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Funder: University of Cambridge, Lupus is a multi-system autoimmune rheumatic disease with increased morbidity and mortality. Some manifestations are life-threatening with many aspects of living with the disease, difficulties in diagnosis and accessing appropriate medical care, having an impact on quality of life. The disease itself, and these patients��� perspectives, are currently poorly understood and under-researched. The LUPUS UK forum of conversations between over 25,000 members provides a rich environment to explore the views of these patients. Conversations on the LUPUS UK online forum were qualitatively explored using virtual ethnography and thematic analysis. The forum itself and positive medical relationships were widely considered to provide a means of support, understanding and validation. Forum members expressed difficulties in diagnosis, disease management, and the psychological and physical impact of living with an unpredictable, poorly understood disease, often with life-changing symptoms. Invalidating personal, social and medical environments were perceived as exacerbating these difficulties. Delays in diagnosis and misdiagnoses were frequently discussed as causing significant damage, especially when symptoms were disbelieved or dismissed. Invalidation was the key theme with further themes of: Uncertainty, Medical (mis)communications and misunderstandings, Navigating health systems and Resilience and support. Although effective care and support was reported by some members, the negative impact of living with an incurable, life-changing disease was often exacerbated by perceived invalidation, uncertainty, and difficulties in multiple areas of members��� lives. Improved knowledge of the disease and greater support at all stages of the diagnostic journey could improve outcomes and quality of life for these patients.

BACKGROUND Insufficient physical activity is an increasing public health concern. New technologies may help to change physical activity levels while also enabling the identification of key predictors with high accuracy. The Precious smartphone app was developed to investigate the effect of specific, modular intervention elements on physical activity, and to examine theory-based predictors within individuals. OBJECTIVE This study pilot tested a fully automated factorial N-of-1 RCT with the Precious app and examined if (1) digitalized motivational interviewing (dMI) and (2) heart-rate variability-based biofeedback features increase objectively recorded steps. The secondary aim was to assess whether daily self-efficacy and motivation predict within-person variability in daily steps. METHODS Fifteen adults took part in a 40-day factorial N-of-1 randomized controlled trial. They installed two study apps onto their phones: app 1 to receive intervention elements on individually randomized days and app 2 to collect Ecological Momentary Assessment (EMA) data on self-efficacy, motivation, perceived barriers, pain and illness. Steps were tracked through Xiaomi Mi Band activity bracelets. The factorial design included seven two-day biofeedback interventions with a Firstbeat bodyguard 2 heart-rate variability sensor, and seven two-day dMI interventions, a washout-day after each intervention, and 11 control days. EMA questions were sent twice per day. The effects of self-efficacy, motivation, and the interventions on subsequent steps were analyzed using within-person dynamic regression models and with aggregated data using longitudinal multilevel modeling (level 1: daily observations, level 2: participants). The analyses adjusted for covariates that also predict daily steps, i.e. within- and between-person perceived barriers, pain or illness, time trends and recurring events. RESULTS All participants finished the study, and adherence to activity bracelet and EMA measurements was high. The implementation of the factorial design was successful, with the dMI features used on average 5.1 times of the 7 available interventions. Biofeedback interventions were used on average 5.7 times out of 7, though three participants used this feature a day later than suggested and one missed all suggested timings. Neither within- nor between-persons analyses revealed and significant intervention effects on step counts. Self-efficacy predicted steps in four individuals. Motivation predicted steps in three individuals. Aggregated data from 14 participants showed group-level effects: daily self-efficacy (B=.462, p CONCLUSIONS The automated factorial N-of-1 trial with the Precious app was mostly feasible and acceptable, especially the automated delivery of the dMI components, while self-conducted biofeedback measurements were more difficult to time correctly. The findings suggest that changes in self-efficacy and motivation may have same-day effects on physical activity, but effects vary between individuals. This study provides recommendations based on the lessons learned on the implementation of factorial N-of-1 RCTs. CLINICALTRIAL The trial was not formally pre-registered, as conventions for registration of factorial n-of-1 experimental studies had not been established prior to this study’s commencement in 2016. However, a dated publicly available version of the study protocol was published just after the start of data collection and prior to any data analyses (Helf et al., 2016, pp. 13–17).

INTRODUCTION: Atrial fibrillation (AF) is a common arrhythmia associated with 30% of strokes, as well as other cardiovascular disease, dementia and death. AF meets many criteria for screening, but there is limited evidence that AF screening reduces stroke. Consequently, no countries recommend national screening programmes for AF. The Screening for Atrial Fibrillation with ECG to Reduce stroke (SAFER) trial aims to determine whether screening for AF is effective at reducing risk of stroke. The aim of the pilot study is to assess feasibility of the main trial and inform implementation of screening and trial procedures. METHODS AND ANALYSIS: SAFER is planned to be a pragmatic randomised controlled trial (RCT) of over 100 000 participants aged 70 years and over, not on long-term anticoagulation therapy at baseline, with an average follow-up of 5 years. Participants are asked to record four traces every day for 3 weeks on a hand-held single-lead ECG device. Cardiologists remotely confirm episodes of AF identified by the device algorithm, and general practitioners follow-up with anticoagulation as appropriate. The pilot study is a cluster RCT in 36 UK general practices, randomised 2:1 control to intervention, recruiting approximately 12 600 participants. Pilot study outcomes include AF detection rate, anticoagulation uptake and other parameters to incorporate into sample size calculations for the main trial. Questionnaires sent to a sample of participants will assess impact of screening on psychological health. Process evaluation and qualitative studies will underpin implementation of screening during the main trial. An economic evaluation using the pilot data will confirm whether it is plausible that screening might be cost-effective. ETHICS AND DISSEMINATION: The London-Central Research Ethics Committee (19/LO/1597) and Confidentiality Advisory Group (19/CAG/0226) provided ethical approval. Dissemination will be via publications, patient-friendly summaries, reports and engagement with the UK National Screening Committee. TRIAL REGISTRATION NUMBER: ISRCTN72104369., The SAFER pilot study and main trial are funded by the National Institute for Health and Care Research (NIHR) [Programme Grants for Applied Research Programme (Reference Number RP-PG-0217-20007)]. The SAFER feasibility study is funded by the NIHR [School for Primary Care Research (SPCR-2014-10043, project 410)]. SAFER is a contributor to / partner of AFFECT-EU receiving funding from the European Union’s Horizon 2020 research and innovation Programme under grant agreement NO. 847770. RM and JL are supported by the Wellcome Trust as part of the Wellcome Trust PhD Programme for Primary Care Clinicians [grant number 203921/Z/16/Z]. JB, SH and AP are based in The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge. THIS Institute is supported by the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK. JB is supported by the Health Foundation’s grant to the University of Cambridge for The Healthcare Improvement Studies (THIS) Institute (RG88620). JM and FDRH are NIHR Senior Investigators. FDRH acknowledges support from NIHR ARC OTV and Oxford BRC (OUT). RJM is an NIHR Senior Investigator and acknowledges support from NIHR ARC OTV. NA is supported by a Health Foundation Improvement Science Fellowship and also by the NIHR Applied Research Collaboration East Midlands (ARC EM). RJ is an NIHR-funded Academic Clinical Lecturer. The University of Cambridge has received salary support in respect of SJG from the NHS in the East of England through the Clinical Academic Reserve. BF reports grants to the Heart Research Institute. All the funders and sponsors had no involvement in the development of this protocol and will have no involvement in any aspect of the study itself. The views expressed are those of the author(s) and not necessarily those of the NHS, the Wellcome Trust, the NIHR or the UK Department of Health and Social Care.

