was found for mean Ca intakes: post-UIFSM pupils in School 2 had a similar mean intake as pre; in School 1 intakes had increased (difference of difference: -120 mg; 95 % CI -179, -62); no reflection in total diet. Post-UIFSM mean portions of yogurt decreased in School 2 and remained similar in School 1 (-0·25; -0·46, -0·04); this was similar for 'cake/pudding' and fruit.Conclusions: Within the limitations, these findings highlight positives and limitations following UIFSM implementation and demonstrate the role of school-level food practices on pupil's choices. To facilitate maximum potential of UIFSM, national levers, such as discussions on updating school food standards, including sugars, could consider removing the daily 'pudding' option and advocate 'fruit only' options 1 d/week, as some schools do currently. Small school-level changes could maximise positive health impacts by decreasing NMEs intake. A more robust evaluation is imperative to consider dietary impacts, equitability and wider effects on schools and families. [ABSTRACT FROM AUTHOR]

Background: The workplace has been identified as an ideal setting for health interventions. However, few UK-based workplace intervention studies have been published. Fewer still focus on the practicalities and implications when running an intervention within the workplace setting. The objective of this paper was to qualitatively determine the perceived behaviour changes of participants in a free fruit at work intervention. Understanding the dynamics of a workplace intervention and establishing any limitations of conducting an intervention in a workplace setting were also explored.Methods: Twenty-three face-to-face interviews were conducted with individuals receiving free fruit at work for 18 weeks (74 % female). The worksite was the offices of a regional local government in the North East of England. Analysis was guided theoretically by Grounded Theory research and the data were subjected to content analysis. The transcripts were read repeatedly and cross-compared to develop a coding framework and derive dominant themes.Results: Topics explored included: the workplace food environment; the effect of the intervention on participants and on other related health behaviours; the effect of the intervention on others; participant's fruit consumption; reasons for not taking part in the intervention; expectations and sustainability post-intervention; and how to make the workplace healthier. Five emergent themes included: the office relationship with food; desk based eating; males and peer support; guilt around consumption of unhealthy foods; and the type of workplace influencing the acceptability of future interventions.Conclusion: Exploring the perceptions of participants offered valued insights into the dynamics of a free fruit workplace intervention. Findings suggest that access and availability are both barriers and facilitators to encouraging healthy eating in the workplace. [ABSTRACT FROM AUTHOR]

Background: Active for life year 5 (AFLY5) is a school-based intervention, based on social cognitive theory, which aims to promote healthy levels of physical activity and healthy eating by improving a child's self-efficacy to make healthy choices, their knowledge of how to make such choices and prompting parents to support their children to make healthy choices. Previously published results showed no effect on the three primary outcomes and beneficial effects on three of nine secondary outcomes (time spent screen-viewing at weekends, consumption of snacks and of high energy drinks). This paper aims to determine the effect of the intervention on potential mediators.Methods: We conducted a cluster RCT of a school-based intervention, with allocation concealed by use of a remote system. The study was undertaken in the South West of England between 2011 and 2013. Participants were school children who were age 8-9 years at baseline assessment and 9-10 years during the intervention. Potential mediators were assessed at the end of the intervention. The intervention consisted of teacher training, provision of all materials required for lessons and homeworks and written materials for school newsletters and parents. The ten potential mediators were child-reported self-efficacy for physical activity and fruit and vegetable consumption, perceived parental logistic support and modelling for their child's physical activity, parental efforts to limit their child's sedentary behaviour and modelling of healthy fruit and vegetable consumption, together with a knowledge assessment.Results: We successfully recruited 60 schools with over 2,221 children; valid data for the 10 mediators were available for 87 % to 96 % of participants. Three of the ten potential mediators were greater in the intervention, compared with the control group: fruit and vegetable self-efficacy 2.2 units (95 % CI: 0.7 to 3.8), assessed on a scale 26 to 130; child-reported maternal limitation of sedentary behaviour 0.5 (0.1 to 0.8), scale 4 to 16; and knowledge 0.5 (0.2, 0.7) scale 0 to 9. Reported maternal limitation of sedentary behaviour and the child's knowledge explained 23 % of the effect of the intervention on reducing time spent on sedentary behaviour at the weekend. There was no effect on other mediators.Conclusions: Our findings suggest that the effect of the AFLY5 intervention on reducing screen-viewing at weekends was partially mediated by an effect on mothers limiting their child's time spent sedentary and on increasing the child's knowledge about healthy behaviour. However, overall our findings suggest that theory driven interventions, like AFLY5, can fail to influence most potential mediators and this may explain the failure of the intervention to improve most primary and secondary outcomes.Trial Registration: Current Controlled Trials ISRCTN50133740. Registered 17/03/2011. [ABSTRACT FROM AUTHOR]

