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Abstract Background Primary care plays a central role in most, if not all, health care systems including the care of vulnerable populations such as people who have been incarcerated. Studies linking incarceration records to health care data can improve understanding about health care access following release from prison. This review maps evidence from data-linkage studies about primary care use after prison release. Methods The framework by Arksey and O’Malley and guidance by the Joanna Briggs Institute (JBI) were used in this review. This scoping review followed methods published in a study protocol. Searches were performed (January 2012-March 2023) in MEDLINE, EMBASE and Web of Science Core Collection using key-terms relating to two areas: (i) people who have been incarcerated and (ii) primary care. Using eligibility criteria, two authors independently screened publication titles and abstracts (step 1), and subsequently, screened full text publications (step 2). Discrepancies were resolved with a third author. Two authors independently charted data from included publications. Findings were mapped by methodology, key findings and gaps in research. Results The database searches generated 1,050 publications which were screened by title and abstract. Following this, publications were fully screened (n = 63 reviewer 1 and n = 87 reviewer 2), leading to the inclusion of 17 publications. Among the included studies, primary care use after prison release was variable. Early contact with primary care services after prison release (e.g. first month) was positively associated with an increased health service use, but an investigation found that a large proportion of individuals did not access primary care during the first month. The quality of care was found to be largely inadequate (measured continuity of care) for moderate multimorbidity. There were lower levels of colorectal and breast cancer screening among people released from custody. The review identified studies of enhanced primary care programmes for individuals following release from prison, with studies reporting a reduction in reincarceration and criminal justice system costs. Conclusions This review has suggested mixed evidence regarding primary care use after prison release and has highlighted challenges and areas of suboptimal care. Further research has been discussed in relation to the scoping review findings.

Objective and Approach We describe a collaboration between the Queen’s University Belfast, Administrative Data Research Centre (ADRC) in Northern Ireland (NI) and the NI Healthcare in Prisons Service (HIPS) to develop a novel linked database to assess the health of people in prison in NI. Prison health data were extracted by the HIPS using electronic/manual modes for the period 2012-2021 and transferred to the Honest Broker Service, a trusted research environment, for linkage, de- identification and access to data. Data from prison health records were linked via a unique health identifier to a healthcare population spine, prescriptions data (primary care), hospital admissions data (mental health), income deprivation and mortality data. Results A novel linked dataset has been developed including 16 variables from prison health records for N=14,898 individuals and N=34,213 custodial episodes (individuals may have ≥1 custodial episode during the study period). The entire NI population (healthcare population spine data) will be included as comparator data. Dataset cleaning has commenced for analyses. The study aims are to (i) examine the health/mental health of people in prison in NI, (ii) examine all-cause/drug-related mortality risk after release from prison and (iii) characterise individuals with the greatest mortality risk. Conclusions We discuss the development of a novel linked dataset using prison health records and present results from our research questions about the health of people in prison. Implications This work may direct future research and may be used to guide health services policy changes and improve outcomes after prison release.

Background Most neovascular age-related macular degeneration treatments involve long-term follow-up of disease activity. Home monitoring would reduce the burden on patients and those they depend on for transport, and release clinic appointments for other patients. The study aimed to evaluate three home-monitoring tests for patients to use to detect active neovascular age-related macular degeneration compared with diagnosing active neovascular age-related macular degeneration by hospital follow-up. Objectives There were five objectives: Estimate the accuracy of three home-monitoring tests to detect active neovascular age-related macular degeneration. Determine the acceptability of home monitoring to patients and carers and adherence to home monitoring. Explore whether inequalities exist in recruitment, participants’ ability to self-test and their adherence to weekly testing during follow-up. Provide pilot data about the accuracy of home monitoring to detect conversion to neovascular age-related macular degeneration in fellow eyes of patients with unilateral neovascular age-related macular degeneration. Describe challenges experienced when implementing home-monitoring tests. Design Diagnostic test accuracy cohort study, stratified by time since starting treatment. Setting Six United Kingdom Hospital Eye Service macular clinics (Belfast, Liverpool, Moorfields, James Paget, Southampton, Gloucester). Participants Patients with at least one study eye being monitored by hospital follow-up. Reference standard Detection of active neovascular age-related macular degeneration by an ophthalmologist at hospital follow-up. Index tests KeepSight Journal: paper-based near-vision tests presented as word puzzles. MyVisionTrack®: electronic test, viewed on a tablet device. MultiBit: electronic test, viewed on a tablet device. Participants provided test scores weekly. Raw scores between hospital follow-ups were summarised as averages. Results Two hundred and ninety-seven patients (mean age 74.9 years) took part. At least one hospital follow-up was available for 317 study eyes, including 9 second eyes that became eligible during follow-up, in 261 participants (1549 complete visits). Median testing frequency was three times/month. Estimated areas under receiver operating curves were < 0.6 for all index tests, and only KeepSight Journal summary score was significantly associated with the lesion activity (odds ratio = 3.48, 95% confidence interval 1.09 to 11.13, p = 0.036). Older age and worse deprivation for home address were associated with lower participation (χ2 = 50.5 and 24.3, respectively, p 6 and < 42 months earlier. We tried to recruit equal numbers by time since starting treatment in the first-treated study eye (6–17 months; 18–29 months; 30–41 months) to ensure test performance was estimated across this range of duration of nAMD. Patients were followed for at least 6 months. Reference standard The reference standard was the reviewing ophthalmologist’s decision about the activity status of a study eye at a HES monitoring visit, recorded as active, inactive or uncertain. There were no additional hospital visits for the study. Such decisions are usually based on clinical examination and the results of hospital-based retinal imaging investigations, for example, colour fundus photographs and ocular coherence tomograms (OCTs). The reference standard grouped uncertain with inactive judgements for analyses. Index tests Three home-monitoring (‘index’) tests were evaluated, spanning low to moderate cost and complexity. These were: KeepSight Journal (KSJ): a paper-based booklet of near-vision tests presented as word puzzles developed in the United States and adapted by the study team for use in the study. MyVisionTrack® (mVT®): electronic vision test, intended to be viewed on a tablet device. MultiBit (MBT): electronic vision test, intended to be viewed on a tablet device. Specific thresholds indicating a significant clinical change were not provided for any of index tests in advance by their developers. Outcomes The primary outcome was classification of a study eye at a monitoring visit as having active or inactive disease (active, inactive, uncertain), that is, the reviewing ophthalmologist’s decision. A secondary outcome (new reference standard) for Objective A was a change from inactive to active status from one management visit to the next. This was considered better to represent how home monitoring might be implemented. For Objective C, outcomes investigated were willingness in principle to participate; ability to carry out index tests; adherence to weekly testing. For Objective D, the outcome was conversion of a fellow eye to active nAMD as judged by an ophthalmologist, that is, same reference standard. For Objective E, the following outcomes were described as measures of the technical and logistical challenges identified during the study: Frequency and reason for incoming calls made to the helpline and outgoing calls made to participants. Frequency and duration of events leading to the digital tests being unavailable for testing. Other technical and logistical challenges. Objective B study recruitment and data collection Recruitment to the qualitative component began 3 months after the monitoring for neovascular age-related macular degeneration reactivation at home (MONARCH) study began recruiting. During the consent process for participation in the study, patients could consent to further contact from the qualitative research team to discuss participation in the qualitative study. Maximum variation sampling ensured a range of perspectives were captured in relation to: age (young-old 50–69 years and older-old > 70 years), gender, one or both eyes with nAMD, time since first treatment (defined as above) and adherence to home monitoring (test data from the two electronic tests were used to categorise participants into ‘regular’ testers and ‘irregular’ testers). Patients who declined to participate in MONARCH but provided consent to be contacted about the qualitative study, informal ‘carers’, supporters or significant others in the lives of patients and healthcare professionals who interacted with participants at study sites visits were also approached to gather their perspectives about the acceptability of home monitoring. Statistical analysis Objective A: The test accuracy of index tests was estimated by fitting a logistic regression model to predict the reference standard from summary test scores for the interval between monitoring visits, adjusting for participants’ baseline data. Accuracy was estimated for the primary outcome using all index test data, data only for the 4 weeks preceding the monitoring visit, the reference standard based on reading centre decisions made from OCT images and for the secondary outcome. Test scores were summarised as: means (MBT and mVT); median (KSJ reported near visual acuity (VA), ordinal six-point scale); proportions (KSJ reported VA, Amsler grid and household object appearance reported worse than baseline vs. same or better). All four scores were fitted in the KSJ model and a single area under the receiving operator curve (AUROC) was estimated. Separate models were fitted for each test for the primary outcome, the two sensitivity analyses and the secondary outcome. Model performance was quantified by the odds ratio (OR) for the index test summary score(s) and the estimate of the AUROC and their respective confidence intervals (CIs). AUROCs were based on predicted probabilities calculated using only the fixed effects in the models. Sensitivity, specificity, positive and negative predictive values and 95% CIs were calculated using cut-off thresholds corresponding to Youden’s index for each model, which minimises overall misclassifications. Average test scores above and below the thresholds were also calculated. Analyses took account of the structure within the data, that is, the nesting of visits and eyes within patients. Objective B: All interviews were audio-recorded and transcribed. A directed content analysis approach based on deductive and inductive coding was used. NVivo version 12 was used to manage data and facilitate the analysis process, which, in summary, included the following stages: (1) independent transcription, (2) data familiarisation, (3) independent coding, (4) development of an analytical framework, (5) indexing, (6) charting and (7) interpreting data. Objective C: Willingness in principle to participate was defined as an approached eligible patient agreeing to attend a research visit for training. Ability to perform an index test was defined as the proportion of monitoring visits for which some valid index test data were available. Adherence was defined as the proportion of weeks between monitoring visits for which some valid data for an index test were available. The ability and adherence models were performed for each test separately at the level of the patient. Regression models estimated associations of age, sex, Index of Multiple Deprivation (IMD), stratum of time since first diagnosis and baseline visual acuity at diagnosis on the outcomes of willingness to participate, ability to perform tests and adherence to weekly testing; models for the latter two outcomes were fitted for each index test. Associations were reported with 95% CIs. Analyses of adherence and ability took account of nesting of visits within participants. Objective D: The test accuracy of the index tests for the reference standard of an ophthalmologist’s classification of a fellow eye as having active disease at a monitoring visit, that is, conversion to active nAMD, was estimated by the same methods as described for Objective A. Two sensitivity analyses were carried out: (1) the same reference standard but using test data only for the 4 weeks preceding the management visit and (2) the alternative reference standard of classification of a fellow eye having active disease based on reading centre grading of OCTs carried out during the monitoring visits. Objective E: This objective used descriptive summary descriptive statistics only. Results The study recruited 297 patients (consented participants) between 21 August 2018 and 31 March 2020. Half of recruited participants were first treated for nAMD 6–17 months before consenting, 28% 18–29 months before consenting and 22% 30–41 months before consenting. At the end of the study, data for at least one monitoring visit after starting to use the index monitoring tests were available for 357 study eyes in 297 patients. Data were available for at least one complete monitoring visit after starting to use the index monitoring tests for 317 study eyes of 261 patients. More participants were women (58.6%). Participants’ mean age was 74.9 (6.6) years [standard deviation (SD)]. The mean visual acuity of study eyes (better seeing eyes if participants had two study eyes) was 0.2 (0.2) Logarithm of the minimum angle of resolution (LogMAR) (SD). Objective A: Median testing frequency was three times per month. In the primary analysis, estimated AUROCs were < 0.6 for all index tests, and only KSJ summary score was significantly associated with the lesion activity (OR = 3.48, 95% CI 1.09 to 11.13; p = 0.036). Estimated AUROCs were < 0.6 for all tests in both sensitivity analyses and for the secondary outcome of change from inactive to active status between adjacent management visits. Objective B: Two overarching meta-themes emerged from the qualitative studies related to acceptance or non-acceptance of home monitoring. Meta-theme 1 encompassed four main themes: (1) the role of home monitoring; (2) suitability of procedures and instruments; (3) experience of home monitoring; and (4) feasibility of home monitoring in usual practice. Meta-theme 2 consisted of one main theme covering key inhibitors to acceptability. The main factors influencing acceptability included a participant’s understanding about the purpose of home monitoring and their experience of using it. While home monitoring was generally seen as a relatively straightforward exercise to undertake and non-burdensome, training and ongoing support were regarded as essential to its success. Home monitoring was acceptable to patients and its potential to reduce clinic visits during non-active treatment phases was recognised. Objective C: A minority of patients who were approached were willing in principle to participate. Increasing age and worse deprivation index for home address were associated with being unwilling in principle to participate (χ2 = 50.5 and 24.3, respectively, both p ≤ 0.001). Recruiting site was also associated with willingness in principle to participate, believed to be due to sites adopting different strategies for approaching and recruiting patients. Increasing age and worse deprivation were not consistently associated with either being able to self-monitor with the index tests or adherence to weekly testing (χ2 for all tests 0.08 for ability and adherence, except for worse IMD being associated with better adherence for the KSJ, χ2 = 12.15, p = 0.016). Recruiting site was also associated with being able to test and adhering to weekly testing. Objective D: There were 132 fellow eyes with data from 544 monitoring visits, 17 of which (12.9%) had nAMD recorded at one or more management visits over about 100 participant-years. This rate of conversion was higher than expected based on epidemiological studies of conversion rates in unaffected fellow eyes, potentially due to study eyes having had nAMD longer ago. Some predictors could not be fitted in models and estimates of associations were imprecise. The no-test model predicted conversion better than for Objective A (AUROC = 0.73) and electronic tests did not increase this (AUROCs = 0.73 and 0.76 for MBT and mVT, respectively). The estimated AUROC for the KSJ was 0.85, due to a strong positive association of the household object summary score with conversion (OR 15.3, p = 0.036). Objective E: Despite two-thirds of the population having previously used a smartphone, there were still a variety of challenges experienced with the electronic devices while testing at home that contributed to both reduced adherence and ultimately withdrawals from the study. Strengths and limitations The study had several strengths. Estimates of the diagnostic test accuracy of index tests were at low risk of bias: the study population was appropriate for the intended use of the tests, and summary test scores were not available to ophthalmologists providing the reference standard, which was judged after the index test data were collected. Limitations A smaller-than-planned sample size (less than half the target number of monitoring visits); nonetheless, 95% CIs for AUROCs were narrow (± 0.04) and estimates were able to rule out tests providing adequate accuracy for diagnosing active nAMD to enable patients to be monitored without hospital review. Tests were sometimes not available for technical reasons that were beyond the control of the research team. The study had no control over monitoring visits and participants are likely to have reported their subjective visual experience to their consultants, which might have influenced the reference standard. We could not define test thresholds a priori, and instead estimated AUROCs. We did not compare AUROCs for tests due to their poor accuracy. The ways in which patients were approached and screened varied across sites, generating a site effect in analyses of potential inequalities; variations may have reflected the pre-conceptions of research staff regarding the capabilities of patients to use the electronic tests. Conclusions Based on the detection of lesion activity assessed by clinicians in the clinic, we have shown that none of the index tests provides acceptable test accuracy for home monitoring in this context. Associations of increasing age and deprivation index for home address with unwillingness in principle to participate despite provision of hardware highlight the potential for inequality with interventions of the kind evaluated. While a proportion of nAMD patients are willing and interested in the potential for home monitoring, substantial practical and technological issues are encountered in the implementation of such, requiring a significant support infrastructure, including a study helpline. Future work Future research should focus on the methodological challenge of efficiently evaluating mobile health technologies which deal with constantly emerging new technology. The clear evidence of inequalities in participation and retention should prompt future research on ways to encourage participant and adoption of mobile health technologies by underserved populations. Focus should also be placed on methods to improve adherence and retention in longitudinal studies involving electronic testing, particularly around the nature of feedback to participants. Trial registration This trial is registered as ISRCTN79058224. Funding This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/97/02) and is published in full in Health Technology Assessment; Vol. 28, No. 32. See the NIHR Funding and Awards website for further award information.