Self-report measures of health behaviour have several limitations including measurement reactivity, i.e. changes in people’s behaviour, cognitions or emotions due to taking part in research. This systematic review investigates whether digital in-the-moment measures induce reactivity to a similar extent and why it occurs. Four databases were searched in December 2020. All observational or experimental studies investigating reactivity to digital in-the-moment measurement of a range of health behaviours were included if they were published in English in 2008 or later. Of the 11,723 records initially screened, 30 publications reporting on 31 studies were included in the qualitative synthesis/ 7 studies in the quantitative synthesis. Eighty-one percent of studies focused on reactivity to the measurement of physical activity indicators; small but meaningful pooled effects were found (Cohen’s ds: 0.27 to 0.30). Only a small number of studies included other behaviours, yielding mixed results. Digital in-the-moment measurement of behaviour thus may be as prone to reactivity as self-reports in questionnaires. Measurement reactivity may be amplified by (1) ease of changing the behaviour, (2) awareness of being measured and social desirability, and (3) resolving discrepancies between actual and desired behaviour through self-regulation.

OBJECTIVE: The purpose of this study was to better understand facilitators', parents', and teachers' experiences, attitudes, and perceived impact of the international alcohol prevention program "Effekt" and its delivery to help explain its ineffectiveness in Estonia. METHOD: One focus group with program facilitators (n = 8, 7 women) and individual interviews with seventh grade teachers (n = 12, 11 women) and parents (n = 24, all women) were carried out. The semi-structured interview schedules sought to explore participants' attitudes toward the program, delivery process, impact, participation barriers, and facilitators and long-term implementation. Interviews were transcribed, and data analysis was guided by the thematic analysis method. RESULTS: Participants identified both positive and negative elements regarding program delivery that are broken down into three main themes: perceived value of the program, perception of low participation rates, and long-term perspective. Perceived value of the program: Participants perceived the program to be effective from the parents' perspective, but they considered its effect on children questionable. Perception of low participation rates: The perception of low participation rates was considered as the main factor reducing the program's impact. This was potentially influenced by factors such as a weak engagement process, lack of perceived relevance, infrequent meetings, and parents not attending school meetings. Long-term perspective: Most participants supported the idea of implementing the program with some adjustments, such as involving children, tailoring the content, and increasing the engagement of teachers. CONCLUSIONS: Limited engagement, low perceived relevance, practical issues, and impractical format were perceived as major contributors to the ineffectiveness of the program. Taking these and other identified factors into account may help inform future prevention programs targeting parents.

The purpose of this study was to better understand facilitators', parents', and teachers' experiences, attitudes, and perceived impact of the international alcohol prevention program "Effekt" and its delivery to help explain its ineffectiveness in Estonia.One focus group with program facilitators (n = 8, 7 women) and individual interviews with seventh grade teachers (n = 12, 11 women) and parents (n = 24, all women) were carried out. The semi-structured interview schedules sought to explore participants' attitudes toward the program, delivery process, impact, participation barriers, and facilitators and long-term implementation. Interviews were transcribed, and data analysis was guided by the thematic analysis method.Participants identified both positive and negative elements regarding program delivery that are broken down into three main themes: perceived value of the program, perception of low participation rates, and long-term perspective. Perceived value of the program: Participants perceived the program to be effective from the parents' perspective, but they considered its effect on children questionable. Perception of low participation rates: The perception of low participation rates was considered as the main factor reducing the program's impact. This was potentially influenced by factors such as a weak engagement process, lack of perceived relevance, infrequent meetings, and parents not attending school meetings. Long-term perspective: Most participants supported the idea of implementing the program with some adjustments, such as involving children, tailoring the content, and increasing the engagement of teachers.Limited engagement, low perceived relevance, practical issues, and impractical format were perceived as major contributors to the ineffectiveness of the program. Taking these and other identified factors into account may help inform future prevention programs targeting parents.

Recreational marine resource use is conducted by a varied group of visitors. Regardless of how minimal this resource use is, or what intentions these visitors have, potentially damaging contacts with these resources are unavoidable. Management authorities need a clear understanding of these contacts so that resource management can be conducted effectively. Traditional monitoring of visitors in the past has relied on self-reported behavior by visitors themselves. Self-reporting of behavior is not always accurate or reliable. This research article illustrates that even though recreational marine visitors (snorkelers) in the Mombasa Marine Park and Reserve had intentions to not disturb the reef when they snorkel and indicated having positive attitudes about not disturbing the reef when they snorkel, they still created contacts with the reef. Furthermore, their self-reported behavior did not correspond with their actual monitored behavior. Monitoring snorkeler behavior is time-consuming and is therefore paired with financial investment; however, this method is the most accurate method of gathering impact data to be used for management purposes. When accurate data on snorkelers' behavior is necessary, in-water behavior monitoring should be used rather than self-reports.

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Establish whether digital self-monitoring of diet and physical activity is effective at supporting weight loss, increasing physical activity and improving eating behavior in adults with obesity or overweight, and determine the intervention components that might explain variations in its effectiveness. A systematic search of MEDLINE, Embase, PsycINFO, Web of Science, Scopus, Cinahl, and CENTRAL identified 4068 studies, of which 12 randomized controlled trials were eligible and included in the review. A random-effect meta-analysis evaluated intervention effectiveness and subgroup analyses tested for effective intervention content. Twelve studies were included in the review and meta-analysis. Digital self-monitoring of both diet and physical activity had a statistically significant effect at supporting weight loss (mean difference [MD] = -2.87 [95% CI -3.78, -1.96], P

Smartphones have become popular in assessing eating behaviour in real-life and real-time. This systematic review provides a comprehensive overview of smartphone-based dietary assessment tools, focusing on how dietary data is assessed and its completeness ensured. Seven databases from behavioural, social and computer science were searched in March 2020. All observational, experimental or intervention studies and study protocols using a smartphone-based assessment tool for dietary intake were included if they reported data collected by adults and were published in English. Out of 21,722 records initially screened, 117 publications using 129 tools were included. Five core assessment features were identified: photo-based assessment (48.8% of tools), assessed serving/ portion sizes (48.8%), free-text descriptions of food intake (42.6%), food databases (30.2%), and classification systems (27.9%). On average, a tool used two features. The majority of studies did not implement any features to improve completeness of the records. This review provides a comprehensive overview and framework of smartphone-based dietary assessment tools to help researchers identify suitable assessment tools for their studies. Future research needs to address the potential impact of specific dietary assessment methods on data quality and participants’ willingness to record their behaviour to ultimately improve the quality of smartphone-based dietary assessment for health research.

The PAM intervention is a behavioural intervention to support adherence to anti-hypertensive medications and therefore to lower blood pressure. This feasibility trial recruited 101 nonadherent patients (54% male, mean age 65.8 years) with hypertension and high blood pressure from nine general practices in the UK. The trial had 15.5% uptake and 7.9% attrition rate. Patients were randomly allocated to two groups: the intervention group (n = 61) received the PAM intervention as an adjunct to usual care; the control group (n = 40) received usual care only. At 3 months, biochemically validated medication adherence was improved by 20% (95% CI 3–36%) in the intervention than control, and systolic blood pressure was reduced by 9.16 mmHg (95% CI 5.69–12.64) in intervention than control. Improvements in medication adherence and reductions in blood pressure suggested potential intervention effectiveness. For a subsample of patients, improvements in medication adherence and reductions in full lipid profile (cholesterol 1.39 mmol/mol 95% CI 0.64–1.40) and in glycated haemoglobin (3.08 mmol/mol, 95% CI 0.42–5.73) favoured the intervention. A larger trial will obtain rigorous evidence about the potential clinical effectiveness and cost-effectiveness of the intervention.Trial registration Trial date of first registration 28/01/2019. ISRCTN74504989. https://doi.org/10.1186/ISRCTN74504989.