Background: Depression is associated with lower educational attainment, but there has been little investigation of long-term educational trajectories in large cohorts with diagnosed depression.Aims: To describe the educational attainment trajectories of children with a depression diagnosis in secondary care, and to investigate whether these trajectories vary by sociodemographic characteristics.Method: We identified new referrals to South London and Maudsley's NHS Foundation Trust between 2007 and 2013 who received a depression diagnosis at under 18 years old. Linking their health records to the National Pupil Database, we standardised their performance on three assessments (typically undertaken at ages 6-7 years (school Year 2), 10-11 (Year 6) and 15-16 (Year 11)) relative to the local reference population in each academic year. We used mixed models for repeated measures to estimate attainment trajectories.Results: In our sample of 1492 children, the median age at depression diagnosis was 15 years (interquartile range = 14-16). Their attainment showed a decline between school Years 6 and 11. Attainment was consistently lower among males and those eligible for free school meals. Black ethnic groups also showed lower attainment than White ethnic groups between Years 2 and 6, but showed a less pronounced drop in attainment at Year 11.Conclusions: Those who receive a depression diagnosis during their school career show a drop in attainment in Year 11. Although this pattern was seen among multiple sociodemographic groups, gender, ethnicity and socioeconomic status predict more vulnerable subgroups within this clinical population who might benefit from additional educational support or more intensive treatment. [ABSTRACT FROM AUTHOR]

Background: Videoconferencing has been proposed as a way of improving access to healthcare for older adults in care homes. Despite this, effective uptake of videoconferencing remains varied. This study evaluates a videoconferencing service for care home staff seeking support from healthcare professionals for the care of residents. The aim was to explore factors affecting the uptake and sustainability of videoconferencing in care homes, to establish what works for whom, in which circumstances and respects. The findings informed recommendations for commissioners and strategic managers on how best to implement videoconferencing for remote healthcare provision in care homes for older adults.Methods: Realist evaluation was used to develop, refine and test theories around the uptake and maintenance of videoconferencing in three care homes across Yorkshire and the Humber, England. The care homes were selected using maximum variation sampling regarding the extent to which they used videoconferencing. A developmental inquiry framework and realist interviews were used to identify Context, Mechanism and Outcome Configurations (CMOCs) regarding uptake and sustainability of the service. Participants included care home residents (aged > 65) and staff, relatives and strategic managers of care home chains. The interviews were an iterative process conducted alongside data analysis. Transcripts of audio recordings were entered into NVIVO 12, initially coded into themes, then hypotheses developed, refined and tested.Results: Outcomes were generated in relation to two main contextual factors, these were: (1) communication culture in the home and (2) the prior knowledge and experience that staff have of videoconferencing. The key facilitators identified were aspects of leadership, social links within the home and psychological safety which promoted shared learning and confidence in using the technology.Conclusions: Videoconferencing is a valuable tool, but successful implementation and sustainability are dependent on care home culture and staff training to promote confidence through positive and supported experiences. [ABSTRACT FROM AUTHOR]

Objective: This study's principal aim was to describe the lived reality for people with cardiovascular disease (CVD) and other chronic health conditions, who live in economically deprived neighbourhoods in a city in North West England. Methodology: This is a qualitative, exploratory study based on in-depth, semi-structured interviews with participants experiencing compromised cardiovascular health, conducted in August 2017. The study sample comprised 14 adults (3 females) aged 54 to 76. Thematic analysis was used for data analysis, and the biographical disruption concept was used as theoretical reference to explore the results. Wider health inequalities literature supplemented the individual experiences of chronic illness. Results: Four main themes were developed from the data: (1) chronic illness as a disruptive experience; (2) struggling for money; (3) lifestyle and health risks; and (4) reflections on current inequalities. The varied nature of participants' narratives about their chronic illness indicated that the experience of biographical disruption depends on the wider socioeconomic and cultural factors of the individual. Discussion: This study suggests that biographical disruption theory combined with health inequalities contexts highlights the role of hidden suffering and enhances the understanding of chronic illness experiences and thus informs clinical management, service and public health planning. [ABSTRACT FROM AUTHOR]

