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The mental health of young people (YP) is a major public health concern that has worsened during the COVID-19 pandemic. Whilst engaging with culture and the arts may have mental health benefits there is a dearth of experimental research regarding the impact of online arts and culture on depression and anxiety in YP. In particular online interventions, which may improve accessibility. Objective: We aimed to compare a co-produced online intervention encompassing the diverse human stories behind art and artefacts, named Ways of Being (WoB), with a typical museum website, the Ashmolean (Ash) on negative affect (NA), positive affect (PA) and psychological distress (K10). Methods: In this parallel group RCT, 463 YP aged 16-24 were randomly assigned, 231 to WoB and 232 to Ash. Results: Over the intervention phase (an aggregate score including all post-allocation timepoints to day-five) a group difference was apparent in favour of WoB for NA (WoB-Ash n=448, NA -0.158, p=0.010) but no differences were detected for PA or K10 and differences were not detected at week six. Group differences in NA in favour of WoB were detected in specific subgroups, e.g. ethnic minorities and males. Across participants (from both groups) mean K10 and NA improved between baseline and six weeks despite increased COVID-19 restrictions. Trial recruitment was rapid, retention high and feedback positive with broad geographical, occupational and ethnic diversity. Conclusions: Online engagement with arts and culture has the potential to impact on mental health in a measurable way in YP with high unmet mental health needs.

This qualitative interview study aimed to understand the potential utility of online arts and culture (OAC) for mental health in young people. Methods: Participants aged 16-24 were selected by purposeful sampling from an online survey of community engagement for mental health and wellbeing. Individual semi-structured interviews were conducted from 30th July to 9th Sept 2020 with thirteen participants who were socio-demographically diverse and varied in their use of OAC and in their mental health status. Rich interview data were analysed using a reflective thematic analysis. Results: Participants identified that culture and the arts could be helpful for their mental health, online engagement had some advantages over in-person engagement and benefits were greater with regular use. Participants described that the features of OAC most likely to benefit mental health were diverse human stories about personal challenges and a variety of viewpoints with which they could connect on a human level. This brought a sense of perspective and provided opportunities for reflection, learning, escapism, creativity, exploration and discovery. Perceived impacts on mental health included the disruption of negative thought patterns, lifting mood and increased feelings of calm and proactivity. Conclusions: This study demonstrates that young people have a critical level of insight and understanding regarding their mental health and ways in which it might be improved. These findings can be used to optimise the mental health benefits of OAC in an engaging and acceptable way for young people. These methodologies could be applied to other types of community resource for mental health. Key Words: Adolescent, Art, Culture, Mental health

International Women's Day will be celebrated on 8 March 2021. Much has changed in the modern world, but it is still a fact that women are underrepresented in many sectors; this is especially true in science and research. Colleagues from the Oxford Brain Health Clinical Trials Unit reflect on the historical contribution of women in STEM and what future challenges and successes may lay ahead.

Introduction: This qualitative interview study aimed to understand the potential utility of digital arts and culture (DAC) for mental health in young adults.Methods: Participants aged 16-24 were selected by purposeful sampling from an online survey of community engagement for mental health and wellbeing. Individual semi-structured interviews were conducted from 30th July to 9th Sept 2020 with thirteen participants who were socio-demographically diverse and varied in their use of DAC and in their mental health status. Rich interview data were analysed using a reflective thematic analysis.Results: Participants identified that culture and the arts could be helpful for their mental health, online engagement had some advantages over in-person engagement and benefits were greater with regular use. Participants described that the features of DAC most likely to benefit mental health were diverse human stories about personal challenges and a variety of viewpoints with which they could connect on a human level. This brought a sense of perspective and provided opportunities for reflection, learning, escapism, creativity, exploration and discovery. Perceived impacts on mental health included the disruption of negative thought patterns, lifting mood and increased feelings of calm and proactivity.Conclusions: This study demonstrates that young people have a critical level of insight and understanding regarding their mental health and the ways in which it might be improved. These findings can be used to optimise the mental health benefits of DAC in an engaging and acceptable way for young people. These methodologies could be applied to other types of community resource for mental health.

Aims and methodTo gain a deeper understanding of the use of online culture and its potential benefits to mental health and well-being, sociodemographic characteristics and self-reported data on usage, perceived mental health benefits and health status were collected in an online cross-sectional survey during COVID-19 restrictions in the UK in June–July 2020.ResultsIn total, 1056 people completed the survey. A high proportion of participants reported finding online culture helpful for mental health; all but one of the benefits were associated with regular use and some with age. Reported benefits were wide-ranging and interconnected. Those aged under 25 years were less likely to be regular users of online culture or to have increased their use during lockdown.Clinical implicationsThere may be benefits in targeting cultural resources for mental health to vulnerable groups such as young adults.

