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An essay about the author’s unexpected discovery about his father’s artistic past, a subsequent search through an archive, and the process of excavating its implications for their relationship and family histories.

BACKGROUND The NHS Digital Diabetes Prevention Programme (NHS-digital-DPP) is a 9-month digital behaviour change intervention, delivered by 4 independent providers, which is implemented nationally across England. No studies have explored the design features included by service providers of digital DPPs to promote engagement and little is known about how participants of nationally implemented digital DPPs like this make use of them. OBJECTIVE This study aims to understand engagement with the NHS-digital-DPP. Specific objectives were to describe how engagement with the NHS-digital-DPP is promoted via design features and strategies, and b) describe participants’ early engagement with the NHS-digital-DPP apps. METHODS Mixed methods were used. Qualitative study: A secondary analysis of documents detailing the NHS-digital-DPP intervention design, and interviews with program developers (n=6). Data were deductively coded according to an established framework of engagement with digital health interventions. Quantitative study: Anonymous usage data, collected over 9 months for each provider, representing participants’ first 30 days of use of the apps, was obtained for participants enrolled to the NHS-digital-DPP. Usage data fields were categorised into four intervention features (Track, Learn, Coach Interactions and Peer Support). Amount of engagement with intervention features were calculated for the whole cohort and differences between providers were explored statistically. RESULTS Data were available for 12,857 participants who enrolled on the NHS-digital-DPP during the data collection phase. Overall, 94% of those enrolled (12,133/12,857), engaged with the apps in the first 30 days. The median number of days of use was 11 (IQR 23). Track features were engaged with most (median number of tracking events 46.0 (IQR 119)), and Peer Support features were the least engaged with (0.0 (IQR 0)). Significant differences in engagement with features were observed across providers. Qualitative findings offer explanations for the variations including suggesting the importance of health coaches, reminders and regular content updates to facilitate early engagement. CONCLUSIONS Almost all participants of the NHS-digital-DPP started using the apps. Differences across providers identified by the mixed methods analysis provide the opportunity to identify features that are important for engagement with digital health interventions and could inform the designs of other digital behaviour change interventions.

Cancer, and the complex nature of treatment, has a profound impact on lives of patients and their families. Subsequently, cancer patients have a wide range of needs. This study aims to identify and synthesise cancer patients’ views about areas where they need support throughout their care. A systematic search of the literature from PsycInfo, Embase and Medline databases was conducted, and a narrative. Synthesis of results was carried out using the Corbin & Strauss “3 lines of work” framework. For each line of work, a group of key common needs were identified. For illness-work, the key needs idenitified were; understanding their illness and treatment options, knowing what to expect, communication with healthcare professionals, and staying well. In regards to everyday work, patients wanted to maintain a sense of normalcy and look after their loved ones. For biographical work, patients commonly struggled with the emotion impact of illness and a lack of control over their lives. Spiritual, sexual and financial problems were less universal. For some types of support, demographic factors influenced the level of need reported. While all patients are unique, there are a clear set of issues that are common to a majority of cancer journeys. To improve care, these needs should be prioritised by healthcare practitioners. Supplementary Information The online version contains supplementary material available at 10.1007/s13187-020-01941-9.

There are potent evidence-based psychological treatments for youth with mental health needs, yet they are rarely implemented in clinical practice, especially for youth with mental health disorders in the context of chronic physical illness such as epilepsy. Implementation science, the study of the translation of research into practice, can promote the uptake of existing effective interventions in routine clinical practice and aid the sustainable integration of psychological treatments with routine health care. The aim of this report was to use four implementation science methods to develop a version of an existing effective psychological treatment for mental health disorders [the Modular Approach to Treatment of Children with Anxiety, Depression or Conduct Problems (MATCH-ADTC)] for use within paediatric epilepsy services: (a) literature search; (b) iterative focus groups underpinned by normalisation process theory; (c) Plan–Do–Study–Act methods; and (d) qualitative patient interviews. Findings: Three modifications were deemed necessary to facilitate implementation in children with both mental health disorders and epilepsy. These were (a) a universal brief psychoeducational component addressing the relationship between epilepsy and mental health; (b) supplementary, conditionally activated interventions addressing stigma, parental mental health and the transition to adulthood; and (c) additional training and supervision. The intervention needed relatively little alteration for implementation in paediatric epilepsy services. The modified treatment reflected the scientific literature and the views of clinicians and service users. The multi-method approach used in this report can serve as a model for implementation of evidence-based psychological treatments for children with mental health needs in the context of other chronic illnesses.