Purpose: Using a theory-led action research process test applicability of humanizing care theory to better understand what matters to people and assess how the process can improve human dimensions of health care services. Consideration of the value of this process to guide enhancements in humanly sensitive care and investigate transferable benefits of the participatory strategy for improving human dimensions of health care services. Methods: Action research with service users, practitioners and academics, with participatory processes led through the application of theory via a novel Humanizing Care Framework in two diverse clinical settings. Results: Participants engaged in a theory-led participatory process, understood and valued the framework seeing how it relates to own experiences. Comparative analysis of settings identified transferable processes with potential to enhance human dimensions of care more generally. We offer transferable strategy with contextualized practical details of humanizing processes and outcomes that can contribute to portable pathways to enhance dignity in care through application of humanizing care theory in practice. Conclusion: The theoretical framework is a feasible and effective guide to enhance human dimensions of care. Our rigorous participative process facilitates sharing of patient and staff experience, sensitizing practitioners' understandings and helping develop new ways of providing theoretically robust person-centred care based on lifeworld approaches. [ABSTRACT FROM AUTHOR]

Background: Operational failures, defined as inadequacies or errors in the information, supplies, or equipment needed for patient care, are known to be highly consequential in hospital environments. Despite their likely relevance for GPs' experiences of work, they remain under-explored in primary care.Aim: To identify operational failures in the primary care work environment and to examine how they influence GPs' work.Design and Setting: Qualitative interview study in the East of England.Method: Semi-structured interviews were conducted with GPs (n = 21). Data analysis was based on the constant comparison method.Results: GPs reported a large burden of operational failures, many of them related to information transfer with external healthcare providers, practice technology, and organisation of work within practices. Faced with operational failures, GPs undertook 'compensatory labour' to fulfil their duties of coordinating and safeguarding patients' care. Dealing with operational failures imposed significant additional strain in the context of already stretched daily schedules, but this work remained largely invisible. In part, this was because GPs acted to fix problems in the here-and-now rather than referring them to source, and they characteristically did not report operational failures at system level. They also identified challenges in making process improvements at practice level, including medicolegal uncertainties about delegation.Conclusion: Operational failures in primary care matter for GPs and their experience of work. Compensatory labour is burdensome with an unintended consequence of rendering these failures largely invisible. Recognition of the significance of operational failures should stimulate efforts to make the primary care work environment more attractive. [ABSTRACT FROM AUTHOR]

Background: Ethnic inequalities in health outcomes are often explained by socioeconomic status and concentrated poverty. However, ethnic disparities in psychotic experiences are not completely attenuated by these factors.Aims: We investigated whether disparities are better explained by interactions between individual risk factors and place-based clustering of disadvantage, termed a syndemic.Method: We performed a cross-sectional survey of 3750 UK men, aged 18-34 years, oversampling Black and minority ethnic (BME) men nationally, together with men residing in London Borough of Hackney. Participants completed questionnaires covering psychiatric symptoms, substance misuse, crime and violence, and risky sexual health behaviours. We included five psychotic experiences and a categorical measure of psychosis based on the Psychosis Screening Questionnaire.Results: At national level, more Black men reported psychotic experiences but disparities disappeared following statistical adjustment for social position. However, large disparities for psychotic experiences in Hackney were not attenuated by adjustment for social factors in Black men (adjusted odds ratio, 3.24; 95% CI 2.14-4.91; P < 0.002), but were for South Asian men. A syndemic model of joint effects, adducing a four-component latent variable (psychotic experiences and anxiety, substance dependence, high-risk sexual behaviour and violence and criminality) showed synergy between components and explained persistent disparities in psychotic experiences. A further interaction confirmed area-level effects (Black ethnicity × Hackney residence, 0.834; P < 0.001).Conclusions: Syndemic effects result in higher rates of non-affective psychosis among BME persons in certain inner-urban settings. Further research should investigate how syndemics raise levels of psychotic experiences and related health conditions in Black men in specific places with multiple deprivations. [ABSTRACT FROM AUTHOR]

