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Objective To assess whether a weight management intervention for pregnant women with obesity was effective in reducing body mass index (BMI) 12 months after giving birth. Methods Pragmatic, cluster randomised controlled trial (RCT) with embedded cost-effectiveness analysis. 598 women with a BMI of ≥30 kg/m2 (between 12 and 20 weeks gestation) were recruited from 20 secondary care maternity units in England and Wales. BMI at 12 months postpartum was the primary outcome. A range of clinical and behavioural secondary outcomes were examined. Interventions Women attending maternity units randomised to intervention were invited to a weekly weight management group, which combined expertise from a commercial weight loss programme with clinical advice from midwives. Both intervention and control participants received usual care and leaflets on diet and physical activity in pregnancy. Results Mean (SD) BMI at 12 months postpartum was 36.0 kg/m2 (5.2) in the control group, and 37.5 kg/m2 (6.7) in the intervention group. After adjustment for baseline BMI, the intervention effect was −0.02 (95% CI −0.04 to 0.01). The intervention group had an improved healthy eating score (3.08, 95% CI 0.16 to 6.00, p p p Conclusions There was no significant difference between groups on the primary outcome of BMI at 12 months. Analyses of secondary outcomes indicated improved healthy eating and lower levels of risky drinking. Trial registration: Current Controlled Trials ISRCTN25260464.

Background There is a need to develop weight management interventions that fit seamlessly into the busy lives of women during the postpartum period. Objective The objective was to develop and pilot-test an evidence- and theory-based intervention, delivered by short message service, which supported weight loss and weight loss maintenance in the postpartum period. Design Stage 1 involved the development of a library of short message service messages to support weight loss and weight loss maintenance, with personal and public involvement, focusing on diet and physical activity with embedded behaviour change techniques, and the programming of a short message service platform to allow fully automated intervention delivery. Stage 2 comprised a 12-month, single-centre, two-arm, pilot, randomised controlled trial with an active control. Setting This study was set in Northern Ireland; women were recruited via community-based approaches. Participants A total of 100 women with overweight or obesity who had given birth in the previous 24 months were recruited. Interventions The intervention group received an automated short message service intervention about weight loss and weight loss maintenance for 12 months. The active control group received automated short message service messages about child health and development for 12 months. Main outcome measures The main outcomes measured were the feasibility of recruitment and retention, acceptability of the intervention and trial procedures, and evidence of positive indicative effects on weight. Weight, waist circumference and blood pressure were measured by the researchers; participants completed a questionnaire booklet and wore a sealed pedometer for 7 days at baseline, 3, 6, 9 and 12 months. Outcome assessments were collected during home visits and women received a voucher on completion of each of the assessments. Qualitative interviews were conducted with women at 3 and 12 months, to gather feedback on the intervention and active control and the study procedures. Quantitative and qualitative data were used to inform the process evaluation and to assess fidelity, acceptability, dose, reach, recruitment, retention, contamination and context. Results The recruitment target of 100 participants was achieved (intervention, n = 51; control, n = 49); the mean age was 32.5 years (standard deviation 4.3 years); 28 (28%) participants had a household income of n = 9; control, n = 6) and withdrew from the study for this reason. At the end of the 12-month study, the majority of women remained in the study [85.7% (36/42) in the intervention group and 90.7% (39/43) in the active control group]. The research procedures were well accepted by women. Both groups indicated a high level of satisfaction with the short message service intervention that they were receiving. There was evidence to suggest that the intervention may have a positive effect on weight loss and prevention of weight gain during the postpartum period. Limitations The interviews at 3 and 12 months were conducted by the same researchers who collected other outcome data. Conclusions An evidence- and theory-based intervention delivered by short message service was successfully developed in conjunction with postpartum women with overweight and obesity. The intervention was acceptable to women and was feasible to implement in the 12-month pilot randomised controlled trial. The progression criteria for a full randomised controlled trial to examine effectiveness and cost-effectiveness were met. Future work Some minor refinements need to be made to the intervention and trial procedures based on the findings of the pilot trial in preparation for conducting a full randomised controlled trial. Trial registration Current Controlled Trial ISRCTN90393571. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information. The intervention costs were provided by the Public Health Agency, Northern Ireland.