Background Digital health research encompasses methods from human-computer interaction and health research. Objective This paper aims to describe how these methods were combined to develop HeLP-Diabetes: Starting Out, a web-based structured education program for people newly diagnosed with type 2 diabetes. Methods The development process consisted of three phases: initial design for effectiveness, optimization for usability, and in the wild testing in the National Health Service with people newly diagnosed with type 2 diabetes, and further revisions. We adopted an iterative user-centered approach and followed steps from the human-computer interaction design life cycle and the Medical Research Council guidelines on developing and evaluating complex interventions. Results The initial design process resulted in an 8-session program containing information and behavior change techniques targeting weight loss, being more active, and taking medication. The usability testing was highlighted at an early stage, where changes needed to be made to the language and layout of the program. The in the wild testing provided data on uptake of and barriers to use. The study suggested low uptake and completion of the program, but those who used it seemed to benefit from it. The qualitative findings suggested that barriers to use included an expectation that the program would take too long. This informed refinements to the program. Conclusions The use of interdisciplinary methods resulted in an iterative development process and refinements to the program that were based on user needs and data on uptake. The final intervention was more suitable for a definitive evaluation than the initial version. The description of our approach informs other digital health researchers on how to make interventions more sensitive to user needs.

Introduction Cardiovascular diseases (CVDs) are the number one cause of death, and there is evidence that work exposures could be associated with their development. This study aimed to systematically review observational studies of adults exposed to job strain, effort–reward imbalance, long working hours, job insecurity, shift work, and occupational noise, and assess the association of those work exposures with CVDs. Methods The Navigation Guide framework was applied. The population were adults of working age (18–65), and cohort and case–control studies were included. The work exposures were job strain, effort–reward imbalance, long working hours, job insecurity, shift work, and occupational noise. The outcomes were cerebrovascular diseases, ischaemic heart disease, and hypertensive diseases. The selection, data extraction, risk of bias assessment, and quality assessment were carried out by two reviewers independently and disagreements were solved by a third reviewer or by consensus. The synthesis of the results was done by applying the ‘vote counting based on direction’ method, and the results were summarized in an effect direction plot. The strength of the evidence for every risk factor and CVD was defined by consensus. Results A total of 17 643 papers were initially identified in the literature search, but after applying the filters by title and abstract, and full text, 86 studies were finally included. From the included studies, sufficient evidence was found of the harmfulness of job strain for cerebrovascular disease and ischemic heart disease. Furthermore, there was sufficient evidence of the harmfulness of shift work for ischemic heart disease. Evidence of no relationship was found between long working hours and shift work with ischaemic heart disease and hypertensive disease, respectively. The other associations of work exposures and CVDs had limited or inadequate evidence of harmfulness. Conclusions In this comprehensive review, there was sufficient evidence of a harmful relationship between job strain, shift work, and CVDs. For the other work exposures, more high-quality studies are needed. In order to improve current prevention strategies for CVDs, the findings of this review imply that job strain and shift work are work exposures that constitute additional risk factors that could be approached as targets for worksite interventions. Systematic review registration PROSPERO CRD42020179972.

BACKGROUND Digital health research encompasses methods from human-computer interaction and health research. OBJECTIVE This paper aims to describe how these methods were combined to develop HeLP-Diabetes: Starting Out, a web-based structured education program for people newly diagnosed with type 2 diabetes. METHODS The development process consisted of three phases: initial design for effectiveness, optimization for usability, and in the wild testing in the National Health Service with people newly diagnosed with type 2 diabetes, and further revisions. We adopted an iterative user-centered approach and followed steps from the human-computer interaction design life cycle and the Medical Research Council guidelines on developing and evaluating complex interventions. RESULTS The initial design process resulted in an 8-session program containing information and behavior change techniques targeting weight loss, being more active, and taking medication. The usability testing was highlighted at an early stage, where changes needed to be made to the language and layout of the program. The in the wild testing provided data on uptake of and barriers to use. The study suggested low uptake and completion of the program, but those who used it seemed to benefit from it. The qualitative findings suggested that barriers to use included an expectation that the program would take too long. This informed refinements to the program. CONCLUSIONS The use of interdisciplinary methods resulted in an iterative development process and refinements to the program that were based on user needs and data on uptake. The final intervention was more suitable for a definitive evaluation than the initial version. The description of our approach informs other digital health researchers on how to make interventions more sensitive to user needs.