IntroductionA lapse (any smoking) early in a smoking cessation attempt is strongly associated with reduced success. A substantial proportion of lapses are due to urges to smoke triggered by situational cues. Currently, no available interventions proactively respond to such cues in real time. Quit Sense is a theory-guided just-in-time adaptive intervention smartphone app that uses a learning tool and smartphone sensing to provide in-the-moment tailored support to help smokers manage cue-induced urges to smoke. The primary aim of this randomised controlled trial (RCT) is to assess the feasibility of delivering a definitive online efficacy trial of Quit Sense.Methods and analysesA two-arm parallel-group RCT allocating smokers willing to make a quit attempt, recruited via online adverts, to usual care (referral to the NHS SmokeFree website) or usual care plus Quit Sense. Randomisation will be stratified by smoking rate (Ethics and disseminationEthics approval has been granted by the Wales NHS Research Ethics Committee 7 (19/WA/0361). The findings will be disseminated to the public, the funders, relevant practice and policy representatives and other researchers.Trial registration numberISRCTN12326962.

Funder: Department of Health, Isotemporal substitution modelling (ISM) and compositional isotemporal modelling (CISM) are statistical approaches used in epidemiology to model the associations of replacing time in one physical behaviour with time in another. This study's aim was to use both ISM and CISM to examine and compare associations of reallocating 60 min of sitting into standing or stepping with markers of cardiometabolic health. Cross-sectional data collected during three randomised control trials (RCTs) were utilised. All participants (n = 1554) were identified as being at high risk of developing type 2 diabetes. Reallocating 60 min from sitting to standing and to stepping was associated with a lower BMI, waist circumference, and triglycerides and higher high-density lipoprotein cholesterol using both ISM and CISM (p < 0.05). The direction and magnitude of significant associations were consistent across methods. No associations were observed for hemoglobin A1c, total cholesterol, or low-density lipoprotein cholesterol for either method. Results of both ISM and CISM were broadly similar, allowing for the interpretation of previous research, and should enable future research in order to make informed methodological, data-driven decisions.

Background Physical activity is associated with a reduced risk of type 2 diabetes and cardiovascular disease but limited evidence exists for the sustained promotion of increased physical activity within diabetes prevention trials. The aim of the study was to investigate the long-term effectiveness of the Walking Away programme, an established group-based behavioural physical activity intervention with pedometer use, when delivered alone or with a supporting mHealth intervention. Methods Those at risk of diabetes (nondiabetic hyperglycaemia) were recruited from primary care, 2013–2015, and randomised to (1) Control (information leaflet); (2) Walking Away (WA), a structured group education session followed by annual group-based support; or (3) Walking Away Plus (WAP), comprising WA annual group-based support and an mHealth intervention delivering tailored text messages supported by telephone calls. Follow-up was conducted at 12 and 48 months. The primary outcome was accelerometer measured ambulatory activity (steps/day). Change in primary outcome was analysed using analysis of covariance with adjustment for baseline, randomisation and stratification variables. Results One thousand three hundred sixty-six individuals were randomised (median age = 61 years, ambulatory activity = 6638 steps/day, women = 49%, ethnic minorities = 28%). Accelerometer data were available for 1017 (74%) individuals at 12 months and 993 (73%) at 48 months. At 12 months, WAP increased their ambulatory activity by 547 (97.5% CI 211, 882) steps/day compared to control and were 1.61 (97.5% CI 1.05, 2.45) times more likely to achieve 150 min/week of moderate-to-vigorous physical activity. Differences were not maintained at 48 months. WA was no different to control at 12 or 48 months. Secondary anthropometric and health outcomes were largely unaltered in both intervention groups apart from small reductions in body weight in WA (~ 1 kg) at 12- and 48-month follow-up. Conclusions Combining a pragmatic group-based intervention with text messaging and telephone support resulted in modest changes to physical activity at 12 months, but changes were not maintained at 48 months. Trial registration ISRCTN 83465245 (registered on 14 June 2012).

Introduction Around 23% of adults worldwide are insufficiently active. Wearable devices paired with virtual coaching software could increase physical activity. The effectiveness of 3 minimal contact interventions (paper-based physical activity diaries, activity trackers, and activity trackers coupled with virtual coaching) in increasing physical activity energy expenditure and cardiorespiratory fitness were compared over 12 weeks among inactive adults. Methods This was an open label, parallel-group RCT. Inactive adults (aged ≥18 years, N=488) were randomized to no intervention (Control; n=121), paper-based diary (Diary; n=124), activity tracker (Activity Band; n=122), or activity tracker plus virtual coaching (Activity Band PLUS; n=121) groups. Coprimary outcomes included 12-week changes in physical activity energy expenditure and fitness (May 2012–January 2014). Analyses were conducted in 2019–2020. Results There were no differences between groups overall (physical activity energy expenditure: p=0.114, fitness: p=0.417). However, there was a greater increase in physical activity energy expenditure (4.21 kJ/kg/day, 95% CI=0.42, 8.00) in the Activity Band PLUS group than in the Diary group. There were also greater decreases in BMI and body fat percentage in the Activity Band PLUS group than in the Control group (BMI= −0.24 kg/m2, 95% CI= −0.45, −0.03; body fat= −0.48%, 95% CI= −0.88, −0.08) and in theActivity Band PLUS group than in the Diary group (BMI= −0.30 kg/m2, 95% CI= −0.50, −0.09; body fat= −0.57%, 95% CI= −0.97, −0.17). Conclusions Coupling activity trackers with virtual coaching may facilitate increases in physical activity energy expenditure compared with a traditional paper‒based physical activity diary intervention and improve some secondary outcomes compared with a traditional paper‒based physical activity diary intervention or no intervention. Trial registration This study is registered at www.clinicaltrials.gov ISRCTN31844443.

1. Atlantic salmon populations have declined in recent decades. Many of the threats to the species during its freshwater and coastal residency periods are known, and management approaches are available to mitigate them. The global scale of climate change and altered ocean ecosystems make these threats more difficult to address. 2. Managers need to be aware that promoting strong, healthy, and resilient wild populations migrating from rivers is the optimal approach currently to reduce the impacts of changing ecosystems and low marine survival. We argue that a fundamental strategy should be to ensure that the highest number of wild smolts in the best condition leave from rivers and coastal areas to the ocean. There is great scope for water quality, river regulation, migration barriers, and physical river habitat improvements. 3. Maintenance of genetic integrity and diversity of wild populations by eliminating interbreeding with escaped farmed salmon, eliminating poorly planned stocking, and reducing impacts that reduce population sizes to dangerously low levels will support the ability of Atlantic salmon to adapt to changing environments. Reducing the impacts from aquaculture and other human activities in coastal areas can greatly increase marine survival in affected areas. 4. As most of the threats to wild salmon are the result of human activities, a focus on human dimensions and improved communication, from scientific and management perspectives, needs to be increasingly emphasized. When political and social will are coupled with adequate resources, managers often have the tools to mitigate many of the threats to wild salmon. aquaculture, catchment management, climate change, conservation evaluation, fish, habitat management, hydropower, ocean, river