Introduction: Postpartum weight management is difficult for many mothers due to the demands of parenthood. Women have highlighted a need for support but experience barriers to engaging with lifestyle interventions hence more adaptable approaches are required. This work examined participants’ engagement with a 12-month, theory-based, automated, text message (SMS) delivered, intervention supporting postpartum weight management.Methods: SMS content was informed by: 1) the ‘Health Action Process Approach’ (HAPA)1; 2) behaviour change techniques associated with effectiveness in weight management interventions2; 3) women's accounts of postpartum weight-related experiences; and 4) personal and public involvement. A two-arm pilot RCT recruited women within two years postpartum, with a BMI ≥ 25 kg/m2, through community sources and social media. Women were randomised via a secure remote system to receive the intervention or an active control delivering child development messages. Participants received 353 messages during the 12 month intervention. Two-way messages were used to assess engagement: 50 messages prompted women to respond with their weight; 36 interactive messages requested participants’ to respond ‘Yes/No’ to a question which then triggered a feedback message. Participant engagement with two-way messages was calculated as a percentage of replies sent by women and was categorised as ‘high’ or ‘low’ according to the median number of replies sent. Weight was measured at 0, 3, 6, 9 and 12 months.Results: 51 of 100 women recruited were randomised to receive the intervention. In months 0–6, (47%) and (95%) of participants responded to the weight messages and the ‘Yes/No’ messages respectively. In months 7–12, the responses were (77%) and (86%) respectively. Participants who were high engagers with weight messages had greater mean weight loss compared with low engagers at all time points: at 12 months high engagers (n = 18) lost -2.66 kg and had a reduction in waist circumference at 12 months of -8.9 cm, compared to changes in low engagers (n = 18) of -0.84 kg and -3.6 cm. Likewise, high engagers with ‘Yes/No’ messages had greater mean weight loss compared with low engagers at all time points: at 12 months high engagers (n = 16) lost -2.87 kg and had a reduction in waist circumference of -9.4 cm, compared to changes in low engagers (n = 20) of -0.86 kg and -3.6 cm.Discussion: The use of two-way text messages was a useful way to encourage engagement with this SMS-delivered intervention. Higher engagement resulted in more weight loss compared to low engagement.

To assess whether a weight management intervention for pregnant women with obesity was effective in reducing body mass index (BMI) 12 months after giving birth.Pragmatic, cluster randomised controlled trial (RCT) with embedded cost-effectiveness analysis. 598 women with a BMI of ≥30 kg/mWomen attending maternity units randomised to intervention were invited to a weekly weight management group, which combined expertise from a commercial weight loss programme with clinical advice from midwives. Both intervention and control participants received usual care and leaflets on diet and physical activity in pregnancy.Mean (SD) BMI at 12 months postpartum was 36.0 kg/mThere was no significant difference between groups on the primary outcome of BMI at 12 months. Analyses of secondary outcomes indicated improved healthy eating and lower levels of risky drinking.Current Controlled Trials ISRCTN25260464.

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Motherhood and mothering are conceived in relation to classed hierarchies through which those in living in poverty become characterised by ‘otherhood’ and ‘othering’. This positioning leaves them vulnerable to overt and indirect forms of criticism, surveillance and policing from family, friends, professionals and strangers; against a background of demonisation of particular types of mothers and mothering practices in the wider mediascape. This paper draws on three studies, involving 28 participants, which explored their journeys into the space of parenthood and their everyday experiences. The participants all resided in low-income locales. Many participants had resided in homeless hostels and mother and baby units before being placed in local authority housing or low grade rented accommodation. The studies all employed forms of visual ethnography including photo-elicitation, timelines, emotion stickers, collage and sandboxing. Participants discussed different forms of surveillance where other people were characterised as ‘watching what I’m doing, watching how I’m doing it’. These forms of watching ranged from the structured policing encountered in mother-and-baby units to more informal comments from passers-by or passengers on a bus journey; and an awareness of how mothers in state housing are depicted in the media. These interactions were sometimes met with resistance, at other times they were simply another incident that participants negotiated in a growing tapestry of disrespect and devaluation. This chapter argues that these discourses demonise and alienate mothers living on the margins, making already difficult journeys a constant struggle in the moral maze of contemporary motherhood and its accompanying conceptualisations of ‘otherhood’.