Background: Cardiovascular Diseases (CVDs) are the number one cause of death, representing 31.8% of all global deaths. Several lifestyle behaviours are associated with the development and clinical manifestation of CVDs, however, these behavioural risk factors by themselves do not fully explain the population burden of CVDs. There is increasing recognition that working conditions and risk factors of the work environment are associated with health, including the development of CVDs. We will systematically review observational studies of adults exposed to work risk factors and their association with CVDs.Methods: We will follow the Navigation Guide framework. We will include cohort and case-control studies. The population will be adults of working age (18-65). The exposure will include six categories of work exposure: job strain, effort-reward imbalance, long working hours, job insecurity, shift work and occupational noise; the comparator will be the unexposed group or specified control group. The outcomes will be cerebrovascular diseases, ischaemic heart disease and hypertensive diseases. Published and unpublished studies will be included. The selection, data extraction, risk of bias assessment, quality assessment and strength of evidence will be carried out by two reviewers independently and disagreements will be solved by a third. Due to the diversity in the populations and exposures in the studies, the synthesis of the results, the quality and the strength of the evidence will be done by a synthesis without meta-analysis (SWiM), following the SWiM reporting guideline.Discussion: This systematic review will identify and synthesise the evidence for the association between work risk factors and risk of CVDs. This work will underpin and inform a broader objective to examine the effectiveness of interventions to minimise the effects of risk factors for CVDs in workplaces, with the final aim of informing occupational health policies in the future. Systematic review registration: PROSPERO CRD42020179972.

IntroductionCardiovascular diseases (CVDs) are the number one cause of death globally, impacting on public and private sectors. Current traditional interventions to prevent CVDs are mainly provided in healthcare centres and even when they are effective, they are not enough to reduce the rising prevalence; therefore, additional strategies are needed. Evidence suggests that health interventions in the workplace supply numerous benefits improving cardiovascular risk factor profiles in individuals. Hence, the aim of this systematic review and meta-analysis is to collate the evidence from randomised controlled trials, cluster randomised trials and quasi-experimental studies of workplace interventions to determine their effectiveness in terms of improving cardiovascular risk factors and preventing CVDs.Methods and analysisEMBASE, PsycINFO, PubMed, the Cochrane Central Register of Controlled Trials, LILACS, Scopus, Web of Science, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov and ProQuest Dissertations & Theses Global will be searched to include articles on workplace interventions in adults for CVDs events, cardiometabolic risk factors or behavioural risk factors. The study selection, data extraction, risk of bias and the assessment of the quality of the body of evidence will be conducted by two reviewers working in parallel and disagreements will be resolved by consensus or consultations with a third reviewer. Data synthesis will be done by meta-analysis using random-effects models when possible, otherwise the vote counting method will be applied. Statistical heterogeneity will be assessed by a χ2test and I2statistics. The quality of the body of evidence for each outcome will be assessed by applying the Grading of Recommendations, Assessment, Development and Evaluation approach.Ethics and disseminationEthical approval is not required for this systematic review protocol. The results of the systematic review will be published in a peer-reviewed journal and will be publicly available.PROSPERO registration numberCRD42021276161.

Objectives The aim of structured education for type 2 diabetes is to improve knowledge, skills and confidence in self-management. It is recommended in the UK for everyone who is newly diagnosed with type 2 diabetes. We developed an on-line programme called HeLP-Diabetes: Starting Out to address poor uptake of face-to-face structured education. The aim of this paper is to describe the intervention in line with the Template for Intervention Description and Replication guide, which calls for better reporting of interventions. Methods The Template for Intervention Description and Replication guide provided the item headings for the description. These included the theoretical underpinning, materials, procedures, providers, and mode of delivery. Results The programme was developed to meet NICE requirements for structured education and therefore followed a structured curriculum with four sessions covering content such as what diabetes is and how it is treated, possible complications, and how lifestyle changes can improve health. Content was delivered in text, images and video, and behaviour change techniques, self-assessment and feedback were used to help people target key health behaviours. The programme was delivered entirely online, but the team were available for support via telephone. Email feedback and reminders were sent. Conclusions The TIDieR checklist allowed us to provide a clear structure for the description of the intervention. However, it could not capture the full complexity of the programme, and intervention developers considering using it in the future may find that it needs to be adapted to make it more specific to their intervention.

Objectives This study explored how health behaviours were supported and changed in people with severe mental illness by primary health care professionals trained in delivering behaviour change techniques (BCTs) within a cardiovascular disease risk reducing intervention. Design Secondary qualitative analysis of 30 staff and patient interviews. Methods We mapped coded data to the BCT Taxonomy (version 1) to identify BCT application. Thematic analysis was conducted to explore the barriers and facilitators of supporting and changing health behaviours. Themes were then interpreted using the Capability, Opportunity, Motivation, and Behaviour model to gain greater explanation behind the processes. Results Twenty BCTs were identified. Staff and patients perceived that health behaviours were commonly affected by both automatic and reflective motivation, sometimes in turn affected by psychological capability, social, and physical opportunity. Staff and patients suggested that motivation was enhanced by both patient and staff ability to observe health benefits, in some cases patients' health knowledge, mental health status, and social support networks. It was suggested that engaging in/sustaining healthy behaviours was influenced by physical opportunities to engrain behaviours into routine. Conclusions According to staff and patients, health behaviour change in this population was driven by complex processes. It was suggested that capability, opportunity, and motivation were in some cases enhanced by BCTs, but variable. Behaviour change may be optimized by individualized behavioural assessments, identifying drivers of behaviour and applying a range of BCTs may help to target individual needs. Patient peer-led approaches, techniques to encourage awareness of visible success, and normalizing health behaviours may increase behaviour change. Statement of contribution What is already known on this subject? Poorer health behaviours may contribute to early mortality rates in people with severe mental illness. Health care professionals are encouraged to target the uptake of healthy behaviours, but there is limited guidance on how. The processes that cause or inhibit health behaviour change within interventions that use behaviour change techniques by health care practitioners are unclear. What does the study add? Staff and patients suggested that behaviour change techniques (BCTs) in some cases increased capability, opportunity, and motivation to engage in healthy behaviours, but in other cases had variable success. Staff and patients reported that in some cases, motivation impacted health behaviour change and was in turn affected by psychological capability, social, and physical opportunity. Individualized behavioural assessments, flexible approaches to BCT application, involvement from patient peer support and different ways of targeting patient motivation may help to increase healthy behaviour changes in this population.