Background: Given the protective effect of nurturing caregivers and families for child and adolescent mental health, there is a need to review and synthesize research evidence regarding the effectiveness of parenting and family interventions in low and middle-income countries, including humanitarian settings. To advance practice, further understanding of the active ingredients of such interventions and implementation factors that lead to effectiveness are essential. Method: This systematic review, an update from a previous review, included studies on any parenting or family intervention for children and adolescents aged 0–24, living in a low- or middle-income country, that quantitatively measured child or adolescent mental health outcomes. We searched Global Health, PubMed, PsychINFO, PILOTS and the Cochrane Library databases on the 9th July 2020, and updated on the 12th August 2022. Risk of bias was assessed using an adapted version of the NIH Quality Assessment Tool. We extracted data on: effectiveness outcomes, practice elements included in effective interventions, and implementation challenges and successes. Main findings: We found a total of 80 studies (n = 18,193 participants) representing 64 different family or parenting interventions, 43 of which had evidence of effect for a child or adolescent mental health outcome. Only 3 studies found no effect on child, adolescent or caregiver outcomes. The most common practice elements delivered in effective interventions included caregiver psychoeducation, communication skills, and differential reinforcement. Key implementation strategies and lessons learned included non-specialist delivery, the engagement of fathers, and integrated or multi-sector care to holistically address family needs. Preliminary conclusions: Despite a high level of heterogeneity, preliminary findings from the review are promising and support the use of parenting and family interventions to address the wider social ecology of children in low resource and humanitarian contexts. There are remaining gaps in understanding mechanisms of change and the empirical testing of different implementation models. Our findings have implications for better informing task sharing from specialist to non-specialist delivery, and from individual-focused to wider systemic interventions.

BackgroundA significant rise in childhood obesity worldwide over the past three decades highlights the urgent need for early interventions, especially in preschools as key settings for child development. This study aimed to assess the feasibility and fidelity of a randomised controlled trial of “I’m an Active Hero” (IAAH), a theory- and evidence-based multi-component behaviour change intervention targeting physical activity and sedentary behaviour amongst preschool-aged children.MethodsTwo preschools in Taif city, Saudi Arabia were randomly assigned to either the intervention (n = 3 classrooms) or the usual curriculum control group (n = 3 classrooms). The intervention ran for 10 weeks from February to April 2023 and consisted of teacher-led physical activity and sedentary behaviour sessions in preschools, with an additional interactive home component. Primary outcome measures included intervention fidelity, recruitment rates, attrition rates, and compliance with trial procedures. Secondary outcomes included body mass index (BMI), objectively measured physical activity, and sedentary time via the ActiGraph GT3X accelerometer. Outcomes were measured at baseline and at 10 weeks in both study arms.ResultsThe preschool intervention component had high fidelity (93.3%), but the home component fidelity was lower (74%). A cluster-level recruitment rate of 12% (13/112 centres) was attained, whilst the individual-level recruitment rate stood at 36% (52/143 children, mean age of 4.16 years; 23 girls). Attrition was 10%. Compliance varied with 90% for BMI, 71% for accelerometery, and 45% for questionnaires. The intervention group showed small decreases in BMI, slight increases in physical activity, and decreases in sedentary time at follow-up compared to the control group. Parents, facilitators, and assistant teachers considered the intervention to be feasible and beneficial.ConclusionThe IAAH intervention was feasible to implement in Saudi Arabian preschools. Facilitators showed high fidelity in delivering it. However, preliminary data did not demonstrate effectiveness. A more comprehensive evaluation across a broader population is warranted. The intervention could be revised to optimise recruitment, compliance, and fidelity of the home-based component. Successful elements from this pilot should be retained whilst adaptations to implementation are made to strengthen key areas.Clinical trial registration: ClinicalTrials.gov, NCT05754359.