AimsThe aim of this study was to explore from the perspectives of key stakeholders involved in the pathway to diagnosis, the barriers and facilitators to a timely diagnosis of type 1 diabetes in childhood.MethodsQualitative interviews and free‐text analyses were undertaken in 21 parents with a child diagnosed with type 1 diabetes, 60 parents without a child diagnosed with type 1 diabetes, 9 primary healthcare professionals, 9 teachers and 3 community diabetes liaison nurses. Data were analysed thematically and 30% double coded.ResultsTwo key themes were identified, namely the importance of widespread awareness and knowledge and seeking healthcare professional help. Parents with a child diagnosed with type 1 diabetes described seeking opinions from a number of individuals prior to seeking health professional help. Healthcare professionals recognized the rarity of the condition and the need for it to be kept on their “radar”, to ensure they considered it when examining an unwell child. The process of obtaining a primary healthcare appointment was identified as potentially playing a crucial role in the diagnostic process. However, most parents with a child diagnosed with type 1 diabetes described receiving an appointment on the day they sought it.ConclusionsKnowledge and awareness of type 1 diabetes in childhood remain limited in the general population and misconceptions persist relating to how children present with this serious condition. An effective community‐based intervention to raise awareness amongst key stakeholders is required to ensure children receive a timely diagnosis once symptomatic.

Aims To design, develop, and evaluate the feasibility of delivering a multi-component community based intervention to parents and primary health care professionals to raise awareness of the symptoms of Type 1 diabetes (T1D) in childhood in 3 adjoining borough counties of South Wales. Materials and Methods Parent and primary health care advisory groups were established to design the intervention. Qualitative interviews with stakeholders and parents assessed the acceptability, feasibility and any potential impact of the intervention. Results The parent component of the intervention developed was a re-useable shopping bag with the 4 main symptoms of T1D illustrated on the side, based on the road traffic system of red warning triangles and an octagon “stop” sign stating “Seek Medical Help”. Accompanying the bag was an A5 leaflet giving further information. Both were overwrapped with clear plastic and delivered to 98% (323/329) schools, equating to 101 371 children. The primary health care professional component was a dual glucose/ketone meter, single use lancets, stickers, the A5 parent leaflet displayed as a poster and an educational visit from a Community Diabetes Liaison Nurse. 87% (73/84) of GP practices received the intervention, 100% received the materials. The intervention was delivered within Cardiff, the Vale of Glamorgan and Bridgend. Qualitative analyses suggest that the intervention raised awareness and had some impact. Conclusion This study showed that it is feasible and acceptable to design, develop and deliver a community based intervention to raise awareness of T1D. There is some suggestion of impact but a definitive evaluation of effectiveness is still required.

Introduction:\ud The HELP trial of a healthy lifestyle and eating programme for obese pregnant women resulted in a final response rate of 70%. More women in the intervention arm than the control arm were lost to follow-up, leading the trial team to suspect a MNAR mechanism for missing outcome data.\ud \ud Methods:\ud Missing-ness in the primary outcome (BMI) was explored in relation to all baseline demographic and post-randomisation variables using logistic regression. An imputation model was developed with cluster (study site) included as a factor together with significant predictors of missing outcome, variables in the primary analysis model, variables used to balance the randomisation and the outcome. The number of imputations performed was equal to the proportion of missing data. Sensitivity analyses using two approaches were performed on the pooled primary analysis to examine the change in effect for plausible departures from missing at random (MAR) towards MNAR. MI was carried out in STATA v13.1, REALCOM-IMPUTE and SPSS v20 for comparison.\ud \ud Results:\ud Opinions were gathered from the study team to gauge the extent to which they thought BMI data would differ in those who dropped out prior to revealing the results of the trial. The team found this difficult to estimate in order to facilitate the pattern mixture approach to sensitivity analysis. The re-weighting approach to sensitivity analysis was a suitable alternative in this study.\ud \ud Discussion:\ud The pitfalls, challenges and practical considerations of using MI and sensitivity analyses in cluster trials with MAR or MNAR will be discussed.