Background Digital health interventions have potential to contribute to better health outcomes, better healthcare and lower costs. However, evidence for their effectiveness is variable. The development and content of digital health interventions are often not described in enough detail to enable others to replicate the research or improve on previous interventions. This has led to a call for transparent reporting of intervention content and development. Purpose To describe the development process and content of a digital self-management intervention for people with type 2 diabetes (HeLP-Diabetes) that has been found to achieve its target clinical outcome, the reduction of HbA1c, a measure of glycaemic control. Method We synthesised theory, data from existing research evidence and international guidelines, and new qualitative data from target users to identify the determinants of self-management and the content to be included in HeLP-Diabetes. Using an ongoing iterative participatory design approach the content of the intervention was written, produced, reviewed and changed. Conclusion It is possible to develop and transparently report self-management programmes for long-term conditions, which reflect current best evidence, theoretical underpinning and user involvement. We intend that reporting the development process and content will inform future digital intervention development., Highlights • Uptake of group based self-management education by people with T2DM is low. Digital health interventions may provide an additional mode of delivery. • A participatory design approach provides a way of synthesising different sources of data to develop a self-management intervention for people living with a long-term condition. • It is important that the content and development process of interventions are described for other researchers to build on, so that science is cumulative.

Objectives: Family carers towards the end of life face a range of difficult challenges and have high levels of support needs. The aim of this study was to explore the challenges carers of people with dementia face towards the end of life and the support needs which could be addressed by online support.Methods: Qualitative study using semi-structured interviews with 23 current and former family carers of people with dementia in England in 2016-2017. Interviews were analysed using thematic analysis methods.Results: Most carers interviewed had positive views of receiving support online via a website. Participants described a series of challenges they felt online support could address and help support them with when caring for someone with dementia towards the end of life: 1) feeling prepared and equipped; 2) feeling connected and supported; 3) balancing their own needs with those of the individual; and 4) maintaining control and being the co-ordinator of care. However many valued a mix of technology and human interaction in receiving support.Conclusions: This study has identified the key challenges for carers at the end of life that could be met by online support. Online support offers a source of support to supplement face-to-face contact, as many carers still wish to talk to someone in person. This could help alleviate pressures which health and social care systems currently face.

ObjectivesSignificant problems with patients engaging with diabetes self-management education (DSME) exist. The role of healthcare professionals (HCPs) has been highlighted, with a lack of enthusiasm, inadequate information provision and poor promotion of available programmes all cited as affecting patients’ decisions to attend. However, little is known about HCPs’ views towards DSME. This study investigates the views of HCPs towards self-management generally and self-management in the context of DSME more specifically.DesignA qualitative study using semi-structured interviews to investigate HCPs views of type 2 diabetes self-management and DSME. Data were analysed thematically and emergent themes were mapped on to the constructs of Normalisation Process Theory (NPT).SettingTwo boroughs in London, UK.ParticipantsSampling was purposive to recruit a diverse range of professional roles including GPs, practice nurses, diabetes specialist nurses, healthcare assistants (HCAs), receptionists and commissioners of care.ResultsInterviews were conducted with 22 participants. The NPT analysis demonstrated that while a self-management approach to diabetes care was viewed by HCPs as necessary and, in principle, valuable, the reality is much more complex. HCPs expressed ambivalence about pushing certain patients into self-managing, preferring to retain responsibility. There was a lack of awareness among HCPs about the content of DSME and benefits to patients. Commitment to and engagement with DSME was tempered by concerns about suitability for some patients. There was little evidence of communication between providers of group-based DSME and HCPs or of HCPs engaging in work to follow-up non-attenders.ConclusionsHCPs have concerns about the appropriateness of DSME for all patients and discussed challenges to engaging with and performing the tasks required to embed the approach within practice. DSME, as a means of supporting self-management, was considered important in theory, but there was little evidence of HCPs seeing their role as extending beyond providing referrals.