Background Despite the high prevalence of common mental disorders in adolescents and young adults, and their association with poor health and socio-economic outcomes throughout the lifespan, many young people do not seek or receive help for such disorders. There is growing interest in the community sector in supporting mental health in young people; however, there is little by way of experimental research in this area. During the COVID-19 pandemic and lockdown, we designed an online cultural experience to reduce anxiety and depression and support mental health in people aged 16–24. Methods/design The O-ACE POP (Online Active Community Engagement Proof of Principle) study is a UK-based online randomised controlled trial of an online cultural experience named Ways of Being, involving human centred narratives and viewpoints, compared with a typical museum website (the Ashmolean Museum). We aim to compare efficacy on affect, symptoms of epression and anxiety, flourishing and loneliness as well as investigating potential mechanisms of action. Discussion The COVID-19 pandemic has provided a unique opportunity to design an innovative approach to supporting mental health in young adults. Findings derived from this study will allow us to evaluate the efficacy of this intervention and will inform the design of studies to further refine the resource and test it further. Trial registration ClinicalTrials.gov NCT04663594. Registered on 11 December 2020 (submitted in same form 27 November 2020). Protocol v1.0: 27 November 2020. Date recruitment began: 4 December 2020. Recruitment complete (estimate): February 2021

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BackgroundC-reactive protein (CRP) point-of-care testing can reduce antibiotic use in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in primary care, without compromising patient care. Further safe reductions may be possible.AimTo investigate the associations between presenting features and antibiotic prescribing in patients with AECOPD in primary care.Design and settingSecondary analysis of a randomised controlled trial of participants presenting with AECOPD in primary care (the PACE trial).MethodClinicians collected participants’ demographic features, comorbid illnesses, clinical signs, and symptoms. Antibiotic prescribing decisions were made after participants were randomised to receive a point-of-care CRP measurement or usual care. Multivariable regression models were fitted to explore the association between patient and clinical features and antibiotic prescribing, and extended to further explore any interactions with CRP measurement category (CRP not measured, CRP ResultsA total of 649 participants from 86 general practices across England and Wales were included. Odds of antibiotic prescribing were higher in the presence of clinician-recorded crackles (adjusted odds ratio [AOR] = 5.22, 95% confidence interval [CI] = 3.24 to 8.41), wheeze (AOR = 1.64, 95% CI = 1.07 to 2.52), diminished vesicular breathing (AOR = 2.95, 95% CI = 1.70 to 5.10), or clinician-reported evidence of consolidation (AOR = 34.40, 95% CI = 2.84 to 417.27). Increased age was associated with lower odds of antibiotic prescribing (AOR per additional year increase = 0.98, 95% CI = 0.95 to 1.00), as was the presence of heart failure (AOR = 0.32, 95% CI = 0.12 to 0.85).ConclusionSeveral demographic features and clinical signs and symptoms are associated with antibiotic prescribing in AECOPD. Diagnostic and prognostic value of these features may help identify further safe reductions.

Background: Despite the high prevalence of common mental disorders in adolescents and young adults, and their association with poor health and socio-economic outcomes throughout the lifespan, many young people do not seek or receive help for such disorders. There is growing interest in the community sector in supporting mental health in young people, however, there is little by way of experimental research in this area. During the COVID-19 pandemic and lockdown we designed an online cultural experience to reduce anxiety and depression and promote positive mental health in people aged 16-24. Methods/design: The O-ACE POP (Online Active Community Engagement Proof of Principle) study is a randomised controlled trial of an online cultural experience named Ways of Being, based on human centred narratives and viewpoints, compared with a typical museum website (the Ashmolean Museum). We aim to compare efficacy on mood, distress (depression and anxiety), flourishing and loneliness as well as investigating potential mechanisms of action, and feasibility of a larger scale RCT. Discussion: COVID-19 has provided a unique opportunity to design an innovative approach to supporting mental health in young adults. Findings derived from this study will allow us to evaluate the efficacy of this intervention and will inform the design of studies to further refine the resource and test it further.Trial StatusTrial Registration: NCT04663594First Registered: 11th Dec 2020 (submitted in same form 27th Nov 2020)Protocol v1.0: 3rd Dec 2020Date recruitment began: 4th Dec 2020Recruitment complete (estimate): Feb 2021