Objective The aim was to explore the self-reported impact of the COVID-19 pandemic on changes to care and behaviour in UK patients with systemic autoimmune rheumatic diseases, to help ensure that patient experiences are considered in future pandemic planning. Methods This was a longitudinal mixed methods study, with a cohort completing baseline surveys in March 2020 and follow-up surveys in June 2020 (n = 111), combined with thematic analysis of the LUPUS UK forum and participant interviews (n = 28). Results Cancellations of routine care and difficulties in accessing medical support contributed to some participants deteriorating physically, including reports of hospitalizations. The majority of participants reported that fear of COVID-19 and disruptions to their medical care had also adversely impacted their mental health. Feeling medically supported during the pandemic was correlated with multiple measures of mental health and perceptions of care, including the Warwick–Edinburgh mental well-being score (r = 0.44, P = 0.01). Five themes were identified: detrimental reduction in care; disparities in contact and communication (medical security vs abandonment sub-theme); perceived and actual endangerment; the perfect storm of reduced clinician ability to help and increased patient reticence to seek help; and identifying the patients most vulnerable to reduced medical care. Conclusion The diversion of resources away from chronic disease care was perceived by many participants to have caused adverse outcomes. Fear about increased vulnerability to COVID-19 was high, contributing to health-care-avoidant behaviours. This study also highlights the influence of clinician accessibility and patients feeling medically supported on multiple measures of physical and mental health.

Aims and objectives This paper describes a pilot non-randomised controlled study of a highly tailored 56-day text messaging and smartphone app prototype intervention to increase adherence to anti-hypertensive medication in primary care. The aim of this study was to evaluate the acceptability of the intervention and obtain patients’ views about the intervention content, the delivery mode, and the mechanisms by which the intervention supported medication adherence. Methods Patients diagnosed with hypertension were invited and recruited to the study via general practice text messages and attended a face to face meeting with a member of the researcher team. Participants were asked to test the text messaging intervention for 28 consecutive days and switch to the smartphone app for 28 more days. Participants completed baseline and follow-up questionnaires and took part in semi-structured telephone interviews. Digital log files captured patients’ engagement with the intervention. Participant transcripts were analysed using thematic analysis. Descriptive statistics were used to summarise data from questionnaires and log files. A mixed methods analysis generated data to respond to the research questions. Results Seventy-nine patients expressed interest to participate in this study, of whom 23 (64% male, 82% above 60 years old) were registered to take part. With one drop-out, 22 participants tested the text messaging delivery mode (with 20 being interviewed) and four of them (17%) switched to the app (with 3 being interviewed). All participants engaged and interacted with the text messages and app notifications, and all participants found the intervention content and delivery mode acceptable. They also self-reported that the interactive elements of the intervention motivated them to take their medications as prescribed. Conclusion This study provides evidence that the digital intervention is acceptable by hypertensive patients recruited in primary care. Future research could usefully investigate its feasibility and effectiveness using rigorous research methods. Trial registration ISRCTN12805654

Background This review aimed to (i) identify efficacy of face to face interventions on medication adherence behaviour in adults with Long Term Health Conditions (LTHCs) and (ii) identify Behaviour Change Techniques (BCTs) and study characteristics associated with the efficacy of face to face interventions. Methods Cochrane Controlled Register of Trials, Embase, MEDLINE (ovid), PsycINFO, Web of science, PubMed, and Scopus databases were searched (from start date till May 2019). Randomized Controlled Trials (RCTs) were included if they described the intervention to improve medication adherence delivered via face to face; included any LTHC, included a comparator group, conducted in any setting and published in English language. Studies were excluded if used additional delivery mode (e.g. leaflet, SMS, apps, follow up phone call related to medication adherence), involved adolescents ( Results Results from 50 studies were included in the analysis (n=10576). Most face to face interventions took place in secondary care (n=26), included pharmacists in delivery (n=12) and involved counselling (n=10) and behavioural (n=8) approaches on multiple occasions. Majority of the studies were published in years 2014–2019 (n=26) and conducted in the USA (n=16). Most common health condition was HIV (n=10) in comparison to other LTHCs. The first follow up time point (related to medication adherence outcome), will be analysed from all included studies. In terms of risk of bias, most studies were rated as having overall high risk of bias (n=37), followed by some concern due to lack of information (n=12) and low risk of bias (n=1). BCTs were only used in the intervention groups (n=18), in which most commonly used were: ‘self-monitoring behaviour’ and ‘action planning’. The impact of specific individual BCTs and BCTs domains on effectiveness will be examined. Subgroup analyses will be conducted related to age and gender. Results related to the aims of this meta-analysis and meta-regression will be available by the time of the conference. Conclusion Efficacy of these interventions related to medication adherence outcome and core components of face to face consultations with BCT coding could be very useful to design a cost and time effective face to face very brief or brief interventions related to medication adherence to be implemented in primary care practices in the future.

A positive patient experience has been long recognised as a key feature of a high-quality health service, however, often assessment of patient experience excludes diagnostic care. Experience of diagnostic services and the acceptability of diagnostic tests are often conflated, with lack of clarity about when and how either should be measured. These problems contrast with the growth in the development and marketing of new tests and investigation strategies. Building on the appraisal of current practice, we propose that the experience of diagnostic services and the acceptability of tests should be assessed separately, and describe distinct components of each. Such evaluations will enhance the delivery of patient-centred care, and facilitate patient choice.

IntroductionPrimary care interventions are often multicomponent, with several targets (eg, patients and healthcare professionals). Improving Primary Care After Stroke (IPCAS) is a novel primary care-based model of long-term stroke care involving a review of stroke-related needs, a self-management programme, a direct point of contact in general practice, enhanced communication between care services, and a directory of national and local community services, currently being evaluated in a cluster randomised controlled trial (RCT). Informed by Medical Research Council guidance for complex interventions and the Behaviour Change Consortium fidelity framework, this protocol outlines the process evaluation of IPCAS within this RCT. The process evaluation aimed to explore how the intervention was delivered in context and how participants engaged with the intervention.Methods and analysisMixed methods will be used: (1) design: intervention content will be compared with ‘usual care’; (2) training: intervention training sessions will be audio/video-recorded where feasible; (3) delivery: healthcare professional self-reports, audio recordings of intervention delivery and observations of My Life After Stroke course (10% of reviews and sessions) will be coded separately; semistructured interviews will be conducted with a purposive sample of healthcare professionals; (4) receipt and (5) enactment: where available, structured stroke review records will be analysed quantitatively; semistructured interviews will be conducted with a purposive sample of study participants. Self-reports, observations and audio/video recordings will be coded and scored using specifically developed checklists. Semistructured interviews will be analysed thematically. Data will be analysed iteratively, independent of primary endpoint analysis.Ethics and disseminationFavourable ethical opinion was gained from Yorkshire & The Humber-Bradford Leeds NHS Research Ethics Committee (19 December 2017, 17/YH/0441). Study results will be published in a peer-reviewed journal and presented at relevant conferences.Trial registration numberNCT03353519; Pre-results.