Green eco-friendly housing includes approaches to reduce indoor air pollutant sources and to increase energy efficiency. Although sealing/tightening buildings can save energy and reduce the penetration of outdoor pollutants, an adverse outcome can be increased buildup of pollutants with indoor sources. The objective of this study was to determine the differences in the indoor air quality (IAQ) between green and non-green homes in low-income housing complexes. In one housing complex, apartments were renovated using green principles (n=28). Home visits were conducted immediately after the renovation, and subsequently at 6 months and at 12 months following the renovation. Of these homes, eight homes had pre-renovation home visits; this allowed pre- and post-renovation comparisons within the same homes. Parallel visits were conducted in non-green (control) apartments (n=14) in a nearby low-income housing complex. The IAQ assessments included PM2.5, black carbon, ultrafine particles, sulfur, total volatile organic compounds (VOCs), formaldehyde, and air exchange rate. Data were analyzed using linear mixed-effects models. None of the indoor pollutant concentrations were significantly different between green and non-green homes. However, we found differences when comparing the concentrations before and after renovation. Measured immediately after renovation, indoor black carbon concentrations were significantly lower averaging 682 ng/m(3) in post-renovation vs. 2364 ng/m(3) in pre-renovation home visits (p=0.01). In contrast, formaldehyde concentrations were significantly higher in post-renovated (0.03 ppm) than in pre-renovated homes (0.01 ppm) (p=0.004). Questionnaire data showed that opening of windows occurred less frequently in homes immediately post-renovation compared to pre-renovation; this factor likely affected the levels of indoor black carbon (from outdoor sources) and formaldehyde (from indoor sources) more than the renovation status itself. To reduce IAQ problems and potentially improve health, careful selection of indoor building materials and ensuring sufficient ventilation are important for green building designs.

Introduction Exchange procedures involve tunneled dialysis catheter (TDC) removal and exchange over a wire, using the same exit site and venotomy site. Diagnostic imaging or intervention was generally not performed in exchange procedures. Revision procedures involve placement of new TDC using the previous venotomy site and a new tunnel and exit site. The majority of revisions usually include diagnostic imaging and intervention in the central circulation if needed. Methods A retrospective single review of 70 patients who underwent 97 TDC replacements from 2010 to early 2012 because of catheter malfunction was evaluated for either infection or malfunction within 30 days of the procedure. Results There were 41 exchanges and 56 revisions out of the 97 procedures performed. There were eight infections (documented by positive blood culture) in the exchanges (19.5%) and one in the revision group (1.8%). The need for an additional procedure due to malfunction was 10 in the exchange (24.4%) and 10 (17.8%) in the revision group. Conclusions Revision is a clearly superior procedure with regard to infection and more data need to be gathered as to whether it will decrease repeat procedures.

Understanding factors that contribute towards physical activity and diet outcomes are important for health improvement in people with severe mental illness. Cross-sectional findings on factors associated with diet and physical activity outcomes provide limited information on what predicts changes or long-term outcomes in lifestyle behaviours in people with severe mental illness. A systematic review was therefore conducted to identify prospective studies with quantitative data on baseline factors associated with follow-up diet or physical activity related outcomes. MEDLINE, EMBASE, PsycINFO, CINAHL Plus and grey literature databases were searched from inception to March 2018. From 6921 studies, 5 were eligible for physical activity related outcomes and 2 for diet related outcomes. The follow-up duration was 4 weeks to 24 months and participants were mostly diagnosed with schizophrenia. Older age was commonly related to better physical activity related outcomes, whilst higher negative symptoms were related to poorer-related outcomes. Physical activity intentions and gender were unrelated to physical activity outcomes. There was a lack of data on factors influencing dietary outcomes. Although there were some common factors predictive of physical activity including older age and negative symptoms, more high-quality research is needed to determine the effect of sociodemographic, mental health, social, clinical, lifestyle and other factors on both physical activity and dietary outcomes.