Background: The Clinical Practice Research Datalink (CPRD) GOLD is an extremely influential U.K. primary care dataset for epidemiological research having a number of published papers based on its data much bigger than any other U.K. primary care dataset. The Office for National Statistics (ONS) death data for England can be linked to GOLD at the patient level and are considered the gold standard on mortality. GOLD, which also holds death data, has been recently assessed against ONS linked dataset and the accuracy of its dates of death has been deemed sufficient for the majority of observational studies. However, there is a lack of guidance on how to manage the challenges existing when ONS mortality and GOLD datasets are linked, including linkage coverage period, linkage correctness likelihood, linkage regional limitations and data discrepancy.Objectives: Provide reconciling guidelines on how to make maximum and at the same time trustworthy use of mortality information coming from both GOLD and ONS linked datasets with the aim of improving the quality, reproducibility, transparency and comparison of clinical research.Method and Results: We have developed recommendations on how to manage mortality data coming from both GOLD and linked ONS, taking into account linkage coverage period, linkage correctness likelihood, linkage regional limitations and data discrepancies between these two datasets. We have also implemented these guidelines in an SQL algorithm for researchers to use.Conclusion: We have provided detailed guidelines on the reconciliation of mortality data between GOLD and ONS linked death datasets, taking into account both their strengths and limitations. The consistent application of these guidelines made practical by an SQL algorithm, has the potential to improve clinical research quality, reproducibility, transparency and comparison. [ABSTRACT FROM AUTHOR]

Background: There is little evidence on the impact of national pressures on primary care provision for type 2 diabetes from the perspectives of patients, their GPs, and nurses.Aim: To explore experiences of primary care provision for people with type 2 diabetes and their respective GPs and nurses.Design and Setting: A qualitative primary care interview study in the East of England.Method: Semi-structured interviews were conducted, between August 2017 and August 2018, with people who have type 2 diabetes along with their respective GPs and nurses. Purposive sampling was used to select for heterogeneity in glycaemic control and previous healthcare experiences. Interviews were audio-recorded and analysed thematically. The consolidated criteria for reporting qualitative research were followed.Results: The authors interviewed 24 patients and 15 GPs and nurses, identifying a changing landscape of diabetes provision owing to burgeoning pressures that were presented repeatedly. Patient responders wanted GP-delivered care with continuity. They saw GPs as experts best placed to support them in managing diabetes, but were increasingly receiving nurse-led care. Nurses reported providing most of the in-person care, while GPs remained accountable but increasingly distanced from face-to-face diabetes care provision. A reluctant acknowledgement surfaced among GPs, nurses, and their patients that only minimum care standards could be maintained, with aspirations for high-quality provision unlikely to be met.Conclusion: Type 2 diabetes is a tracer condition that reflects many aspects of primary care. Efforts to manage pressures have not been perceived favourably by patients and providers, despite some benefits. Reframing expectations of care, by communicating solutions to both patients and providers so that they are understood, managed, and realistic, may be one way forward. [ABSTRACT FROM AUTHOR]

Background: Crisis resolution teams (CRTs) offer brief, intensive home treatment for people experiencing mental health crisis. CRT implementation is highly variable; positive trial outcomes have not been reproduced in scaled-up CRT care.Aims: To evaluate a 1-year programme to improve CRTs' model fidelity in a non-masked, cluster-randomised trial (part of the Crisis team Optimisation and RElapse prevention (CORE) research programme, trial registration number: ISRCTN47185233).Method: Fifteen CRTs in England received an intervention, informed by the US Implementing Evidence-Based Practice project, involving support from a CRT facilitator, online implementation resources and regular team fidelity reviews. Ten control CRTs received no additional support. The primary outcome was patient satisfaction, measured by the Client Satisfaction Questionnaire (CSQ-8), completed by 15 patients per team at CRT discharge (n = 375). Secondary outcomes: CRT model fidelity, continuity of care, staff well-being, in-patient admissions and bed use and CRT readmissions were also evaluated.Results: All CRTs were retained in the trial. Median follow-up CSQ-8 score was 28 in each group: the adjusted average in the intervention group was higher than in the control group by 0.97 (95% CI -1.02 to 2.97) but this was not significant (P = 0.34). There were fewer in-patient admissions, lower in-patient bed use and better staff psychological health in intervention teams. Model fidelity rose in most intervention teams and was significantly higher than in control teams at follow-up. There were no significant effects for other outcomes.Conclusions: The CRT service improvement programme did not achieve its primary aim of improving patient satisfaction. It showed some promise in improving CRT model fidelity and reducing acute in-patient admissions. [ABSTRACT FROM AUTHOR]