Background Most patients presenting with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in primary care are prescribed antibiotics, but these may not be beneficial, and they can cause side effects and increase the risk of subsequent resistant infections. Point-of-care tests (POCTs) could safely reduce inappropriate antibiotic prescribing and antimicrobial resistance. Objective To determine whether or not the use of a C-reactive protein (CRP) POCT to guide prescribing decisions for AECOPD reduces antibiotic consumption without having a negative impact on chronic obstructive pulmonary disease (COPD) health status and is cost-effective. Design A multicentre, parallel-arm, randomised controlled open trial with an embedded process, and a health economic evaluation. Setting General practices in Wales and England. A UK NHS perspective was used for the economic analysis. Participants Adults (aged ≥ 40 years) with a primary care diagnosis of COPD, presenting with an AECOPD (with at least one of increased dyspnoea, increased sputum volume and increased sputum purulence) of between 24 hours’ and 21 days’ duration. Intervention CRP POCTs to guide antibiotic prescribing decisions for AECOPD, compared with usual care (no CRP POCT), using remote online randomisation. Main outcome measures Patient-reported antibiotic consumption for AECOPD within 4 weeks post randomisation and COPD health status as measured with the Clinical COPD Questionnaire (CCQ) at 2 weeks. For the economic evaluation, patient-reported resource use and the EuroQol-5 Dimensions were included. Results In total, 653 participants were randomised from 86 general practices. Three withdrew consent and one was randomised in error, leaving 324 participants in the usual-care arm and 325 participants in the CRP POCT arm. Antibiotics were consumed for AECOPD by 212 out of 274 participants (77.4%) and 150 out of 263 participants (57.0%) in the usual-care and CRP POCT arm, respectively [adjusted odds ratio 0.31, 95% confidence interval (CI) 0.20 to 0.47]. The CCQ analysis comprised 282 and 281 participants in the usual-care and CRP POCT arms, respectively, and the adjusted mean CCQ score difference at 2 weeks was 0.19 points (two-sided 90% CI –0.33 to –0.05 points). The upper limit of the CI did not contain the prespecified non-inferiority margin of 0.3. The total cost from a NHS perspective at 4 weeks was £17.59 per patient higher in the CRP POCT arm (95% CI –£34.80 to £69.98; p = 0.408). The mean incremental cost-effectiveness ratios were £222 per 1% reduction in antibiotic consumption compared with usual care at 4 weeks and £15,251 per quality-adjusted life-year gained at 6 months with no significant changes in sensitivity analyses. Patients and clinicians were generally supportive of including CRP POCT in the assessment of AECOPD. Conclusions A CRP POCT diagnostic strategy achieved meaningful reductions in patient-reported antibiotic consumption without impairing COPD health status or increasing costs. There were no associated harms and both patients and clinicians valued the diagnostic strategy. Future work Implementation studies that also build on our qualitative findings could help determine the effect of this intervention over the longer term. Trial registration Current Controlled Trials ISRCTN24346473. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 15. See the NIHR Journals Library website for further project information.

BACKGROUND Diabetes is a highly prevalent long-term condition with high morbidity and mortality rates. People with diabetes commonly worry about their diabetes medicines and do not always take them regularly as prescribed. This can lead to poor diabetes control. The Support Through Mobile Messaging and Digital Health Technology for Diabetes (SuMMiT-D) study aims to deliver brief messages as tailored interventions to support people with type 2 diabetes in better use of their diabetes medicines and to improve treatment adherence and health outcomes. OBJECTIVE This paper describes the overall architecture of a tailored intervention delivery system used in the pilot and randomized controlled feasibility studies of SuMMiT-D and reports its performance. METHODS The SuMMiT-D system includes several platforms and resources to recruit participants and deliver messages as tailored interventions. Its core component is called the clinical system and is responsible for interacting with the participants by receiving and sending SMS text messages from and to them. The personalization and tailoring of brief messages for each participant is based on a list of built-in commands that they can use. RESULTS For the pilot study, a total of 48 participants were recruited; they had a median age of 64 years (first quartile, third quartile [Q1, Q3: 54.5, 69]). For the feasibility study, a total of 209 participants were recruited and randomly assigned to either the control or intervention group; they had a median age of 65 years (Q1, Q3: 56, 71), with 41.1% (86/209) being female. The participants used the SuMMiT-D system for up to 6 months (26 weeks) and had a wide range of different interactions with the SuMMiT-D system while tailored interventions were being delivered. For both studies, we had low withdrawal rates: only 4.2% and 5.3% for the pilot and feasibility studies, respectively. CONCLUSIONS A system was developed to successfully deliver brief messages as tailored health interventions to more than 250 people with type 2 diabetes via SMS text messages. On the basis of the low withdrawal rates and positive feedback received, it can be inferred that the SuMMiT-D system is robust, user-friendly, useful, and positive for most participants. From the two studies, we found that online recruitment was more efficient than recruitment via postal mail; a regular SMS text reminder (eg, every 4 weeks) can potentially increase the participants’ interactions with the system. CLINICALTRIAL ISRCTN Registry ISRCTN13404264; http://www.isrctn.com/ISRCTN13404264