Abstract Background Context including the external context may considerably affect the adoption, implementation, sustainment, and scale-up of evidence-based practices. We investigated external contextual features by conducting a scoping review of empirical research regarding the implementation of an evidence-based psychiatric or mental health vocational rehabilitation service called Individual Placement and Support (IPS). Methods The protocol for the scoping review was registered with the Open Science Framework. We used the methodology by Joanna Briggs Institute for conducting the scoping review and reported it according to the PRISMA-ScR checklist. We searched 12 databases for research regarding ‘Individual Placement and Support’ or ‘Evidence-Based Supported Employment’. We retained peer-reviewed empirical studies investigating external contextual factors and their impact on IPS implementation outcomes. We extracted data from the eligible articles and conducted descriptive and thematic analyses. Results Fifty-nine original research papers met our eligibility requirements and were retained after reviewing 1124 titles and abstracts and 119 full texts. The analysis generated two main themes: (1) external contextual determinants of service delivery and (2) external systems influencing the evidence-to-practice process. The first main theme encompassed policies and laws, financing, and administratively instituted support resources, and organizational arrangements associated with external stakeholders that may facilitate or hinder the local implementation. The second main theme comprised strategies and actions used by different stakeholders to facilitate implementation locally or scale-up efforts at a system level. Discussion Our scoping review illustrates the important role that external contextual factors play and how they may facilitate or hinder the implementation and scale-up of the IPS model across mental health services in different countries. Consideration of these factors by decision-makers in mental health and welfare services, planners, providers, and practitioners is likely to facilitate the development of effective strategies for bridging the evidence-practice gap in implementing the EBPs. Finally, the scoping review identified gaps in knowledge and offered suggestions for future research. Trial registration Open Science Framework

Abstract Background Insufficient physical activity (PA) is a significant risk factor that contributes to several health problems and there is a need to improve our understanding of how to increase PA, particularly among young children. This review (PROSPERO registration: CRD42022328841) investigated the relationship between behaviour change techniques (BCTs) and interventions that increased PA among pre-school children aged

Background: Interventions within preschool settings have gained prominence due to the need to increase physical activity (PA) in early childhood. We first developed a 10-week preschool-based behaviour change intervention, guided by the UK Medical Research Council’s framework for complex interventions. We then conducted a cluster feasibility randomised controlled trial (RCT) among young children. Aim: This process evaluation was embedded within the cluster feasibility RCT and aimed to assess the acceptability of the 10-week IAAH intervention among both preschool staff and parents. Methods: The study utilised a mixed method, involving post-intervention questionnaires completed by preschool staff (n = 4) and children’s parents/caregivers (n = 9) and focus groups with preschool staff (n = 3) and parents/caregivers (n = 7). Quantitative data were analysed using SPSS to calculate acceptability scores, while qualitative data underwent thematic analysis using NVivo 12. Results: The intervention was well-received, with preschool staff reporting a 94.5% acceptability rate (mean score of 10.4 out of 11) and parents/caregivers indicating an 86% acceptance rate (mean score of 5.2 out of 6). Thematic analysis of focus group discussions revealed facilitators to intervention delivery, such as user-friendly materials and alignment with preschool curricula, and identified barriers, including time constraints, spatial limitations, and policy conflicts. Parental engagement was hindered by time restrictions, although the intervention materials were praised for their clarity and visual appeal. Conclusions: The findings suggest that the IAAH programme was acceptable to both preschool staff and parents. However, the identified barriers to intervention delivery and engagement should be addressed in the planning of a future cluster RCT to evaluate the efficacy of the intervention.

Objectives Remote monitoring of health has the potential to reduce the burden to patients of face-to-face appointments and make healthcare more efficient. Apps are available for patients to self-monitor vision at home, for example, to detect reactivation of age-related macular degeneration (AMD). Describing the challenges when implementing apps for self-monitoring of vision at home was an objective of the MONARCH study to evaluate two vision-monitoring apps on an iPod Touch (Multibit and MyVisionTrack).Design Diagnostic Test Accuracy study.Setting Six UK hospitals.Methods The study provides an example of the real-world implementation of such apps across health sectors in an older population. Challenges described include the following: (1) frequency and reason for incoming calls made to a helpline and outgoing calls made to participants; (2) frequency and duration of events responsible for the tests being unavailable; and (3) other technical and logistical challenges.Results Patients (n=297) in the study were familiar with technology; 252/296 (85%) had internet at home and 197/296 (67%) had used a smartphone. Nevertheless, 141 (46%) called the study helpline, more often than anticipated. Of 435 reasons for calling, all but 42 (10%) related to testing with the apps or hardware, which contributed to reduced adherence. The team made at least one call to 133 patients (44%) to investigate why data had not been transmitted. Multibit and MyVisionTrack apps were unavailable for 15 and 30 of 1318 testing days for reasons which were the responsibility of the app providers. Researchers also experienced technical challenges with a multiple device management system. Logistical challenges included regulations for transporting lithium-ion batteries and malfunctioning chargers.Conclusions Implementation of similar technologies should incorporate a well-resourced helpline and build in additional training time for participants and troubleshooting time for staff. There should also be robust evidence that chosen technologies are fit for the intended purpose.Trial registration number ISRCTN79058224.

BackgroundIn 2018, Scotland became the second country to implement minimum unit pricing (MUP) for all types of alcoholic beverages. The aim of this study was to examine the effect of the policy.MethodThree national household-level surveys were used: Scottish Health Surveys (2008-2021), Health Surveys in England (2011-2019), and Northern Ireland Continuous Household Survey (2011-2015). First, a generalized ordered logistic model examined patterns of drinking solely in Scotland from 2008-2021 covering current drinking, drinking categories and the weekly consumption (in alcohol units). Secondly, difference-in-difference (DID) analysis was employed to examine changes in "social drinking" behaviours in Scotland after the announcement in 2012 (2011-2015, Northern Ireland and England as comparators) and after the adoption of the policy in 2018 (England as a comparator, with two timeframes 2016-2019 and 2013-2019).ResultsOverall, drinking in Scotland began to decline prior to 2012 and dropped further with the enactment of MUP in 2018. In response to MUP, the likelihood of abstention increased along with a slight decrease in the prevalence of heavy drinking. The overall amount of drinking fell by about 8% after 2012 and 12% after 2018 (as compared to 2008-2011 level), with a significant decline seen in moderate drinkers but not of those who drank at hazardous or harmful levels. The DID analyses confirmed the reduction in current drinking in Scotland starting since 2012 and continued post-MUP in 2018.ConclusionThis study points to the impact of MUP in Scotland with a potential role for 'policy signalling' by the Scottish Government's with a multiple-buy discount ban and MUP's announcement since 2011-2012. Indications of impact include a clear decline in alcohol consumption levels and a small but noteworthy change in prevalence of overall drinking and heavy drinking.

BackgroundInsufficient physical activity (PA) in early childhood is linked to adverse health outcomes and a heightened risk of obesity. Successful PA programmes often require input from key stakeholders, such as parents and educators. However, research on stakeholders’ perspectives regarding PA programmes for preschool children is limited, impeding effective programme design and implementation.ObjectivesThis study aims to explore the perspectives of key stakeholders to gain insights into the challenges, facilitators, and motivators that influence the planning, execution, and sustainability of the “I'm an Active Hero (IAAH) intervention component,” a preschool-based initiative designed to promote PA among young children.MethodsSemi-structured interviews were conducted in Saudi Arabia with individual preschool principals (n = 2), and focus group discussions were held, respectively, with preschool staff members (n = 4, all female) and parents (4 mothers, 5 fathers).ResultsA thematic analysis identified four main themes: (1) Barriers to parental involvement in preschool PA interventions, such as time constraints, lack of flexibility, limited space, and a shortage of trained staff; (2) Risks and benefits of children's programme participation; (3) Motivators including rewards, non-financial incentives, and concerns about childhood obesity and a sedentary lifestyle; (4) Facilitating factors for overcoming barriers, including staff training, time reallocation, staff coordination, space optimization, non-financial incentives, and sustaining partnerships.ConclusionThis study's findings are crucial for childcare professionals, preschools, education authorities, and policymakers, offering valuable insights for future research. However, further collaboration with key stakeholders is essential to enhance individual attitudes and preschool policies for effective intervention implementation.

Abstract Background Many upper-middle-income countries (UMICs), including Malaysia, continue to face low breast cancer (BC) screening rates and patients with delayed presentation of BC. This study investigated the role of beliefs about BC and use of screening (e.g. beliefs about whether or not screening reduced the possibility of dying from BC). Methods A nationwide cross-sectional study was conducted in which a total of 813 women (aged ≥ 40 years old) were randomly selected and surveyed using the validated Awareness and Beliefs about Cancer (ABC) measure. The association between BC screening use, sociodemographic characteristics, and negative beliefs about BC screening were analysed using stepwise Poisson regressions. Results Seven out of ten Malaysian women believed that BC screening was necessary only when experiencing cancer symptoms. Women > 50 years and from households with more than one car or motorcycle were 1.6 times more likely to attend a mammogram or a clinical breast examination (mammogram: Prevalence Ratio (PR) = 1.60, 95% Confidence Interval (CI) = 1.19–2.14, Clinical Breast Examination (CBE): PR = 1.61, 95% CI = 1.29–1.99). About 23% of women expected to feel anxious about attending BC screening, leading them to avoid the procedure. Women who held negative beliefs about BC screening were 37% less likely to attend a mammogram (PR = 0.63, 95% CI = 0.42–0.94) and 24% less likely to seek a CBE (PR = 0.75, 95% CI = 0.60–0.95). Conclusions Public health strategies or behaviour interventions targeting negative beliefs about BC screening among Malaysian women may increase uptake and reduce late presentation and advanced-stage cancer. Insights from the study suggest that women under 50 years, in the lower income group without a car or motorcycle ownership, and of Malay or Indian ethnicity (compared to Chinese-Malay) are more likely to hold beliefs inhibiting BC screening.