Background: We have developed an open-source ALgorithm for Generating Address Exposures (ALGAE) that cleans residential address records to construct address histories and assign spatially-determined exposures to cohort participants. The first application of this algorithm was to construct prenatal and early life air pollution exposure for individuals of the Avon Longitudinal Study of Parents and Children (ALSPAC) in the South West of England, using previously estimated particulate matter ≤10  µm (PM10) concentrations.Methods: ALSPAC recruited 14 541 pregnant women between 1991 and 1992. We assigned trimester-specific estimated PM10 exposures for 12 752 pregnancies, and first year of life exposures for 12 525 births, based on maternal residence and residential mobility.Results: Average PM10 exposure was 32.6  µg/m3 [standard deviation (S.D.) 3.0  µg/m3] during pregnancy and 31.4 µg/m3 (S.D. 2.6  µg/m3) during the first year of life; 6.7% of women changed address during pregnancy, and 18.0% moved during first year of life of their infant. Exposure differences ranged from -5.3  µg/m3 to 12.4  µg/m3 (up to 26% difference) during pregnancy and -7.22  µg/m3 to 7.64  µg/m3 (up to 27% difference) in the first year of life, when comparing estimated exposure using the address at birth and that assessed using the complete cleaned address history. For the majority of individuals exposure changed by <5%, but some relatively large changes were seen both in pregnancy and in infancy.Conclusions: ALGAE provides a generic and adaptable, open-source solution to clean addresses stored in a cohort contact database and assign life stage-specific exposure estimates with the potential to reduce exposure misclassification. [ABSTRACT FROM AUTHOR]

Background: Primary care opioid prescribing to treat chronic non-cancer pain (CNCP) has progressively increased despite a lack of evidence for long-term safety and effectiveness. Developing primary care interventions to reduce opioid dependence in patients with CNCP is a public health priority.Aim: To report the acceptability of the South Gloucestershire pain and opioid review service for patients with CNCP, which aimed to help patients understand their relationship with prescribed opioids and support non-drug-based pain management strategies.Design and Setting: A mixed-methods evaluation was performed on the service, which was based in two GP practices in South Gloucestershire, England, and delivered by project workers.Method: Descriptive data were collected on delivered-within-service and community-based interventions. Twenty-five semi-structured interviews (n = 18 patients, n = 7 service providers) explored experiences of the service.Results: The enrolment process, person-centred primary care-based delivery, and service content focused on psychological issues underlying CNCP were found to be acceptable to patients and service providers. Patients welcomed having time to discuss their pain, its management, and related psychological issues. Maintaining a long-term approach was desired as CNCP is a complex issue that takes time to address. GPs recommended that funding was needed to ensure they have dedicated time to support a similar service and to ensure that project workers received adequate clinical supervision.Conclusion: This service model was acceptable and may be a useful means to manage patients with CNCP who develop opioid dependence after long-term use of opioids. A randomised controlled trial is needed to formally test the effectiveness of the service. [ABSTRACT FROM AUTHOR]