Background Limited research exists on interest in and use of smoking cessation support in pregnancy and postpartum. Methods A longitudinal cohort of pregnant smokers and recent ex-smokers were recruited in Nottinghamshire, United Kingdom (N = 850). Data were collected at 8–26 weeks gestation, 34–36 weeks gestation, and 3 months postpartum and used as three cross-sectional surveys. Interest and use of cessation support and belief and behavior measures were collected at all waves. Key data were adjusted for nonresponse and analyzed descriptively, and multiple regression was used to identify associations. Results In early and late pregnancy, 44% (95% CI 40% to 48%) and 43% (95% CI 37% to 49%) of smokers, respectively, were interested in cessation support with 33% (95% CI 27% to 39%) interested postpartum. In early pregnancy, 43% of smokers reported discussing cessation with a midwife and, in late pregnancy, 27% did so. Over one-third (38%) did not report discussing quitting with a health professional during pregnancy. Twenty-seven percent of smokers reported using any National Health Service (NHS) cessation support and 12% accessed NHS Stop Smoking Services during pregnancy. Lower quitting confidence (self-efficacy), higher confidence in stopping with support, higher quitting motivation, and higher age were associated with higher interest in support (ps ≤ .001). A recent quit attempt and greater interest in support was associated with speaking to a health professional about quitting and use of NHS cessation support (ps ≤ .001). Conclusions When asked in early or late pregnancy, about half of pregnant smokers were interested in cessation support, though most did not engage. Cessation support should be offered throughout pregnancy and after delivery. Implications There is relatively high interest in cessation support in early and late pregnancy and postpartum among smokers; however, a much smaller proportion of pregnant or postpartum women access any cessation support, highlighting a gap between interest and engagement. Reflecting women’s interest, offers of cessation support should be provided throughout pregnancy and after delivery. Increasing motivation to quit and confidence in quitting with assistance may enhance interest in support, and promoting the discussion of stopping smoking between women and health practitioners may contribute to higher support engagement rates.

Objective: Walking Away from Diabetes (Walking Away) is a low resource 3-hour group-based behavioural intervention designed to promote physical activity through pedometer use in those with prediabetes. This trial aimed to investigate whether Walking Away leads to sustained increases in physical activity when delivered with and without an integrated mHealth intervention compared to control. Methods: Those with a history of prediabetes (HbA1c ≥42 [6.0], Results: 1366 individuals were randomised (median age = 61 years, BMI = 28.4 kg/m2, ambulatory activity = 6638 steps/day, women = 49%, black and minority ethnicity = 28%). Accelerometer data were available for 1017 (74%) and 993 (73%) individuals at 12 and 48 months, respectively. At 12 months, WA+ increased their ambulatory activity by 547 (97.5% CI, 211, 882) steps/day compared to CON and were 1.61 (97.5% CI 1.05, 2.45) times more likely to achieve 150 min/week of MVPA. However, differences were not sustained at 48 months. There were no differences between WA and CON at 12 or 48 months. Conclusion: Combining a physical activity intervention with text messaging and telephone support resulted in modest, but clinically meaningful, changes in physical activity at 12 months, but changes are not sustained after 48 months. Disclosure K. Khunti: Advisory Panel; Self; Amgen, AstraZeneca, Bayer AG, Berlin-Chemie AG, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Menarini Group, Merck Sharp 0026& Dohme Corp., Napp Pharmaceuticals, Novartis AG, Novo Nordisk A/S, Roche Pharma, Sanofi-Aventis, Servier. Board Member; Self; AstraZeneca, Eli Lilly and Company, Merck Sharp & Dohme Corp., Novo Nordisk A/S, Sanofi-Aventis. Consultant; Self; Amgen, AstraZeneca, Bayer AG, Berlin-Chemie AG, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Menarini Group, Merck Sharp & Dohme Corp., Napp Pharmaceuticals, Novartis AG, Novo Nordisk A/S, Roche Pharma, Sanofi-Aventis, Servier. Research Support; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Merck Sharp & Dohme Corp., Novartis AG, Novo Nordisk A/S, Pfizer Inc., Sanofi-Aventis, Servier. Speaker’s Bureau; Self; Amgen, AstraZeneca, Bayer AG, Berlin-Chemie AG, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Menarini Group, Merck Sharp & Dohme Corp., Napp Pharmaceuticals, Novartis AG, Novo Nordisk A/S, Roche Pharma, Sanofi-Aventis, Servier. S. Griffin: Speaker’s Bureau; Self; AstraZeneca, Napp Pharmaceuticals. Other Relationship; Self; Eli Lilly and Company. M.J. Davies: Advisory Panel; Self; Boehringer Ingelheim International GmbH, Novo Nordisk A/S, Sanofi, Sanofi US. Speaker’s Bureau; Self; Boehringer Ingelheim International GmbH, Napp Pharmaceuticals, Novo Nordisk A/S, Sanofi. Other Relationship; Self; Ingeus UK. H.C. Eborall: None. C. Edwardson: None. W. Hardeman: None. J. Henson: None. S. Sharp: None. S. Sutton: None. J. Troughton: None. T. Yates: Research Support; Self; AstraZeneca. Other Relationship; Self; Ingeus UK. Funding National Institute for Health Research

BACKGROUND The efficacy of a highly tailored digital intervention to support medication adherence and feasibility to support clinical effectiveness as an adjunct to the primary care setting has not been evaluated. OBJECTIVE This trial aimed to assess the behavioral efficacy of a highly tailored digital intervention to support medication adherence and to evaluate the feasibility of its clinical effectiveness, in patients with either or both hypertension and type 2 diabetes. We also examined quality of life and mechanisms of behavior change. Intervention fidelity, engagement, and satisfaction were also explored. METHODS This was a multicenter, individually randomized controlled trial of 2 parallel groups: an intervention group that received a highly tailored text message and interactive voice response intervention for 12 weeks, and a control group that received usual care. Medication adherence was measured using self-reports and assessor-blinded practice records of a repeat prescription. Systolic blood pressure and glucose levels were assessed by nurses blinded to group allocation during practice visits at 3 months follow-up. Questionnaires obtained data to assess intervention mechanisms of action and satisfaction and digital log files captured data to evaluate fidelity and engagement. RESULTS A total of 135 nonadherent patients (62/135, 46% female; 122/135, 90.3%; aged above 50 years) were randomly allocated in the intervention (n=79) or in the control group (n=56); of whom 13% (18/135) were lost at follow-up. Medication adherence was significantly improved in the intervention group compared with the control group (t116=2.27; P=.02, 2-tailed). Systolic blood pressure was 0.6 mmHg (95% CI −7.423 to 6.301), and hemoglobin A1c was 4.5 mmol/mol (95% CI −13.099 to 4.710) lower in the intervention group compared with the control group. Changes in intentional nonadherence and nonintentional nonadherence explained the improvements in medication adherence in the intervention group (beta=.074, SE=0.464; P=.04), but not in the control group (beta=.00, SE 1.35; P=.37). The intervention had 100% fidelity, a median of 12 days of engagement, and 76% overall satisfaction. CONCLUSIONS Our trial is the first that has been conducted in the United Kingdom and showed that among nonadherent patients with either or both hypertension and type 2 diabetes, a highly tailored digital intervention was effective at improving treatment adherence and feasible to obtain clinically meaningful outcomes. Changes in intentional and nonintentional nonadherence predicted the improvements in medication adherence. The intervention had high fidelity, engagement, and satisfaction. Future research using a rigorous design is needed to evaluate the clinical effectiveness and cost-effectiveness of the intervention in primary care. CLINICALTRIAL International Standard Randomized Controlled Trial Number (ISRCTN) 10668149; http://www.controlled-trials.com/ISRCTN10668149.