Abstract Background There are public health concerns about an increased risk of mortality after release from prison. The objectives of this scoping review were to investigate, map and summarise evidence from record linkage studies about drug-related deaths among former adult prisoners. Methods MEDLINE, EMBASE, PsychINFO and Web of Science were searched for studies (January 2011- September 2021) using keywords/index headings. Two authors independently screened all titles and abstracts using inclusion and exclusion criteria and subsequently screened full publications. Discrepancies were discussed with a third author. One author extracted data from all included publications using a data charting form. A second author independently extracted data from approximately one-third of the publications. Data were entered into Microsoft Excel sheets and cleaned for analysis. Standardised mortality ratios (SMRs) were pooled (where possible) using a random-effects DerSimonian-Laird model in STATA. Results A total of 3680 publications were screened by title and abstract, and 109 publications were fully screened; 45 publications were included. The pooled drug-related SMR was 27.07 (95%CI 13.32- 55.02; I 2 = 93.99%) for the first two weeks (4 studies), 10.17 (95%CI 3.74–27.66; I 2 = 83.83%) for the first 3–4 weeks (3 studies) and 15.58 (95%CI 7.05–34.40; I 2 = 97.99%) for the first 1 year after release (3 studies) and 6.99 (95%CI 4.13–11.83; I 2 = 99.14%) for any time after release (5 studies). However, the estimates varied markedly between studies. There was considerable heterogeneity in terms of study design, study size, location, methodology and findings. Only four studies reported the use of a quality assessment checklist/technique. Conclusions This scoping review found an increased risk of drug-related death after release from prison, particularly during the first two weeks after release, though drug-related mortality risk remained elevated for the first year among former prisoners. Evidence synthesis was limited as only a small number of studies were suitable for pooled analyses for SMRs due to inconsistencies in study design and methodology.

BackgroundThere is a dearth of research on the nature and extent of variation in patterns of health service use in Saudi Arabia. This is an important gap in knowledge, given ongoing efforts to improve service provision and delivery. This study examined the relationship between the region of residence and socio-demographic factors and patterns of health service use in Saudi Arabia.MethodsData were taken from the 2013 Saudi Health Interview Survey (SHIS), a national multistage survey of individuals aged 15 years and above in Saudi Arabia. Data included measures of service use, respondent health, socio-demographic characteristics, and region or area of residence. Descriptive statistics, Chi-square tests, and multivariable logistic regression analyses were used to describe the data and examine the likelihood of a respondent visiting a doctor or healthcare professional in the preceding 12 months. In addition, the analyses examined the role of health and socio-demographic characteristics within selected regions.ResultsThe increased likelihood of using health services in terms of visiting a doctor or healthcare professional was related to poor health status, being female, married, having a low income, and residing in particular regions. Respondents aged

Abstract Introduction The Colorectal Cancer Screening Intervention for Malaysia (CRC-SIM) was a CRC study of home-based testing designed to improve low screening uptake using the immunochemical fecal occult blood test (iFOBT) in Malaysia. Methods This quasi-experimental study was informed by the Implementation Research Logic Model and evaluated with the RE-AIM framework. Trained data collectors recruited by phone, randomly selected, asymptomatic adults aged 50-75 years from Segamat District, who previously completed a health census form for the South East Asia Community Observatory (SEACO). Participants were posted an iFOBT kit and asked to return a photo of the completed test for screening by health care professionals. A regression analysis of evaluation data was conducted to identify which variables were associated with the outcome indicators of ‘study participation’ and ‘iFOBT completion’ and the CRC-SIM was evaluated in terms of its appropriateness, feasibility and acceptability. Results Seven hundred forty-seven eligible adults (52%) agreed to participate in this study and received an iFOBT kit. Participation was significantly lower amongst Chinese Malaysians (adjusted OR 0.45, 95% CI 0.35 - 0.59, p

Objectives We describe the progress made in the development of a novel linked database designed to improve understanding about the health, mental health, health service use and mortality risk of people following their release from prison in Northern Ireland (NI). Methods This is a collaborative project between the ADRC-NI and the NI Healthcare in Prisons service (HIPS) - South Eastern Health and Social Care Trust (SEHSCT). Data about the health of all adult prisoners between 2012 and 2021 (HIPS) will be linked to a healthcare population spine (National Health Application and Infrastructure Services - NHAIS) via a Health and Care Number (HCN), a unique health identifier for each patient in the NHS in Northern Ireland. Data will subsequently be linked to prescribing data (Enhanced Prescribing Database - EPD), in-patient services data (mental health) and mortality data (General Register Office - GRO). Results Ethical and governance approvals have been obtained. A stepwise approach to the development of this novel health database will be presented. Data cleaning has been undertaken by the HIPS team and records with missing HCNs have been identified and updated. Extraction of prison health data is underway for N=14,898 individuals and N=34,213 custodial episodes. Individuals may have more than one prison episode during the study period. Electronic and manual modes were used to extract 25 health-related variables from prison records. Data will be transferred to the Honest Broker Service (HBS), the trusted research environment for health and social care in NI, for data de-identification and linkage, and data access for analysis. Preliminary results and lessons for other related data-linkage projects will be presented and discussed. Conclusion We will describe our progress regarding the development of a novel health dataset comprising routinely collected administrative data and our work about prisoner health. We will report about our experience of assessing data access, cleaning, extracting, and analysing data and the linkage possibilities with respect to the prison health dataset.

Objective To conduct a cultural adaptation and validation of the Champion Health Belief Model Scale (CHBMS) for colorectal cancer (CRC) screening (CHBMS-CRC-M) in order to assess and investigate perceptions and beliefs about CRC screening in Malaysia.Designs and participants The results from an evidence synthesis and the outcomes from an expert panel discussion were used to shape CHBMS scale content into an assessment of beliefs about CRC screening (CHBMS-CRC). This questionnaire assessment was translated into the official language of Malaysia. An initial study tested the face validity of the new scale or questionnaire with 30 men and women from various ethnic groups. Factorial or structural validity was investigated in a community sample of 954 multiethnic Malaysians.Setting Selangor state, Malaysia.Results The new scale was culturally acceptable to the three main ethnic groups in Malaysia and achieved good face validity. Cronbach’s alpha coefficients ranged from 0.66 to 0.93, indicating moderate to good internal consistency. Items relating to perceived susceptibility to CRC ‘loaded’ on Factor 1 (with loadings scoring above 0.90); perceived benefits of CRC screening items loaded on factor 2 and were correlated strongly (loadings ranged between 0.63 and 0.83) and perceived barriers (PBA) to CRC screening (PBA) items loaded on factor 3 (range 0.30–0.72).Conclusion The newly developed CHBMS-CRC-M fills an important gap by providing a robust scale with which to investigate and assess CRC screening beliefs and contribute to efforts to enhance CRC screening uptake and early detection of CRC in Malaysia and in other Malay-speaking communities in the region.

Abstract Background Many countries are introducing low‐dose computed tomography screening programmes for people at high risk of lung cancer. Effective communication strategies that convey risks and benefits, including unfamiliar concepts and outcome probabilities based on population risk, are critical to achieving informed choice and mitigating inequalities in uptake. Methods This study investigated the acceptability of an aspect of NHS England's communication strategy in the form of a leaflet that was used to invite and inform eligible adults about the Targeted Lung Health Check (TLHC) programme. Acceptability was assessed in terms of how individuals engaged with, comprehended and responded to the leaflet. Semi‐structured, ‘think aloud’ interviews were conducted remotely with 40 UK screening‐naïve current and former smokers (aged 55–73). The verbatim transcripts were analysed thematically using a coding framework based on the Dual Process Theory of cognition. Results The leaflet helped participants understand the principles and procedures of screening and fostered cautiously favourable intentions. Three themes captured the main results of the data analysis: (1) Response—participants experienced anxiety about screening results and further investigations, but the involvement of specialist healthcare professionals was reassuring; (2) Engagement—participants were rapidly drawn to information about lung cancer prevalence, and benefits of screening, but deliberated slowly about early diagnosis, risks of screening and less familiar symptoms of lung cancer; (3) Comprehension—participants understood the main principles of the TLHC programme, but some were confused by its rationale and eligibility criteria. Radiation risks, abnormal screening results and numerical probabilities of screening outcomes were hard to understand. Conclusion The TLHC information leaflet appeared to be acceptable to the target population. There is scope to improve aspects of comprehension and engagement in ways that would support informed choice as a distributed process in lung cancer screening. Patient or Public Contribution The insight and perspectives of patient representatives directly informed and improved the design and conduct of this study.

Abstract Background Adolescents growing up in communities characterised by adversity face multiple risk factors for poor mental health and wellbeing. There is currently a scarcity of research on effective approaches for preventing and treating psychological distress in this population, particularly in humanitarian settings. The powerful impact of the home environment and family support is well known; however, approaches targeting the family are seldom developed or evaluated in such settings. We developed a brief family systemic psychosocial support intervention to be delivered through existing child protection systems with non-specialist facilitators. This paper outlines the study protocol for a randomised controlled trial of the intervention in Lebanon. Methods We will conduct a single-blind hybrid effectiveness-implementation multi-site RCT comparing the locally developed systemic family intervention to a waitlist control group for families residing in vulnerable regions in North Lebanon and Beqaa governorates (including families of Syrian, Palestinian, and Lebanese backgrounds). Outcomes on a range of family, adolescent, and caregiver measures will be assessed at baseline (T0) and post-intervention (T1), and at a 3-month follow-up for the treatment arm (T2). Families will be eligible for the trial if they are identified by implementing organisations as being medium-to-high risk for child protection concerns and have one or more adolescent aged 12–17 who demonstrates significant psychological distress on a self-report brief screening tool. Families will be randomly assigned to a treatment or a waitlist control condition. Families in the waitlist condition will receive a group version of the programme after completion of the study, to allow us to assess feasibility, acceptability, and preliminary indications of intervention effects of this modality. The primary outcome is reduction in overall adolescent-reported psychological distress over time, with post-intervention (T1) as the primary endpoint. Secondary adolescent-reported outcomes include family functioning, psychosocial wellbeing, and emotional regulation difficulties. Secondary caregiver-reported outcomes include parenting style, family functioning, psychological distress, and emotional regulation difficulties. Discussion This trial will provide the first assessment of the effectiveness of the family systemic psychosocial support intervention for use in Lebanon, with important implications for the use of systemic, low-cost, non-specialist interventions for this age range. Trial registration Local registry: National Mental Health Program, Ministry of Public Health, Lebanese Republic. Registered on 19 October 2021 Lebanese Clinical Trial Registry LBCTR2021104870 . Registered on 13 October 2021 Global registry: ISRCTN ISRCTN13751677 . Registered on 1 November 2021

This work presents X-ray computed tomography (XCT) as a dimensional quality assurance technique for micro-injection moulded polymeric test objects for the establishment of predictive quality models and quantifying soft-tool deformation. The results are compared against an industry standard laser-scanning-confocal microscope (LSCM) for the evaluation of XCT’s capability. The work demonstrates; (i) the exploitation of a XCT equipment for dimensional characterisation of micro-injection moulded products made out of polymers with adequate acquisition times, (ii) that acquired XCT data from the 3D visualisation of the micromouldings perform on par with a laser-scanning-confocal microscope in a quality prediction model, (iii) that the deformation occurring in an additively manufactured soft-tool can be quantified using XCT. The technique was particularly superior in volumetric data acquisition compared to LSCM in the filling prediction of the micromouldings. Better accuracy and repeatability in predicting the quality of the mouldings up to 92% achieved with XCT, in conjunction with an in-line collected soft-tool surface temperature data as an indirect quality assurance method. Given the capability of the XCT for the 3D data acquisition of polymeric miniature components, the approach described here has great potential in high-value micro-manufacturing process quality modelling for in-line quality assessment of miniature and added value products in data-rich contexts.Rendered 3D animation of the X-ray CT data: https://youtu.be/KwZty_yoDfs.