Background In the UK, 6% of the UK population have diabetes mellitus, 90% of whom have type 2 diabetes mellitus (T2DM). Diabetes mellitus accounts for 10% of NHS expenditure (£14B annually). Good self-management may improve health outcomes. NHS policy is to refer all people with T2DM to structured education, on diagnosis, to improve their self-management skills, with annual reinforcement thereafter. However, uptake remains low (5.6% in 2014–15). Almost all structured education is group based, which may not suit people who work, who have family or other caring commitments or who simply do not like group-based formats. Moreover, patient needs vary with time and a single education session at diagnosis is unlikely to meet these evolving needs. A web-based programme may increase uptake. Objectives Our aim was to develop, evaluate and implement a web-based self-management programme for people with T2DM at any stage of their illness journey, with the goal of improving access to, and uptake of, self-management support, thereby improving health outcomes in a cost-effective manner. Specific objectives were to (1) develop an evidence-based theoretically informed programme that was acceptable to patients and health-care professionals (HCPs) and that could be readily implemented within routine NHS care, (2) determine the clinical effectiveness and cost-effectiveness of the programme compared with usual care and (3) determine how best to integrate the programme into routine care. Design There were five linked work packages (WPs). WP A determined patient requirements and WP B determined HCP requirements for the self-management programme. WP C developed and user-tested the Healthy Living for People with type 2 Diabetes (HeLP-Diabetes) programme. WP D was an individually randomised controlled trial in primary care with a health economic analysis. WP E used a mixed-methods and case-study design to study the potential for implementing the HeLP-Diabetes programme within routine NHS practice. Setting English primary care. Participants People with T2DM (WPs A, D and E) or HCPs caring for people with T2DM (WPs B, C and E). Intervention The HeLP-Diabetes programme; an evidence-based theoretically informed web-based self-management programme for people with T2DM at all stages of their illness journey, developed using participatory design principles. Main outcome measures WPs A and B provided data on user ‘wants and needs’, including factors that would improve the uptake and accessibility of the HeLP-Diabetes programme. The outcome for WP C was the HeLP-Diabetes programme itself. The trial (WP D) had two outcomes measures: glycated haemoglobin (HbA1c) level and diabetes mellitus-related distress, as measured with the Problem Areas in Diabetes (PAID) scale. The implementation outcomes (WP E) were the adoption and uptake at clinical commissioning group, general practice and patient levels and the identification of key barriers and facilitators. Results Data from WPs A and B supported our holistic approach and addressed all areas of self-management (medical, emotional and role management). HCPs voiced concerns about linkage with the electronic medical records (EMRs) and supporting patients to use the programme. The HeLP-Diabetes programme was developed and user-tested in WP C. The trial (WP D) recruited to target (n = 374), achieved follow-up rates of over 80% and the intention-to-treat analysis showed that there was an additional improvement in HbA1c levels at 12 months in the intervention group [mean difference –0.24%, 95% confidence interval (CI) –0.44% to –0.049%]. There was no difference in overall PAID score levels (mean difference –1.5 points, 95% CI –3.9 to 0.9 points). The within-trial health economic analysis found that incremental costs were lower in the intervention group than in the control group (mean difference –£111, 95% CI –£384 to £136) and the quality-adjusted life-years (QALYs) were higher (mean difference 0.02 QALYs, 95% CI 0.000 to 0.044 QALYs), meaning that the HeLP-Diabetes programme group dominated the control group. In WP E, we found that the HeLP-Diabetes programme could be successfully implemented in primary care. General practices that supported people in registering for the HeLP-Diabetes programme had better uptake and registered patients from a wider demographic than those relying on patient self-registration. Some HCPs were reluctant to do this, as they did not see it as part of their professional role. Limitations We were unable to link the HeLP-Diabetes programme with the EMRs or to determine the effects of the HeLP-Diabetes programme on users in the implementation study. Conclusions The HeLP-Diabetes programme is an effective self-management support programme that is implementable in primary care. Future work The HeLP-Diabetes research team will explore the following in future work: research to determine how to improve patient uptake of self-management support; develop and evaluate a structured digital educational pathway for newly diagnosed people; develop and evaluate a digital T2DM prevention programme; and the national implementation of the HeLP-Diabetes programme. Trial registration Research Ethics Committee reference number 10/H0722/86 for WPs A–C; Research Ethics Committee reference number 12/LO/1571 and UK Clinical Research Network/National Institute for Health Research (NIHR) Portfolio 13563 for WP D; and Research Ethics Committee 13/EM/0033 for WP E. In addition, for WP D, the study was registered with the International Standard Randomised Controlled Trial Register as reference number ISRCTN02123133. Funding details This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 6, No. 5. See the NIHR Journals Library website for further project information.

Summary Digital health interventions present an important opportunity to improve health care for people with psychosis or bipolar disorder, but despite their potential, integrating and implementing them into clinical settings has been difficult worldwide. This Review aims to identify factors affecting implementation of digital health interventions for people affected by psychosis or bipolar disorder. We searched seven databases and synthesised data from 26 studies using the Consolidated Framework for Implementation Research. Attitudes and beliefs about interventions were crucial factors for both staff and service users, with negative attitudes and scepticism resulting in a lack of motivation to engage with interventions or complete them. The complexity of the interventions was a barrier for people with psychiatric symptoms, low premorbid intelligence quotient, or minimal information technology skills. The accessibility and adaptability of interventions were key facilitators, but insufficient resources, finances, and staff time were barriers to implementation. Interventions need to be user friendly and adaptable to the needs and capabilities of people with psychosis or bipolar disorder, and the staff who support their implementation. Service users and staff should cofacilitate the process of developing and implementing the interventions.