Background Point-of-care testing of C-reactive protein (CRP) may be a way to reduce unnecessary use of antibiotics without harming patients who have acute exacerbations of chronic obstructive pulmonary disease (COPD). Methods We performed a multicenter, open-label, randomized, controlled trial involving patients with a diagnosis of COPD in their primary care clinical record who consulted a clinician at 1 of 86 general medical practices in England and Wales for an acute exacerbation of COPD. The patients were assigned to receive usual care guided by CRP point-of-care testing (CRP-guided group) or usual care alone (usual-care group). The primary outcomes were patient-reported use of antibiotics for acute exacerbations of COPD within 4 weeks after randomization (to show superiority) and COPD-related health status at 2 weeks after randomization, as measured by the Clinical COPD Questionnaire, a 10-item scale with scores ranging from 0 (very good COPD health status) to 6 (extremely poor COPD health status) (to show noninferiority). Results A total of 653 patients underwent randomization. Fewer patients in the CRP-guided group reported antibiotic use than in the usual-care group (57.0% vs. 77.4%; adjusted odds ratio, 0.31; 95% confidence interval [CI], 0.20 to 0.47). The adjusted mean difference in the total score on the Clinical COPD Questionnaire at 2 weeks was −0.19 points (two-sided 90% CI, −0.33 to −0.05) in favor of the CRP-guided group. The antibiotic prescribing decisions made by clinicians at the initial consultation were ascertained for all but 1 patient, and antibiotic prescriptions issued over the first 4 weeks of follow-up were ascertained for 96.9% of the patients. A lower percentage of patients in the CRP-guided group than in the usual-care group received an antibiotic prescription at the initial consultation (47.7% vs. 69.7%, for a difference of 22.0 percentage points; adjusted odds ratio, 0.31; 95% CI, 0.21 to 0.45) and during the first 4 weeks of follow-up (59.1% vs. 79.7%, for a difference of 20.6 percentage points; adjusted odds ratio, 0.30; 95% CI, 0.20 to 0.46). Two patients in the usual-care group died within 4 weeks after randomization from causes considered by the investigators to be unrelated to trial participation. Conclusions CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm. (Funded by the National Institute for Health Research Health Technology Assessment Program; PACE Current Controlled Trials number, ISRCTN24346473. opens in new tab.)

Background: C-reactive protein point of care tests (CRP-POCTs) for reducing unnecessary antibiotic use without harming patients with acute exacerbations of COPD (AECOPD) in primary care have not been evaluated in randomized trials. Methods: Patients consulting at 86 general practices in England and Wales with AECOPD were randomized to undergo CRP-POCT guided management or usual management without a CRP-POCT. The co-primary outcomes were patient-reported antibiotic consumption for AECOPD within four weeks (superiority), and COPD health status measured by the Clinical COPD Questionnaire (CCQ) at two weeks (non-inferiority). Results: 653 participants were randomized. Antibiotics were consumed by 57.0% CRP-POCT and 77.4% usual care participants (adjusted odds ratio = 0.31, 95% CI: 0.20 to 0.47). Adjusted mean CCQ score difference at two-weeks was -0.19 points lower (better) for CRP-POCT participants (two-sided 90% CI: -0.33 to -0.05). CRP-POCT participants were prescribed 22% fewer antibiotics at initial consultation (47.7% vs 69.7%, AOR = 0.31, 95% CI: 0.21 to 0.45), and 21% fewer antibiotics over four-week follow-up (59.1% vs 79.7%, AOR = 0.30, 95% CI: 0.20 to 0.46). There were no meaningful between-group differences in secondary clinical, microbiological, condition specific quality of life, or service utilization outcomes. Conclusions: Primary care physician use of CRP-POCT guided management of AECOPD in primary care achieves meaningful reductions in patient reported antibiotic consumption and clinician antibiotic prescribing without a detrimental effect on patient-reported specific health status.