Objectives The 2020–2022 research project ‘Colorectal Cancer Screening Intervention for Malaysia’ (CRC-SIM) evaluated the implementation of a home-based CRC screening pilot in Segamat District. This budget impact analysis (BIA) assessed the expected changes in health expenditure of the Malaysian Ministry of Health budget in the scenario where the pilot programme was implemented nationwide vs current opportunistic screening.Design Budget impact analysis. Assumptions and costs in the opportunistic and novel CRC screening scenarios were derived from a previous evaluation of opportunistic CRC screening in community health clinics across Malaysia and the CRC-SIM research project, respectively.Setting National level (with supplement analysis for district level). The BIA was conducted from the viewpoint of the federal government and estimated the annual financial impact over a period of 5 years.Results The total annual cost of the current practice of opportunistic screening was RM1 584 321 (~I$1 099 460) of which 80% (RM1 274 690 or ~I$884 587) was expended on the provision of opportunistic CRC to adults who availed of the service. Regarding the implementation of national CRC screening programme, the net budget impact in the first year was estimated to be RM107 631 959 (~I$74 692 546) and to reach RM148 485 812 (~I$103 043 589) in the fifth year based on an assumed increased uptake of 5% annually. The costs were calculated to be sensitive to the probability of adults who were contactable, eligible and agreeable to participating in the programme.Conclusions Results from the BIA provided direct and explicit estimates of the budget changes to when implementing a population-based national CRC screening programme to aid decision making by health services planners and commissioners in Malaysia about whether such programme is affordable within given their budget constraint. The study also illustrates the use and value of the BIA approach in low-income and middle-income countries and resource-constrained settings.

IntroductionBreast cancer (BC) screening uptake in Malaysia is low and a high number of cases present at a late stage. Community navigation and mobile health (mHealth) may increase screening attendance, particularly by women from rural communities. This randomized controlled study evaluated an intervention that used mHealth and community health workers to educate women about BC screening and navigate them to clinical breast examination (CBE) services in the context of the COVID-19 pandemic.MethodsWomen aged 40-74 years, from Segamat, Malaysia, with a mobile phone number, who participated in the South East Asian Community Observatory health survey, (2018) were randomized to an intervention (IG) or comparison group (CG). The IG received a multi-component mHealth intervention, i.e. information about BC was provided through a website, and telephone calls and text messages from community health workers (CHWs) were used to raise BC awareness and navigate women to CBE services. The CG received no intervention other than the usual option to access opportunistic screening. Regression analyses were conducted to investigate between-group differences over time in uptake of screening and variable influences on CBE screening participation.ResultsWe recruited 483 women in total; 122/225 from the IG and 144/258 from the CG completed the baseline and follow-up survey. Uptake of CBE by the IG was 45.8% (103/225) whilst 3.5% (5/144) of women from the CG who completed the follow-up survey reported that they attended a CBE during the study period (adjusted OR 37.21, 95% CI 14.13; 98.00, pConclusionThe results suggested that the bespoke multicomponent mHealth intervention may be used to address the significant public health problem of low uptake of BC screening in rural Malaysia.

IntroductionThere is a need to improve the implementation and provision of continuity of care between prison and community in order that people who have been in prison and have a history of low engagement with services or who are vulnerable receive appropriate and timely health care and treatment. Observational studies using record linkage have investigated continuity of care after release from prison but this type of research evidence has not been synthesised.ObjectiveThis paper presents a protocol designed to review record linkage studies about primary care utilisation after prison release in order to inform future research and guide service organisation and delivery towards people who are at-risk following release from prison.MethodsThis scoping review will follow the framework by Arksey and O'Malley (5 stages) and guidance developed by the Joanna Briggs Institute (JBI). MEDLINE, EMBASE and Web of Science Core Collection will be searched (January 2012-March 2023) using terms relating to (i) 'former prisoners' and (ii) 'primary care'. The review will focus on observational studies that have investigated this topic using linked data from two or more sources. Two authors will independently screen titles and abstracts (step 1) and full publications (step 2) using predefined eligibility criteria. Data will be extracted from included publications using a piloted data charting form. This review will map the findings in this research area by methodology, key findings and gaps in research, and current evidence will be synthesised narratively given the expected considerable heterogeneity across studies.DiscussionThis review is part of a work programme on health in prison (Administrative Data Research Centre, Northern Ireland). This work may be used to inform future research, policy and practice. Findings will be shared with stakeholders, published in a peer-reviewed journal and presented at relevant conferences. Ethical approval is not required.

Abstract Background Expansion of healthcare insurance coverage to bariatric surgeries has led to an increased demand from patients for post-bariatric contouring surgeries. This study examined the relationship between the use of contouring procedures on post-bariatric surgery patients, clinical need and sociodemographic factors. Methods Data were extracted from the Healthcare Cost and Utilization Project (HCUP) Nationwide Ambulatory Surgery Sample (NASS) regarding hospital-owned ambulatory surgical centres in the US. Episodes without missing values relating to patients, 18 years old or above were the primary unit of analysis. Episodes were excluded if the field regarding expected payer was reported as “no charge.” The primary outcome was the likelihood of panniculectomy, abdominoplasty, and mastopexy among post-bariatric surgery patients; and the degree to which uptake of these types of contouring surgery were associated with age, gender, median households’ income, expected payer, patient’s location, and comorbidity. Results A total of 66,368 weighted episodes of care received by patients who had had bariatric surgery were extracted (54,684 female [82.4%]; mean age, 51.3 [SD, 12.1]; 6219 episodes had contouring surgeries [9.37%]). Panniculectomy was the most common post-bariatric contouring procedure (3.68%). Uptake of post-bariatric contouring procedures was associated with age, sex, payment type, area-based measures of median household income, and patient location. Compared to Medicare insured patients, the odds of receiving contouring surgery among self-payers were 1.82 (95% CI, 1.47 to 2.26) for panniculectomy, 14.79 (95% CI, 12.19 to 17.93) for abdominoplasty and 47.97 (95% CI, 32.76 to 70.24) for mastopexy. Rank order of comorbidity profiles also differed between insured and self-paying recipients of contouring surgery. Conclusions Insurance status of bariatric surgery patients and their sex were strongly associated with receipt of a range of contouring procedures. Self-payments were associated with a doubling of the odds of having panniculectomy and an increase in the odds to approximately 14 times for abdominoplasty and 48 times for mastopexy. Thus, access to contouring surgery by post-bariatric patients may be disproportionately dependent on personal preference supported by ability to pay rather than clinical need. Further research is needed to examine the impact of contouring or delayed/denied contouring on health status.

Abstract Background There is a paucity of research on the cost of breast cancer (BC) treatment from the patient’s perspective in Vietnam. Methods Individual-level data about out-of-pocket (OOP) expenditures on use of services were collected from women treated for BC (n = 202) using an online survey and a face-to-face interview at two tertiary hospitals in 2019. Total expenditures on diagnosis and initial BC treatment were presented in terms of the mean, standard deviation, and range for each type of service use. A generalised linear model (GLM) was used to assess the relationship between total cost and socio-demographic characteristics. Results 19.3% of respondents had stage 0/I BC, 68.8% had stage II, 9.4% had stage III, none had stage IV. The most expensive OOP elements were targeted therapy with mean cost equal to 649.5 million VND ($28,025) and chemotherapy at 36.5 million VND ($1575). Mean total OOP cost related to diagnosis and initial BC treatment (excluding targeted therapy cost) was 61.8 million VND ($2667). The mean OOP costs among patients with stage II and III BC were, respectively, 66 and 148% higher than stage 0/I. Conclusions BC patients in Vietnam incur significant OOP costs. The cost of BC treatment was driven by the use of therapies and presentation stage at diagnosis. It is likely that OOP costs of BC patients would be reduced by earlier detection through raised awareness and screening programmes and by providing a higher insurance reimbursement rate for targeted therapy.