Background: Type 2 Diabetes Mellitus is one of the commonest long term conditions, and costs health services approximately 10% of their total budget. Active self-management by patients improves outcomes and reduces health service costs. The uptake of face-to-face self-management education is low, and there is hope that delivering self-management support online may improve this. Objective: To establish the cost-effectiveness of a web-based self-management programme for people with type 2 Diabetes (HeLP-Diabetes) compared to usual care. Methods: An incremental cost-effectiveness analysis was conducted, from a collective National Health Service and personal social services perspective, based on data collected from a multi-centre, two-arm individually randomised controlled trial over 12 months. Adults aged 18 or over with a diagnosis of type 2 diabetes and registered with the 21 participating general practices (primary care) in England, UK, were approached. People who were unable to provide informed consent or to use the intervention, terminally ill, or currently participating in a trial of an alternative self-management intervention, were excluded. The participants were then randomised to usual care plus either nurse-facilitated access to HeLP-Diabetes, an interactive, theoretically-informed web-based self-management programme, or access to a comparator web-site containing basic information only with an initial nurse-facilitated session. Participants were blinded to their allocation. The participants’ intervention costs and wider health care resource use were collected as well as two self-reported health-related quality of life measures: the Problem Areas in Diabetes (PAID) Scale and EQ-5D-3L. EQ-5D-3L was then used to calculate quality-adjusted life years (QALYs). The primary analysis was based on intention-to-treat, using multiple imputation to deal with the missing data. Results: In total, 374 participants were randomised, with 185 in the intervention group and 189 in the control group. The primary analysis showed incremental cost-effectiveness ratios (ICERs) of £58 (-£268 to £742) per unit improvement on PAID scale and £5,550 (-£15,515 to £59,275) per QALY gained by HeLP-Diabetes, compared to the control. The complete case analysis showed less cost-effectiveness and more uncertainty with ICERs of £116 (95% CI -£1,299 to £1,690) per unit improvement on PAID scale and £18,500 (95%CI -£203,949 to £190,267) per QALY. The cost-effectiveness acceptability curve showed an 87% probability of cost-effectiveness at £20,000 per QALY willingness-to-pay threshold. Cost-effectiveness was highly sensitive to the number of users, with the one-way sensitivity analysis suggesting that the intervention would become less costly than usual care with 363 or more users. Conclusion: Facilitated access to HeLP-Diabetes is cost-effective, compared to usual care, under the recommended threshold of £20,000 to £30,000 per QALY by National Institute of Health and Care Excellence. The effect of economies of scale suggests very low costs per user with sufficient number of users.

Background: Caring for someone with dementia is one of the most challenging caring roles. The need for support for family caregivers has been recognized for some time but is often still lacking. With an aging population, demand on health and social care services is growing, and the population is increasingly looking to the internet for information and support. Objective: In this review, we aimed to (1) identify the key components of existing internet-based interventions designed to support family caregivers of people with dementia, (2) develop an understanding of which components are most valued by caregivers, and (3) consider the evidence of effectiveness of internet-based interventions designed to support family caregivers of people with dementia. Methods: We conducted a systematic search of online databases in April 2018. We searched reference lists and tracked citations. All study designs were included. We adopted a narrative synthesis approach with thematic analysis and tabulation as tools. Results: We identified 2325 studies, of which we included 40. The interventions varied in the number and types of components, duration and dose, and outcomes used to measure effectiveness. The interventions focused on (1) contact with health or social care providers, (2) peer interaction, (3) provision of information, (4) decision support, and (5) psychological support. The overall quality of the studies was low, making interpretation and generalizability of the effectiveness findings difficult. However, most studies suggested that interventions may be beneficial to family caregiver well-being, including positive impacts on depression, anxiety, and burden. Particular benefit came from psychological support provided online, where several small randomized controlled trials suggested improvements in caregiver mental health. Provision of information online was most beneficial when tailored specifically for the individual and used as part of a multicomponent intervention. Peer support provided in online groups was appreciated by most participants and showed positive effects on stress. Finally, online contact with a professional was appreciated by caregivers, who valued easy access to personalized practical advice and emotional support, leading to a reduction in burden and strain. Conclusions: Although mixed, the results indicate a positive response for the use of internet-based interventions by caregivers. More high-quality studies are required to identify the effectiveness of internet interventions aimed at supporting family caregivers, with particular focus on meeting the needs of caregivers during the different stages of dementia. [J Med Internet Res 2018;20(6):e216]