Background: Opioid prescribing to treat chronic non-cancer pain has rapidly increased, despite a lack of evidence for long-term safety and effectiveness. A pain review service was developed to work with patients taking opioids long-term to explore opioid use, encourage non-drug-based alternatives, and, where appropriate, support dose reduction.Aim: To evaluate the service and its potential impact on opioid use, health and wellbeing outcomes, and quality of life (QoL).Design and Setting: Mixed-methods evaluation of a one-to-one service based in two GP practices in South Gloucestershire, England, which took place from September 2016 to December 2017.Method: Quantitative data were collected on baseline demographics; data on opioid use, misuse, and dose, health, wellbeing, QoL, and pain and interference with life measures were collected at baseline and follow-up. Twenty-five semi-structured interviews (n = 18 service users, n = 7 service providers) explored experiences of the service including perceived impacts and benefits.Results: Of 59 patients who were invited, 34 (57.6%) enrolled in the service. The median prescribed opioid dose reduced from 90 mg (average daily morphine equivalent; interquartile range [IQR] 60 to 240) at baseline to 72 mg (IQR 30 to 160) at follow-up (P<0.001); three service users stopped using opioids altogether. On average, service users showed improvement on most health, wellbeing, and QoL outcomes. Perceived benefits were related to wellbeing, for example, improved confidence and self-esteem, use of pain management strategies, changes in medication use, and reductions in dose.Conclusion: The service was well received, and health and wellbeing outcomes suggest a potential benefit. Following further service development, a randomised controlled trial to test this type of care pathway is warranted. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the feasibility and acceptability of the Takeaway Masterclass, a three-hour training session delivered to staff of independent takeaway food outlets that promoted healthy cooking practices and menu options.Design: A mixed-methods study design. All participating food outlets provided progress feedback at 6 weeks post-intervention. Baseline and 6-week post-intervention observational and self-reported data were collected in half of participating takeaway food outlets.Setting: North East England.Participants: Independent takeaway food outlet owners and managers.Results: Staff from eighteen (10 % of invited) takeaway food outlets attended the training; attendance did not appear to be associated with the level of deprivation of food outlet location. Changes made by staff that required minimal effort or cost to the business were the most likely to be implemented and sustained. Less popular changes included using products that are difficult (or expensive) to source from suppliers, or changes perceived to be unpopular with customers.Conclusion: The Takeaway Masterclass appears to be a feasible and acceptable intervention for improving cooking practices and menu options in takeaway food outlets for those who attended the training. Further work is required to increase participation and retention and explore effectiveness, paying particular attention to minimising adverse inequality effects. [ABSTRACT FROM AUTHOR]

Background: Memory and cognitive deficits post stroke are common and associated with increased risk of future dementia. Rehabilitation tends to focus on physical recovery; however, once in the community, it is unclear what happens in the longer term to the stroke-survivor with new memory difficulties.Objective: The aim of this qualitative study was to examine in stroke-survivors what factors influence contact with health professionals.Method: Semi-structured interviews were conducted with stroke-survivors and their family carers where memory difficulties were reported at 6 months post stroke. A topic guide was used which sought to critically examine participants care experience following their stroke diagnosis. All participants were interviewed at baseline (around 6 months post stroke) and offered an interview at around 12 months post stroke. All interviews were conducted in the North East of England. All transcripts were coded and thematically analysed.Results: Ten stroke-survivors (age range 72-84 years) were interviewed alongside five carers at baseline; eight stroke-survivors and four carers agreed to a follow-up interview. Three main barriers were identified: (i) fear of a dementia diagnosis; (ii) denial or minimization of symptoms leading to adaptation and (iii) obstacles to seeking help in the community.Conclusions: With an ageing population and increase in stroke-survival, the burden of post-stroke cognitive impairment and dementia will only increase. Stroke-survivors and their family carers in this study have identified issues that may hinder their presentation to health care professionals at a personal and organizational level. Health professionals need to be aware of these potential issues when planning services for stroke-survivors. [ABSTRACT FROM AUTHOR]

Objective: Recovery Colleges are widespread, with little empirical research on their key components. This study aimed to characterize key components of Recovery Colleges and to develop and evaluate a developmental checklist and a quantitative fidelity measure.Methods: Key components were identified through a systematized literature review, international expert consultation (n = 77), and semistructured interviews with Recovery College managers across England (n = 10). A checklist was developed and refined through semistructured interviews with Recovery College students, trainers, and managers (n = 44) in 3 sites. A fidelity measure was adapted from the checklist and evaluated with Recovery College managers (n = 39, 52%), clinicians providing psychoeducational courses (n = 11), and adult education lecturers (n = 10).Results: Twelve components were identified, comprising 7 nonmodifiable components (Valuing Equality, Learning, Tailored to the Student, Coproduction of the Recovery College, Social Connectedness, Community Focus, and Commitment to Recovery) and 5 modifiable components (Available to All, Location, Distinctiveness of Course Content, Strengths Based, and Progressive). The checklist has service user student, peer trainer, and manager versions. The fidelity measure meets scaling assumptions and demonstrates adequate internal consistency (0.72), test-retest reliability (0.60), content validity, and discriminant validity.Conclusions: Coproduction and an orientation to adult learning should be the highest priority in developing Recovery Colleges. The creation of the first theory-based empirically evaluated developmental checklist and fidelity measure (both downloadable at researchintorecovery.com/recollect ) for Recovery Colleges will help service users understand what Recovery Colleges offer, will inform decision making by clinicians and commissioners about Recovery Colleges, and will enable formal evaluation of their impact on students. [ABSTRACT FROM AUTHOR]