Abstract Background Low- and middle-income countries (LMICs) experienced increasing rates of colorectal cancer (CRC) incidence in the last decade and lower 5-year survival rates compared to high-income countries (HICs) where the implementation of screening and treatment services have advanced. This review scoped and mapped the literature regarding the content, implementation and uptake of CRC screening interventions as well as opportunities and challenges for the implementation of CRC screening interventions in LMICs. Methods We systematically followed a five-step scoping review framework to identify and review relevant literature about CRC screening in LMICs, written in the English language before February 2020. We searched Medline, Embase, Web of Science and Google Scholar for studies targeting the general, asymptomatic, at-risk adult population. The TIDieR tool and an implementation checklist were used to extract data from empirical studies; and we extracted data-informed insights from policy reviews and commentaries. Results CRC screening interventions (n = 24 studies) were implemented in nine middle-income countries. Population-based screening programmes (n = 11) as well as small-scale screening interventions (n = 13) utilised various recruitment strategies. Interventions that recruited participants face-to-face (alone or in combination with other recruitment strategies) (10/15), opportunistic clinic-based screening interventions (5/6) and educational interventions combined with screening (3/4), seemed to be the strategies that consistently achieved an uptake of > 65% in LMICs. FOBT/FIT and colonoscopy uptake ranged between 14 and 100%. The most commonly reported implementation indicator was ‘uptake/reach’. There was an absence of detail regarding implementation indicators and there is a need to improve reporting practice in order to disseminate learning about how to implement programmes. Conclusion Opportunities and challenges for the implementation of CRC screening programmes were related to the reporting of CRC cases and screening, cost-effective screening methods, knowledge about CRC and screening, staff resources and training, infrastructure of the health care system, financial resources, public health campaigns, policy commitment from governments, patient navigation, planning of screening programmes and quality assurance.

Abstract Background Evidence for the health benefits of urban green space tends to stem from small, short-term quasi-experimental or cross-sectional observational research, whilst evidence from intervention studies is sparse. The development of an urban greenway (9 km running along 3 rivers) in Northern Ireland provided the opportunity to conduct a natural experiment. This study investigated the public health impact of the urban greenway on a range of physical activity, health, wellbeing, social, and perceptions of the environment outcomes. Methods A repeated cross-sectional household survey of adult residents (aged ≥16 years) who lived ≤1-mile radius of the greenway (intervention sample) and > 1-mile radius of the greenway (control sample) was conducted pre (2010/2011) and 6-months post implementation (2016/2017). We assessed changes in outcomes pre- and post-intervention follow-up including physical activity behaviour (primary outcome measure: Global Physical Activity Questionnaire), quality of life, mental wellbeing, social capital and perceptions of the built environment. Linear regression was used to calculate the mean difference between post-intervention and baseline measures adjusting for age, season, education, car ownership and deprivation. Multi-level models were fitted using a random intercept at the super output area (smallest geographical unit) to account for clustering within areas. The analyses were stratified by distance from the greenway and deprivation. We assessed change in the social patterning of outcomes over time using an ordered logit to make model-based outcome predictions across strata. Results The mean ages of intervention samples were 50.3 (SD 18.9) years at baseline (n = 1037) and 51.7 (SD 19.1) years at follow-up (n = 968). Post-intervention, 65% (adjusted OR 0.60, 95% CI 0.35 to 1.00) of residents who lived closest to the greenway (i.e., ≤400 m) and 60% (adjusted OR, 0.64 95% CI 0.41 to 0.99) who lived furthest from the greenway (i.e.,≥1200 m) met the physical activity guidelines - 68% of the intervention sample met the physical activity guidelines before the intervention. Residents in the most deprived quintiles had a similar reduction in physical activity behaviour as residents in less deprived quintiles. Quality of life at follow-up compared to baseline declined and this decline was significantly less than in the control area (adjusted differences in mean EQ5D: -11.0 (95% CI − 14.5 to − 7.4); − 30.5 (95% CI − 37.9 to − 23.2). Significant change in mental wellbeing was not observed despite improvements in some indicators of social capital. Positive perceptions of the local environment in relation to its attractiveness, traffic and safety increased. Conclusions Our findings illustrate the major challenge of evaluating complex urban interventions and the difficulty of capturing and measuring the network of potential variables that influence or hinder meaningful outcomes. The results indicate at this stage no intervention effect for improvements in population-level physical activity behaviour or mental wellbeing. However, they show some modest improvements for secondary outcomes including positive perceptions of the environment and social capital constructs. The public health impact of urban greenways may take a longer period of time to be realised and there is a need to improve evaluation methodology that captures the complex systems nature of urban regeneration.

Introduction Colorectal cancer (CRC) is the second most common cancer in Malaysia and cases are often detected late. Improving screening uptake is key in down-staging cancer and improving patient outcomes. The aim of this study is to develop, implement and evaluate an intervention to improve CRC screening uptake in Malaysia in the context of the COVID-19 pandemic. The evaluation will include ascertaining the budgetary impact of implementing and delivering the intervention.Methods and analysis The implementation research logic model guided the development of the study and implementation outcome measures were informed by the 'Reach, Effectiveness, Adoption, Implementation and Maintenance' (RE-AIM) framework. This CRC screening intervention for Malaysia uses home-testing and digital, small media, communication to improve CRC screening uptake. A sample of 780 people aged 50–75 years living in Segamat district, Malaysia, will be selected randomly from the South East Asia Community Observatory (SEACO) database. Participants will receive a screening pack as well as a WhatsApp video of a local doctor to undertake a stool test safely and to send a photo of the test result to a confidential mobile number. SEACO staff will inform participants of their result. Quantitative data about follow-up clinic attendance, subsequent hospital tests and outcomes will be collected. Logistic regression will be used to investigate variables that influence screening completion and we will conduct a budget impact-analysis of the intervention and its implementation. Qualitative data about intervention implementation from the perspective of participants and stakeholders will be analysed thematically.Ethics and dissemination Ethics approval has been granted by Monash University Human Research Ethics Committee (MUHREC ID: 29107) and the Medical Review and Ethics Committee (Reference: 21-02045-O7G(2)). Results will be disseminated through publications, conferences and community engagement activities.Trial registration number National Medical Research Register Malaysia: 21-02045-O7G(2).

BackgroundCancer screening provision in resource-constrained settings tends to be opportunistic, and uptake tends to be low, leading to delayed presentation and treatment and poor survival. ObjectiveThe aim of this study was to identify, review, map, and summarize findings from different types of literature reviews on the use of mobile health (mHealth) technologies to improve the uptake of cancer screening. MethodsThe review methodology was guided by the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Ovid MEDLINE, PyscINFO, and Embase were searched from inception to May 2021. The eligible criteria included reviews that focused on studies of interventions that used mobile phone devices to promote and deliver cancer screening and described the effectiveness or implementation of mHealth intervention outcomes. Key data fields such as study aims, types of cancer, mHealth formats, and outcomes were extracted, and the data were analyzed to address the objective of the review. ResultsOur initial search identified 1981 titles, of which 12 (0.61%) reviews met the inclusion criteria (systematic reviews: n=6, 50%; scoping reviews: n=4, 33%; rapid reviews: n=1, 8%; narrative reviews: n=1, 8%). Most (57/67, 85%) of the interventions targeted breast and cervical cancer awareness and screening uptake. The most commonly used mHealth technologies for increasing cancer screening uptake were SMS text messages and telephone calls. Overall, mHealth interventions increased knowledge about screening and had high acceptance among participants. The likelihood of achieving improved uptake-related outcomes increased when interventions used >1 mode of communication (telephone reminders, physical invitation letters, and educational pamphlets) together with mHealth. ConclusionsmHealth interventions increase cancer screening uptake, although multiple modes used in combination seem to be more effective.

A project designed to examine, for the first time, the health records of adult prisoners in Northern Ireland and their linkage to other available health data: the test case of prisoner post-release mortality risk Objectives The linkage of routinely collected administrative data for research purposes has the potential to improve knowledge and public benefit. We describe a novel data linkage study between the Northern Ireland (NI) Healthcare in Prisons and Business Services Organisation (BSO). This work is undertaken within the Administrative Data Research Centre-NI (ADRC-NI). Approach This joint project between ADRC-NI Queen’s University Belfast and NI Healthcare in Prisons (South Eastern Health and Social Care Trust) will test linkage of prisoner health records to health data held in the BSO and the potential to generate a population-based cohort for a retrospective analysis of prisoner health (2012-2021) that will attempt to characterise prisoners according to socio-demographic, health and committal factors, compare post-release mortality rates with a reference group from the NI population using indirect standardisation and estimate post-release mortality risk using Cox proportional hazards models. Results Using novel data-linkages, a dataset will be created to examine the health of prisoners (and former prisoners) in NI. Ethics and governance approvals are in place for this data-linkage. The linkage will be undertaken via the Honest Broker Service (HBS) in NI and the dataset will be accessed in the safe setting at the BSO. The processes involved, experiences including significant delays or difficulties, and recommendations for future data-linkage studies will be discussed. In addition, a key deliverable of this project will be an assessment of access and linkage capabilities of the prisoner health data, with metadata created and made available to future researchers. In addition, we plan to present preliminary results relating to the test research question. Conclusion We will describe the processes involved and first-hand research experience in the development of a novel data-linkage project, in addition we will detail access and linkage capabilities in relation to this new dataset to examine health in prisoners (and former prisoners) in NI.

Objectives Substance use disorders are common in prisoners before they are admitted to prison. Epidemiological studies have demonstrated an increased risk of death following release from prison. The aim of this scoping review is to identify, map and summarise evidence from record linkage studies about drug-related deaths among former adult prisoners. Approach We followed the framework for conducting scoping reviews by Arksey and O’Malley, and guidance by the Joanna Briggs Institute. MEDLINE, EMBASE, PsychINFO and Web of Science were searched for studies from January 2011 to September 2021 using keywords and index headings relating to ‘mortality’, ‘drugs’ and ‘ex-prisoner’. Two authors independently screened titles and abstracts for eligibility using pre-defined inclusion criteria. Full publication screening for inclusion was performed independently by two authors. Two authors tested the charting form and are independently extracting information from the eligible publications using this form. There were no geographical restrictions but non-English language papers were excluded. Results Following the removal of duplicates, 3680 publications were screened using title and abstract. Full text publications were subsequently screened for eligibility. A total of 48 publications have been included in this review. Publications may be added from a search of reference lists. Two authors are performing data extraction and data will be presented and analysed in relation to answering the following scoping review questions: • What is the scope of the literature on record linkage studies of drug-related deaths among former adult prisoners who have been released to the community? • How is research conducted on this topic? • What methodologies are used? • What are the findings in relation to mortality? • Where are the knowledge gaps on this topic? Conclusion This review will help identify and profile at risk former prisoners, contribute to potential interventions, and inform future research and policy. Where possible, evidence will be reported about the time period to death after prison release and the specific drugs related to mortality.