Background Type 2 diabetes mellitus is one of the most common long-term conditions, and costs health services approximately 10% of their total budget. Active self-management by patients improves outcomes and reduces health service costs. While the existing evidence suggested that uptake of self-management education was low, the development of internet-based technology might improve the situation. Objective To establish the cost-effectiveness of a Web-based self-management program for people with type 2 diabetes (HeLP-Diabetes) compared to usual care. Methods An incremental cost-effectiveness analysis was conducted, from a National Health Service and personal and social services perspective, based on data collected from a multi-center, two-arm individually randomized controlled trial over 12 months. Adults aged 18 or over with a diagnosis of type 2 diabetes and registered with the 21 participating general practices (primary care) in England, UK, were approached. People who were unable to provide informed consent or to use the intervention, terminally ill, or currently participating in a trial of an alternative self-management intervention, were excluded. The participants were then randomized to either usual care plus HeLP-Diabetes, an interactive, theoretically-informed Web-based self-management program, or to usual care plus access to a comparator website containing basic information only. The participants’ intervention costs and wider health care resource use were collected as well as two health-related quality of life measures: the Problem Areas in Diabetes (PAID) Scale and EQ-5D-3L. EQ-5D-3L was then used to calculate quality-adjusted life years (QALYs). The primary analysis was based on intention-to-treat, using multiple imputation to handle the missing data. Results In total, 374 participants were randomized, with 185 in the intervention group and 189 in the control group. The primary analysis showed incremental cost-effectiveness ratios of £58 (95% CI –411 to 587) per unit improvement on PAID scale and £5550 (95% CI –21,077 to 52,356) per QALY gained by HeLP-Diabetes, compared to the control. The complete case analysis showed less cost-effectiveness and higher uncertainty with incremental cost-effectiveness ratios of £116 (95% CI –1299 to 1690) per unit improvement on PAID scale and £18,500 (95% CI –203,949 to 190,267) per QALY. The cost-effectiveness acceptability curve showed an 87% probability of cost-effectiveness at £20,000 per QALY willingness-to-pay threshold. The one-way sensitivity analyses estimated 363 users would be needed to use the intervention for it to become less costly than usual care. Conclusions Facilitated access to HeLP-Diabetes is cost-effective, compared to usual care, under the recommended threshold of £20,000 to £30,000 per QALY by National Institute of Health and Care Excellence. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN) 02123133; http://www.controlled-trials.com/ISRCTN02123133 (Archived by WebCite at http://www.webcitation.org/6zqjhmn00)

BACKGROUND Type 2 diabetes mellitus is one of the most common long-term conditions, and costs health services approximately 10% of their total budget. Active self-management by patients improves outcomes and reduces health service costs. While the existing evidence suggested that uptake of self-management education was low, the development of internet-based technology might improve the situation. OBJECTIVE To establish the cost-effectiveness of a Web-based self-management program for people with type 2 diabetes (HeLP-Diabetes) compared to usual care. METHODS An incremental cost-effectiveness analysis was conducted, from a National Health Service and personal and social services perspective, based on data collected from a multi-center, two-arm individually randomized controlled trial over 12 months. Adults aged 18 or over with a diagnosis of type 2 diabetes and registered with the 21 participating general practices (primary care) in England, UK, were approached. People who were unable to provide informed consent or to use the intervention, terminally ill, or currently participating in a trial of an alternative self-management intervention, were excluded. The participants were then randomized to either usual care plus HeLP-Diabetes, an interactive, theoretically-informed Web-based self-management program, or to usual care plus access to a comparator website containing basic information only. The participants’ intervention costs and wider health care resource use were collected as well as two health-related quality of life measures: the Problem Areas in Diabetes (PAID) Scale and EQ-5D-3L. EQ-5D-3L was then used to calculate quality-adjusted life years (QALYs). The primary analysis was based on intention-to-treat, using multiple imputation to handle the missing data. RESULTS In total, 374 participants were randomized, with 185 in the intervention group and 189 in the control group. The primary analysis showed incremental cost-effectiveness ratios of £58 (95% CI –411 to 587) per unit improvement on PAID scale and £5550 (95% CI –21,077 to 52,356) per QALY gained by HeLP-Diabetes, compared to the control. The complete case analysis showed less cost-effectiveness and higher uncertainty with incremental cost-effectiveness ratios of £116 (95% CI –1299 to 1690) per unit improvement on PAID scale and £18,500 (95% CI –203,949 to 190,267) per QALY. The cost-effectiveness acceptability curve showed an 87% probability of cost-effectiveness at £20,000 per QALY willingness-to-pay threshold. The one-way sensitivity analyses estimated 363 users would be needed to use the intervention for it to become less costly than usual care. CONCLUSIONS Facilitated access to HeLP-Diabetes is cost-effective, compared to usual care, under the recommended threshold of £20,000 to £30,000 per QALY by National Institute of Health and Care Excellence. CLINICALTRIAL International Standard Randomized Controlled Trial Number (ISRCTN) 02123133; http://www.controlled-trials.com/ISRCTN02123133 (Archived by WebCite at http://www.webcitation.org/6zqjhmn00)