Background The majority of people do not achieve recommended levels of physical activity. There is a need for effective, scalable interventions to promote activity. Self-monitoring by pedometer is a potentially suitable strategy. We assessed the effectiveness and cost-effectiveness of a very brief (5-minute) pedometer-based intervention (‘Step It Up’) delivered as part of National Health Service (NHS) Health Checks in primary care. Methods and findings The Very Brief Intervention (VBI) Trial was a two parallel-group, randomised controlled trial (RCT) with 3-month follow-up, conducted in 23 primary care practices in the East of England. Participants were 1,007 healthy adults aged 40 to 74 years eligible for an NHS Health Check. They were randomly allocated (1:1) using a web-based tool between October 1, 2014, and December 31, 2015, to either intervention (505) or control group (502), stratified by primary care practice. Participants were aware of study group allocation. Control participants received the NHS Health Check only. Intervention participants additionally received Step It Up: a 5-minute face-to-face discussion, written materials, pedometer, and step chart. The primary outcome was accelerometer-based physical activity volume at 3-month follow-up adjusted for sex, 5-year age group, and general practice. Secondary outcomes included time spent in different intensities of physical activity, self-reported physical activity, and economic measures. We conducted an in-depth fidelity assessment on a subsample of Health Check consultations. Participants’ mean age was 56 years, two-thirds were female, they were predominantly white, and two-thirds were in paid employment. The primary outcome was available in 859 (85.3%) participants. There was no significant between-group difference in activity volume at 3 months (adjusted intervention effect 8.8 counts per minute [cpm]; 95% CI −18.7 to 36.3; p = 0.53). We found no significant between-group differences in the secondary outcomes of step counts per day, time spent in moderate or vigorous activity, time spent in vigorous activity, and time spent in moderate-intensity activity (accelerometer-derived variables); as well as in total physical activity, home-based activity, work-based activity, leisure-based activity, commuting physical activity, and screen or TV time (self-reported physical activity variables). Of the 505 intervention participants, 491 (97%) received the Step it Up intervention. Analysis of 37 intervention consultations showed that 60% of Step it Up components were delivered faithfully. The intervention cost £18.04 per participant. Incremental cost to the NHS per 1,000-step increase per day was £96 and to society was £239. Adverse events were reported by 5 intervention participants (of which 2 were serious) and 5 control participants (of which 2 were serious). The study’s limitations include a participation rate of 16% and low return of audiotapes by practices for fidelity assessment. Conclusions In this large well-conducted trial, we found no evidence of effect of a plausible very brief pedometer intervention embedded in NHS Health Checks on objectively measured activity at 3-month follow-up. Trial registration Current Controlled Trials (ISRCTN72691150)., Wendy Hardeman and colleagues investigate a short physical activity intervention in a randomized controlled trial., Author summary Why was this study done? Systematic reviews support the effectiveness and cost-effectiveness of brief (up to 30 minutes) physical activity interventions in primary care and the effectiveness of intensive pedometer interventions. There is a need for briefer interventions in primary care, where time is limited but potential reach is large. However, the reviews show uncertainty about the effectiveness and cost-effectiveness of very brief (up to 5 minutes) interventions in primary care. Until now, there have been no randomised controlled trials (RCTs) of a very brief pedometer-based intervention to increase physical activity in primary care. What did the researchers do and find? We randomly assigned participants who attended preventive health checks in primary care (National Health Service [NHS] Health Checks) to the health check alone or additionally a very brief pedometer-based physical activity intervention delivered by practice nurses or healthcare assistants. We measured physical activity objectively at 3 months after the intervention. Our large trial found no benefit of a very brief physical activity intervention in the context of preventive health checks in primary care. Despite the intervention being apparently simple and very brief, fidelity of delivery was suboptimal. Trial participants were more active than might have been expected. The economic evaluation shows a small added cost for a small and uncertain benefit. What do these findings mean? The absence of a positive effect of a very brief physical activity intervention challenges the commissioning of such interventions in this context. Primary care practitioners should continue to opportunistically provide very brief advice about physical activity.

A substantial proportion of primary care patients are long-term users of antidepressant medication. Antidepressants are often started when patients have episodes of mild to...

ObjectivesTo estimate the efficacy of app-based interventions designed to support medication adherence and investigate which behaviour change techniques (BCTs) used by the apps are associated with efficacy.DesignSystematic review of randomised controlled trials (RCTs), with meta-analysis.SettingMedline/PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Embase and Web of Science were searched from 1990 to November 2018 for RCTs conducted in any healthcare setting.ParticipantsStudies of participants of any age taking prescribed medication for any health condition and for any duration.InterventionAn app-based intervention delivered through a smartphone, tablet computer or personal digital assistant to help, support or advise about medication adherence.ComparatorOne of (1) usual care, (2) a control app which did not use any BCTs to improve medication adherence or (3) a non-app-based comparator.Primary and secondary outcome measuresThe primary outcome was the pooled effect size of changes in medication adherence. The secondary outcome was the association between BCTs used by the apps and the effect size.ResultsThe initial search identified 13 259 citations. After title and abstract screening, full-text articles of 83 studies were screened for eligibility. Nine RCTs with 1159 recruited participants were included. The mean age of participants was >50 years in all but one study. Health conditions of target populations included cardiovascular disease, depression, Parkinson’s disease, psoriasis and multimorbidity. The meta-analysis indicated that patients who use mobile apps to support them in taking medications are more likely to self-report adherence to medications (OR 2.120, 95% CI 1.635 to 2.747, n=988) than those in the comparator groups. Meta-regression of the BCTs did not reveal any significant associations with effect size.ConclusionsApp-based medication adherence interventions may have a positive effect on patient adherence. Larger scale studies are required to further evaluate this effect, including long-term sustainability, and intervention and participant characteristics that are associated with efficacy and app usage.Prospero registration numberPROSPERO Protocol Registration Number: CRD42017080150.

Background: Cancer is the second leading cause of death worldwide. Lifestyle choices play an important role in the aetiology of cancer with up to 4 in 10 cases potentially preventable. Interventions delivered by healthcare professionals (HCPs) that incorporate risk information have the potential to promote behaviour change. Our aim was to develop a very brief intervention incorporating cancer risk, which could be implemented within primary care. Methods: Guided by normalisation process theory (NPT), we developed a prototype intervention using literature reviews, consultation with patient and public representatives and pilot work with patients and HCPs. We conducted focus groups and interviews with 65 HCPs involved in delivering prevention activities. Findings were used to refine the intervention before 22 HCPs completed an online usability test and provided further feedback via a questionnaire incorporating a modified version of the NoMAD checklist. Results: The intervention included a website where individuals could provide information on lifestyle risk factors view their estimated 10-year risk of developing one or more of the five most common preventable cancers and access lifestyle advice incorporating behaviour change techniques. Changes incorporated from feedback from the focus groups and interviews included signposting to local services and websites, simplified wording and labelling of risk information. In the usability testing, all participants felt it would be easy to collect the risk information. Ninety-one percent felt the intervention would enable discussion about cancer risk and believed it had potential to be easily integrated into National Health Service (NHS) Health Checks. However, only 36% agreed it could be delivered within 5 min. Conclusions: With the use of NPT, we developed a very brief intervention that is acceptable to HCPs in primary care and could be potentially integrated into NHS Health Checks. However, further work is needed to assess its feasibility and potential effectiveness.

Globally, Indigenous peoples have fire management practices which are not necessarily supported by the centralised land management and natural hazard institutions of nation states. This is changing in Australia with the proliferation of engagements between government authorities and Aboriginal fire management leaders. These engagements raise a series of justice issues that critique the separation of environmental and socio-political matters, and the discriminatory positioning of Indigenous peoples and their interests as local. In this chapter, we share the experiences of Aboriginal people that have been shared with us in three places: Central Arnhem Land, the Western Desert and the Australian Capital Territory. The theory/practice of Disaster Justice offers new opportunities to ensure these socio-natural engagements are ‘just’, which requires careful attention to whose values matter, whose knowledge is important and whose political-legal rights and entities are recognised and resourced.