Abstract Background It has been posited that physical activity (PA) has the potential to improve health outcomes and the health-related quality of life of people living with or beyond cancer. Despite the well-documented health benefits of PA, there is a low level of PA among cancer patients. A systematic scoping review was conducted to investigate attitudes, perceptions, preferences and barriers vs. facilitators to cancer patients’ PA participation. Methods A systematic search was performed across four automated databases (PubMed, Embase, PsycINFO and Medline) in keeping with the PRISMA guideline. All cancer types were included, and any age/gender groups were eligible. Both qualitative and quantitative studies were included. The Health Belief Model provided a conceptual framework for the conduct of the scoping review as well as guiding thinking to inform evidence-based interventions. Results Ninety-eight articles were included in this review. Nearly half of the studies focused on mixed cancer sites; breast cancer was the most commonly examined cancer type (19%). Post-treatment was the most commonly investigated stage (33%), followed by studies of mixed stages of the cancer trajectory (27%), the acute treatment stage (23%) and pre-treatment stage (1%). Patient treatment stage was not reported in 16% of studies. Cancer patients reported positive attitudes to PA and recognized its benefits for health and wellbeing. Cancer-related side effects (e.g. fatigue) were a leading physiological barrier to PA participation, whereas effective symptom management techniques/tools acted as a powerful facilitator. Psychosocial barriers included low motivation and kinesiophobia, and perceived health benefits and social support/guidance by healthcare providers were significant facilitators. Inaccessible fitness facilities hindered cancer patients’ PA engagement though the availability of tailored amenities appeared to be a strong facilitator. PA preferences varied in terms of type, place, time, company and source of information and pointed to the need for individualized PA programs. Conclusions There is a need for further research to identify barriers and facilitators to PA that are faced by patients with particular cancer types. Recommended PA promoting-strategies involve including exercise science professionals in healthcare teams and ensuring that fitness facilities are accessible.

Abstract Background There is a need for novel interventions to target inadequate levels of adolescent physical activity behavior. Previous research indicates that better understanding of the processes by which social networks influence physical activity behavior in adolescents may be useful to enhance intervention design. Methods This study used a multi-methods approach to aid our understanding about the role of social networks for adolescent physical activity behavior. The quantitative phase of data collection was analyzed using a three-step linear regression model using cross-sectional data from the WiSe study (n = 529 participants, 48.6% female, mean age 14.38 years (SD 0.32)). A demographically reflective sub-sample of schools were invited to take part in the qualitative phase, which involved focus group discussions. Thematic analysis was used to explore findings from the quantitative phase in greater depth, and identify other themes pertaining to the association between social networks and physical activity behavior. Results Males’ physical activity behavior was predicted by their friend group (0.46, p = 0.007) whereas females’ physical activity was predicted by their best friend (0.21, p = 0.03). The three main findings that were uncovered by the regression analysis were explored during the qualitative phase: 1) friends have similar physical activity behaviors; 2) friendship social networks may influence differently early adolescent male and female physical activity behavior; 3) popularity and sociability were not associated with physical activity behavior. Two additional themes emerged from the analysis of focus group data: 4) social norms and 5) external factors that may impact the relationship between adolescent physical activity behavior and social networks. Conclusions The investigation of the interplay between the findings from each phase of the inquiry indicated that social networks influence in different ways and to different degrees the physical activity of adolescent males and females. In turn, these insights point to the need for a systematic tailoring process for the development and implementation of physical activity behavior interventions.

Abstract Background There is uncertainty about the effectiveness of clinical breast examination (CBE) and conflicting recommendations regarding its usefulness as a screening tool for breast cancer. This paper provides an overview of systematic reviews that assessed the effectiveness of CBE as a ‘stand-alone’ screening modality for breast cancer compared to no screening and focused on its value in low- and middle-income countries (LMICs). Methods We searched MEDLINE, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews for systematic reviews reporting the effectiveness of CBE published prior to October 29, 2019. The main outcomes assessed were mortality and down staging. The AMSTAR 2 checklist was used to assess the methodological quality of the reviews including risk of bias. Results Eleven systematic reviews published between 1993 and 2019 were identified. There was no direct evidence that CBE reduced breast cancer mortality. Indirect evidence suggested that a well-performed CBE achieved the same effect as mammography regarding mortality despite its apparently lower sensitivity (40–69% for CBE vs 77–95% for mammography). Greater sensitivity was recorded among younger and Asian women. Moreover, CBE contributed between 17 and 47% of the shift from advanced to early stage cancer. Conclusions CBE merits attention from health system and service planners in LMICs where a national screening programme based on mammography would be prohibitively expensive. In particular, it is likely that considerable value would be gained from conducting implementation scientific research in countries with large numbers of Asian women and/or where younger women are at higher risk. Registration PROSPERO, registration number CRD42019126798 .

Abstract Background A series of policy changes in 2011 altered reimbursement arrangements and guidance on use of erythropoiesis-stimulating agents for end-stage renal disease (ESRD) patients with anaemia in the US. While the policy changes were principally directed at care delivered in an outpatient setting, these had the potential to affect inpatient care also. This study used HCUP-NIS data (2008–2016) to examine trends in recorded anaemia among ESRD hospitalizations and analyse disparities in inpatient outcomes among ethnic groups following policy changes. Methods The International Classification of Diseases codes were used to identify ESRD admissions, recorded anaemia due to chronic kidney disease (CKD), and to generate an age-adjusted Deyo-Charlson comorbidity index. Linear splines with a knot placed at the time point of policy changes and multivariable logistic regression were used to examine the likelihood of recorded anaemia, adjusted for a range of socio-demographic and clinical covariates. Difference-in-difference analyses investigated the impact of policies on recorded anaemia. Other outcomes included hospital cost, mortality and place of discharge. Results The percentage of inpatient episodes with recorded anaemia arising from CKD increased from 26.2% in 2008 to 50.0% in 2016. Anaemia was more likely to be recorded as a complication of ESRD among minority ethnic groups and Native American admissions, in particular, (OR 1.20, 95%CI 1.15–1.25) relative to White American admissions; and these disparities widened following changes to reimbursement. Minorities were less likely to die in hospital and to be discharged to another healthcare facility, and (with the exception of Black American admissions) they were more expensive to treat. Conclusions Our findings provide evidence of an increase in recorded anaemia consistent with a shift of patients from outpatient to inpatient settings in the wake of changes to reimbursement enacted in 2011. In addition, the study highlights the existence of ethnic disparities that widened after the policy initiated reimbursement changes.

Background: The important role of primary care in promoting healthy lifestyle behaviours needs informed support. Aim: To elicit views on a 39-item shared decision-making (SDM) aid (SHARE-D) for lifestyle change and refine it to improve implementation. Design & setting: Mixed-methods study. Method: Health professionals, patients, and support workers, with experience of managing or a history of cardio- or cerebrovascular disease, were purposively recruited based on age, sex, and urban/rural location (n = 34). Participants completed a survey, rating the importance of including each item in a decision-aid, designed for use by patients with health professionals, and suggesting modifications. Semi-structured interviews (n = 30/34) were conducted and analysed thematically. Results: Substantial agreement was observed on rating item inclusion. Based on survey and interview data, 9/39 items were removed; 13 were amended. Qualitative themes were: 1) core content of the decision-aid; 2) barriers to use; 3) motivation for lifestyle change; and 4) primary care implementation. ‘Self-reflective’ questions and goal setting were viewed as essential components. The paper-based format, length, clarity, and time required were barriers to its use. Optional support considered within the aid was seen as important to motivate change. A digital version, integrated into patient record systems was regarded as critical to implementation. A revised 30-item aid was considered suitable for facilitating brief conversations and promoting patient autonomy. Conclusion: The SHARE-D decision aid for healthy lifestyle change appears to have good content validity and acceptability. Survey and interview data provided in-depth information to support implementation of a refined version. Further studies should examine its effectiveness.

BackgroundColorectal cancer (CRC) incidence in Malaysia is increasing, and most CRC patients are diagnosed at a late stage. This study investigated participant awareness of CRC and their perceptions and views about CRC screening, barriers, benefits, and facilitators towards CRC screening participation as well as health-seeking behaviour and the use of preventative health services.MethodEleven focus group discussions (FGDs) were conducted with a purposive sample of 89 participants aged > 50 from the major ethnic groups in the Segamat District, Johor State. FGDs were audiotaped, transcribed verbatim, and translated into English. Data were analysed using thematic analysis.ResultsWe identified trust in doctors as a key reason for whether or not to seek health care. Generally, the participants had low awareness of CRC sign/symptoms and screening. Emotional and logistic concerns about sending a stool sample to a clinic emerged as the main barriers to screening. Simplified illustrated instructions about stool collection in Malay, Chinese and Tamil, free screening at health clinics and reminders to complete the iFOBT test were perceived to facilitate engagement in screening, and posited as strategies that were likely to increase iFOBT uptake.ConclusionPrimary care physicians play a crucial role in terms of reducing patient's misperceptions, recommending screening to patients, enhancing attendance, and improving uptake of CRC screening. There is a need for further research to investigate ways in which to reduce identified barriers and implement and test potential facilitative strategies as well as examine adherence by doctors to clinical guidelines about CRC screening.

IntroductionBreast cancer patients in low- and middle-income countries often present at an advanced stage. This qualitative study elicited views regarding the challenges and opportunities for breast cancer screening and early detection among women in a low-income semi-rural community in Segamat district, Malaysia.MethodsIndividual semi-structured interviews with 22 people (health professionals, cancer survivors, community volunteers and member from a non-governmental organization) and four focus group discussions (n = 22 participants) with women from a local community were conducted. All participants were purposively sampled and female residents registered with the South East Asia Community Observatory aged ≥40 years were eligible to participate in the focus group discussions. Data were transcribed verbatim and analyzed using thematic analysis.ResultsThe thematic analysis illuminated barriers, challenges and opportunities across six domains: (i) personal experiences and barriers to help-seeking as well as financial and travel access barriers; (ii) primary care challenges (related to delivering clinical breast examination and teaching breast-self-examination); (iii) secondary care challenges (related to mammogram services); (iv) disconnection between secondary and primary care breast cancer screening pathways; and (v) opportunities to improve breast cancer early detection relating to community civil service society activities (i.e. awareness raising, support groups, addressing stigma/embarrassment and encouraging husbands to support women) and vi) links between public healthcare personnel and community (i.e. improving breast self-examination education, clinical breast examination provision and subsidised mammograms).ConclusionThe results point to a variety of reasons for low uptake and, therefore, to the complex nature of improving breast cancer screening and early detection. There is a need to adopt a systems approach to address this complexity and to take account of the socio-cultural context of communities in order, in turn, to strengthen cancer control policy and practices in Malaysia.