Objectives The aim was to explore patient experiences and views of their symptoms, delays in diagnosis, misdiagnoses and medical support, to identify common experiences, preferences and unmet needs. Methods Following a review of LUPUS UK’s online forum, a questionnaire was posted online during December 2018. This was an exploratory mixed methods study, with qualitative data analysed thematically and combined with descriptive and statistically analysed quantitative data. Results There were 233 eligible respondents. The mean time to diagnosis from first experiencing symptoms was 6 years 11 months. Seventy-six per cent reported at least one misdiagnosis for symptoms subsequently attributed to their systemic autoimmune rheumatic disease. Mental health/non-organic misdiagnoses constituted 47% of reported misdiagnoses and were indicated to have reduced trust in physicians and to have changed future health-care-seeking behaviour. Perceptions of physician knowledge and listening skills were highly correlated with patient ratings of trust. The symptom burden was high. Fatigue had the greatest impact on activities of daily living, yet the majority reported receiving no support or poor support in managing it. Assessing and treating patients holistically and with empathy was strongly felt to increase diagnostic accuracy and improve medical relationships. Conclusion Patient responses indicated that timely diagnosis could be facilitated if physicians had greater knowledge of lupus/related systemic autoimmune diseases and were more amenable to listening to and believing patient reports of their symptoms. Patient priorities included physicians viewing them holistically, with more emotional support and assistance in improving quality of life, especially in relation to fatigue.

Objective The aim was to explore the impact of patient–physician interactions, pre- and post-diagnosis, on lupus and UCTD patients’ psychological well-being, cognition and health-care-seeking behaviour. Methods Participants were purposively sampled from the 233 responses to a survey on patient experiences of medical support. Twenty-one semi-structured interviews were conducted and themes generated using thematic analysis. Results The study identified six principal themes: (i) the impact of the diagnostic journey; (ii) the influence of key physician(s) on patient trust and security, with most participants reporting at least one positive medical relationship; (iii) disparities in patient–physician priorities, with patients desiring more support with quality-of-life concerns; (iv) persisting insecurity and distrust, which was prevalent and largely influenced by previous and anticipated disproportionate (often perceived as dismissive) physician responses to symptoms and experiences of widespread inadequate physician knowledge of systemic autoimmune diseases; (v) changes to health-care-seeking behaviours, such as curtailing help-seeking or under-reporting symptoms; and (vi) empowerment, including shared medical decision-making and knowledge acquisition, which can mitigate insecurity and improve care. Conclusion Negative medical interactions pre- and post-diagnosis can cause a loss of self-confidence and a loss of confidence and trust in the medical profession. This insecurity can persist even in subsequent positive medical relationships and should be addressed. Key physicians implementing empowering and security-inducing strategies, including being available in times of health crises and validating patient-reported symptoms, might lead to more trusting medical relationships and positive health-care-seeking behaviour.

Smong is an indigenous knowledge related to the tsunami. The word of smong comes from the Devayan language of Simeulue and refers to the complex of earthquake/sea receding/giant wave that is typical of tsunami events in Indonesia. Now their pride in the word smong has spread to Aceh and is being adopted in their efforts to adapt to earthquake and tsunami disasters. Simeuluean people, grateful to their nation for the reconstruction after 2004 and want to grow their pride in smong to a national level. They wanted to make a gift of smong to be owned by the Indonesian people. To do this, they feel this study initiates that the word smong should be part of the narrative in Indonesian as the basis for a new understanding of the tsunami disaster by Indonesian people. Initiating the word smong in Indonesian vocabulary does not mean removing the word tsunami that now an international word. But the acceptance of smong should be a source of pride in the protection of our greatest wealth of people.

Introduction Nicotine replacement therapy (NRT) is effective for smoking cessation, but the optimal method of using NRT to maximize benefit is unclear. We examined whether nicotine dependence was associated with consumption of NRT, whether this was mediated by withdrawal symptoms, and the impact of these factors on cessation, in a population advised to use as much NRT as needed. Methods Secondary analysis of data from an open label, parallel group randomized controlled trial. Participants (n = 539) attended a smoking cessation clinic in primary care and remained engaged with treatment for at least one week following a quit attempt. Baseline dependence was measured by the Fagerstrom Test for Cigarette Dependence (FTCD), with tobacco exposure assessed via an exhaled carbon monoxide test. At one week after quit day, mean daily consumption of NRT was measured for all participants; withdrawal (Mood and Physical Symptoms Scale (MPSS)) was also assessed in the subsample who reported being completely abstinent to that point (n = 279). Abstinence was biochemically assessed at four weeks for all participants as the principal smoking cessation outcome. Results Each point higher on the FTCD was associated with 0.83 mg/day more NRT consumption, controlling for tobacco exposure. This relationship was diminished when withdrawal was controlled for, and withdrawal was associated with NRT consumption, with each point higher on the MPSS associated with a 0.12 mg/day increase. Increased consumption of NRT directly predicted subsequent smoking cessation. Conclusions Higher dependence appears to lead to greater withdrawal, which appears to drive greater use of NRT. This effect may partly offset lower abstinence rates in people with higher dependence. Advice to use sufficient NRT to suppress withdrawal may increase abstinence rates.

Although the occurrence of extreme events generally cannot be prevented, their negative effects can be lessened by various risk reductions actions and by improving the capacity of communities and individuals to cope. Improving the resilience of both individuals and communities reduces the effects of hazards allowing a faster recovery and return to normal and is increasingly becoming a goal of communities, organisations and governments throughout the world. Improving resilience is complicated and often requires numerous interrelated actions that vary depending specific circumstances of the people, community and location. To meaningfully determine, co-ordinate, plan and prioritise the most effective measures of improving resilience, a baseline assessment of the community’s strengths and weaknesses is required. This paper contributes by examining the status of community resilience in two remote towns within the Northern Territory of Australia. A qualitative narrative assesses community resilience for small remote locations and discusses relevant issues alongside the scoring achieved using a common scoring methodology. It further provides insights and an examination of the methods of assessment and appropriateness of assessment methodology.

AIMS: To assess the cost‐effectiveness of a two‐component intervention designed to increase attendance at the NHS Stop Smoking Services (SSSs) in England. DESIGN: Cost‐effectiveness analysis alongside a randomized controlled trial (Start2quit). SETTING: NHS SSS and general practices in England. PARTICIPANTS: The study comprised 4384 smokers aged 16 years or more identified from medical records in 99 participating practices, who were motivated to quit and had not attended the SSS in the previous 12 months. INTERVENTION AND COMPARATOR: Intervention was a personalized and tailored letter sent from the general practitioner (GP) and a personal invitation and appointment to attend a taster session providing information about SSS. Control was a standard generic letter from the GP advertising SSS and asking smokers to contact the service to make an appointment. MEASUREMENTS: Costs measured from an NHS/personal social services perspective, estimated health gains in quality‐adjusted life‐years (QALYs) measured with EQ‐5D and incremental cost per QALY gained during both 6 months and a life‐time horizon. FINDINGS: During the trial period, the adjusted mean difference in costs was £92 [95% confidence interval (CI) = –£32 to –£216) and the adjusted mean difference in QALY gains was 0.002 (95% CI = –0.001 to 0.004). This generates an incremental cost per QALY gained of £59 401. The probability that the tailored letter and taster session is more cost‐effective than the generic letter at 6 months is never above 50%. In contrast, the discounted life‐time health‐care cost was lower in the intervention group, while the life‐time QALY gains were significantly higher. The probability that the intervention is more cost‐effective is more than 83% using a £20 000–30 000 per QALY‐gained decision‐making threshold. CONCLUSIONS: An intervention designed to increase attendance at the NHS Stop Smoking Services (tailored letter and taster session in the services) appears less likely to be cost‐effective than a generic letter in the short term, but is likely to become more cost‐effective than the generic letter during the long term.

Growing international appreciation of the increasing risk posed by natural hazard events acknowledges the effects that climate change and increasingly vulnerable populations will have on future costs and casualties of disasters. As concerns about the impacts of natural hazard events increase, researchers and practitioners are interested in identifying effective processes to build individual and community resilience. To date, despite resources, time and effort being made by governments and NGOs to encourage disaster risk reduction (DRR) programs at national, regional and local levels, most communities remain poorly prepared, and improvements have only been incremental. One way to gain insight into systems that may improve local community resilience is to examine (rare) examples where communities have avoided the worst impacts of a natural disaster through implementation of recognizable DRR strategies. One example is Simeulue Island in Indonesia. Simeulue was only 43 km from the epicenter of the earthquake that initiated the Indian Ocean tsunami in December 2004. The 15 m tsunami waves destroyed all but two of the islands 171 schools, 60 bridges, 41 medical centers and left 85% of the population homeless; but only 7 out of the 80,000 inhabitants died [1]. Music and song have been identified as an important part of Simeulue's DRR success [2-4]. This paper discusses the nature of the songs of Simeulue and considers the socio-cognitive processes whereby music was co-opted to entrain risk information about tsunami and their avoidance into the Simeulue community's Sense of Coherence (‘SOC’). The findings indicate that the people of Simeulue applied techniques now understood to optimize learning. While highly effective, they rely on rudimentary human skills and have consequently been overlooked or ignored in most formal DRR contexts.

Recreational fishing provokes conservation concerns given the growing recreational demands on fisheries resources in different countries. Despite the negative impact of recreational fishing on fish...

This systematic review of reviews aims to investigate how brief interventions (BIs) are defined, whether they increase physical activity, which factors influence their effectiveness, who they are effective for, and whether they are feasible and acceptable. We searched CINAHL, Cochrane database of systematic reviews, DARE, HTA database, EMBASE, MEDLINE, PsycINFO, Science Citation Index-Expanded and Social Sciences Citation Index, and Scottish Intercollegiate Guidelines Network from their inception until May 2015 to identify systematic reviews of the effectiveness of BIs aimed at promoting physical activity in adults, reporting a physical activity outcome and at least one BI that could be delivered in a primary care setting. A narrative synthesis was conducted. We identified three specific BI reviews and thirteen general reviews of physical activity interventions that met the inclusion criteria. The BI reviews reported varying definitions of BIs, only one of which specified a maximum duration of 30 minutes. BIs can increase self-reported physical activity in the short term, but there is insufficient evidence about their long-term impact, their impact on objectively measured physical activity, and about the factors that influence their effectiveness, feasibility and acceptability. Current definitions include BIs that are too long for primary care consultations. Practitioners, commissioners and policy makers should be aware of this when interpreting evidence about BIs, and future research should develop and evaluate very brief interventions (of five minutes or less) that could be delivered in a primary care consultation.

Aims To estimate the effectiveness of pregnancy smoking cessation support delivered by SMS text message and key parameters needed to plan a definitive trial. Design Multicentre, parallel-group, single-blinded, individual randomised controlled trial Setting 16 antenatal clinics in England. Participants 407 participants were randomised to the intervention (n = 203) or usual care (n = 204). Eligible women were 5 pre-pregnancy), were able to receive and understand English SMS texts and were not already using text-based cessation support. Intervention All participants received a smoking cessation leaflet; intervention participants also received a 12-week programme of individually-tailored, automated, interactive, self-help smoking cessation text messages (MiQuit). Outcome Measurements Seven smoking outcomes including validated continuous abstinence from 4 weeks post-randomisation until 36 weeks gestation, design parameters for a future trial and cost-per-quitter. Findings Using the validated, continuous abstinence outcome, 5.4% (11/203) of MiQuit participants were abstinent versus 2.0% (4/204) of usual care participants (odds ratio [OR] 2.7, 95% confidence interval [CI] 0.93 to 9.35). The Bayes Factor for this outcome was 2.23. Completeness of follow up at 36 weeks gestation was similar in both groups; provision of self-report smoking data was 64% (MiQuit) and 65% (usual care) and abstinence validation rates were 56% (MiQuit) and 61% (usual care). The incremental cost-per-quitter was £133.53 (95% CI -£395.78 to £843.62). Conclusions There was some evidence, though not conclusive, that a text messaging programme may increase cessation rates in pregnant smokers when provided alongside routine NHS cessation care.

Effective conservation depends upon people's compliance with regulations, yet non-compliance (eg poaching) is often the rule rather than the exception. Poaching is often clandestine and socially undesirable, requiring specialized, multidisciplinary approaches for assessment and management. We estimated poaching by recreational fishers in no-fishing reserves of Australia's Great Barrier Reef Marine Park (GBRMP) by conducting social surveys and quantifying derelict (lost or discarded) fishing gear. Our study revealed that (1)between 3-18% of fishers admitted to poaching within the past year, (2) poaching activities were often concentrated at certain times (holidays) and in specific places (poaching hotspots), and (3) fishers' primary motivations to poach were the perception of higher catches in reserves and a low probability of detection. Our results suggest that extolling certain ecological benefits of marine reserves where enforcement capacity is low could lead to the perverse outcome of encouraging non-compliance. Our combined social-ecological approach revealed that even in an iconic marine park such as the GBRMP, poaching levels are higher than previously assumed, which has implications for effective management.

Summary Background National Health Service Stop Smoking Services (SSSs) offer help to smokers motivated to quit; however, attendance rates are low and recent figures show a downward trend. We aimed to assess the effectiveness of a two-component personalised intervention on attendance at SSSs. Methods We did this randomised controlled trial in 18 SSSs in England. Current smokers (aged ≥16 years) were identified from medical records in 99 general practices and invited to participate by their general practitioner. Individuals who gave consent, were motivated to quit, and had not attended the SSS within the past 12 months, were randomly assigned (3:2), via computer-generated randomisation with permuted blocks (block size of five), to receive either an individually tailored risk letter and invitation to attend a no-commitment introductory session run by the local SSS (intervention group) or a standard generic letter advertising the local SSS (control group). Randomisation was stratified by sex. Masking of participants to receipt of a personal letter and invitation to a taster session was not possible. The personal letter was generated by a research assistant, but the remainder of the research team were masked to group allocation. General practitioners, practice staff, and SSS advisers were unaware of their patients' allocation. The primary outcome was attendance at the first session of an SSS course within 6 months from randomisation. We did analysis by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN 76561916. Findings Recruitment, collection of baseline data, delivery of the intervention, and follow up of participants took place between Jan 31, 2011, and July 12, 2014. We randomly assigned 4384 smokers to the intervention group (n=2636) or the control group (n=1748); 4383 participants comprised the intention-to-treat population. Attendance at the first session of an SSS course was significantly higher in the intervention group than in the control group (458 [17·4%] vs 158 [9·0%] participants; unadjusted odds ratio 2·12 [95% CI 1·75–2·57]; p Interpretation Delivery of personalised risk information alongside an invitation to an introductory session more than doubled the odds of attending the SSS compared with a standard generic invitation to contact the service. This result suggests that a more proactive approach, combined with an opportunity to experience local services, can reduce patient barriers to receiving treatment and has high potential to increase uptake. Funding National Institutes of Health Research Health Technology Assessment.