BackgroundThis study examined current breast cancer (BC) screening practices among Vietnamese women and the factors associated with the uptake of clinical breast examination (CBE).MethodsA total of 508 women aged 30-74 years in Hanoi completed a knowledge-attitude-practice (KAP) survey in 2019 including validated measures of breast cancer awareness (Breast-CAM) and health beliefs (Champion's Health Belief Model Scale). Descriptive statistics, χ2, and ANOVA tests were used to analyse KAP responses across groups with different sociodemographic characteristics. A logistic regression model assessed the associations of knowledge, beliefs, and sociodemographic characteristics with CBE uptake.ResultsOnly 18% of respondents were aware of BC signs, risk factors, and screening modalities although 63% had previously received BC screening. CBE was the most common screening modality with an uptake of 51%. A significantly higher proportion of urban residents compared with rural residents (32% vs 18%, Chi-square test, p = 0.04) received mammography. Unlike mammography, CBE uptake was not associated with sociodemographic characteristics (i.e., residence area/education level/occupation/household monthly income/possession of health insurance). CBE uptake was associated with BC knowledge (OR = 2.44, 95%CI: 1.37-4.32), perceived susceptibility to BC (OR = 1.15, 95%CI: 1.05-1.25), and perceived barriers to accessing CBE (OR = 0.88, 95%CI: 0.84-0.92).ConclusionThe study points to the need for public health education and promotion interventions to address low levels of awareness about BC and to increase uptake of BC screening in Vietnam in advance of screening programme planning and implementation. It also suggests that screening programmes using CBE are promising given current engagement and the absence of socio-demographic disparities.

Abstract Background Obesity and diabetes are related conditions, the prevalence of which has increased globally in recent years. These conditions have been linked to hypertension and vitamin D deficiency though the nature of the relationship remains unclear and is likely to vary between identifiable groups and specific contexts. The aim of this paper is to examine the relationships between obesity, type 2 diabetes, hypertension and vitamin D, among Saudis citizens aged 15 and over. Methods Self-reported and measured data were taken from the 2013 Saudi Health Interview Survey and analysed using a series of seemingly unrelated bivariate probit regression (SURBVP) analyses. Sensitivity analyses were undertaken in which the selection and specification of covariates and outcomes were varied. Results In the main analysis data on 957 women and 1127 men were analysed. Differences were evident between men and women in the prevalence of type 2 diabetes, obesity, central obesity, hypertension and vitamin D deficiency. While men were more likely to experience diabetes and hypertension, women were more likely to experience obesity, central obesity and vitamin D deficiency. In multivariable analyses obesity and age were found to significantly predict hypertension risk in women; central obesity to predict diabetes risk in men and women, as well as hypertension risk in men. Vitamin D was not found to predict diabetes risk nor hypertension risk in either sex. Milk consumption and sun exposure were found to predict vitamin D deficiency in women but not men. While there was evidence of unobserved heterogeneity in models predicting diabetes and hypertension, there was no evidence of unobserved heterogeneity between these and those predicting vitamin D deficiency. Results did not materially change over a range of sensitivity analyses. Conclusion While there is strong evidence of distinct patterns in the relationship between diabetes, hypertension and obesity among men and women in Saudi Arabia and in the risk of vitamin D deficiency, we found no evidence of a relationship between vitamin D levels and risk of either diabetes or hypertension.

Abstract Background Cancer incidence in Malaysia is expected to double by 2040. Understanding cancer awareness is important in order to tailor preventative efforts and reduce the cancer burden. The objective of this research was to assess nationwide awareness about the signs and symptoms as well as risk factors for various cancers in Malaysia and identify socio-demographic factors associated with awareness. Methods This cross-sectional study was conducted from March–November 2014 in the form of a telephone survey. Participants aged 40 years and above were randomly selected across Malaysia and interviewed using the validated Awareness Beliefs about Cancer (ABC) measurement tool. Linear regression was conducted to test the association between symptom and risk factor recognition and socio-demographic variables. Results A sample of 1895 participants completed the survey. On average, participants recognised 5.8 (SD 3.2) out of 11 symptoms and 7.5 (SD 2.7) out of 12 risk factors. The most commonly recognised symptom was ‘lump or swelling’ (74.5%) and the most commonly recognised risk factor was ‘smoking’ (88.7%). Factors associated with prompted awareness were age, ethnicity, education and smoking status. Conclusion Recognition of symptom and risk factors for most cancers was relatively low across Malaysia compared to previous studies in high-income countries and to studies conducted in Malaysia. There is a need to conduct regular public health campaigns and interventions designed to improve cancer awareness and knowledge as a first step towards increasing the early detection of cancer.

Abstract Background Colorectal cancer (CRC) cases are detected late in Malaysia similar to most Asian countries. The Be Cancer Alert Campaign (BCAC) was a culturally adapted mass media campaign designed to improve CRC awareness and reduce late detection in Malaysia. The evaluation of the BCAC-CRC aimed to assess campaign reach, campaign impact and health service use. Methods Participants aged ≥40 years (n = 730) from randomly selected households in Selangor State Malaysia, completed interview-based assessments. Campaign reach was assessed in terms of responses to an adapted questionnaire that was used in evaluations in other countries. The impact of the campaign was assessed in terms of awareness, confidence to detect symptoms and self-efficacy to discuss symptoms with a doctor as captured by the Cancer Awareness Measure (CAM). CAM was administered before-and-after campaign implementation and responses by BCAC recognisers (i.e. participants who recognised one or more of the BCAC television, radio or print advertisements when prompted) and non-recognisers (i.e. participants who did not recognise any of the BCAC advertisements) were compared analytically. Logistic regression analysed comparative differences in cancer awareness by socio-demographic characteristics and recognition of the BCAC materials. Results Over 65% of participants (n = 484) recognised the BCAC-CRC. Campaign-recognisers were significantly more likely to be aware of each CRC symptom at follow-up and were more confident about noticing symptoms (46.9% vs 34.9%, p = 0.018) compared to non-recognisers. There was no difference between groups in terms of self-efficacy to see a doctor about symptoms. Improved symptoms awareness at follow-up was lower for Indians compared to Malays (adjusted odds ratio (OR) 0.53, 95% Confidence Interval (CI): 0.34, 0.83, p = 0.005). Health service use data did not indicate an increase in screening activity during or immediately after the campaign months. Conclusion Overall, the findings of the evaluation indicated that the culturally adapted, evidence-based mass media intervention improved CRC symptom awareness among the Malaysian population; and that impact is more likely when a campaign operates a differentiated approach that matches modes of communication to the ethnic and social diversity in a population.

Abstract Background Loneliness and social isolation are growing public health concerns in our ageing society. Whilst these experiences occur across the life span, 50% of individuals aged over 60 are at risk of social isolation and one-third will experience some degree of loneliness later in life. The aim of this scoping review was to describe the range of interventions to reduce loneliness and social isolation among older adults that have been evaluated; in terms of intervention conceptualisation, categorisation, and components. Methods Three electronic databases (CINAHL, Embase and Medline) were systematically searched for relevant published reviews of interventions for loneliness and social isolation. Inclusion criteria were: review of any type, published in English, a target population of older people and reported data on the categorisation of loneliness and/or social isolation interventions. Data extracted included: categories of interventions and the reasoning underpinning this categorisation. The methodology framework proposed by Arskey and O’Malley and further developed by Levac, et al. was used to guide the scoping review process. Results A total of 33 reviews met the inclusion criteria, evaluating a range of interventions targeted at older people residing in the community or institutionalised settings. Authors of reviews included in this paper often used the same terms to categorise different intervention components and many did not provide a clear definition of these terms. There were inconsistent meanings attributed to intervention characteristics. Overall, interventions were commonly categorised on the basis of: 1) group or one-to-one delivery mode, 2) the goal of the intervention, and 3) the intervention type. Several authors replicated the categorisation system used in previous reviews. Conclusion Many interventions have been developed to combat loneliness and social isolation among older people. The individuality of the experience of loneliness and isolation may cause difficulty in the delivery of standardised interventions. There is no one-size-fits-all approach to addressing loneliness or social isolation, and hence the need to tailor interventions to suit the needs of individuals, specific groups or the degree of loneliness experienced. Therefore, future research should be aimed at discerning what intervention works for whom, in what particular context and how.

Abstract Purpose There is a recent and growing migrant population in Northern Ireland. However, rigorous research is absent regarding access to mental health care by different migrant groups. In order to address this knowledge gap, this study aimed to identify the relative use of psychotropic medication between the largest first generation migrant groups in Northern Ireland and the majority population. Methods Census (2011) data was linked to psychotropic prescriptions for the entire enumerated population of Northern Ireland using data linkage methodology through the Administrative Data Research Centre Northern Ireland (ADRC-NI). Results Lower prescription dispensation for all psychotropic medication types, particularly antidepressants (OR = 0.35, CI 95% 0.33–0.36) and anxiolytics (OR = 0.42, CI 95% 0.40–0.44), was observed for all migrant groups with the exception of migrants from Germany. Conclusions It is likely that the results reflect poorer access to services and indicate a need to improve access and the match between resources, services and the health and social care needs of migrants. Further research is required to identify barriers to accessing primary care and mental health services.

Objective Secondary prevention is recommended to reduce cardiovascular risk after transient ischaemic attack (TIA) or ‘minor’ stroke. Mobile health interventions can provide accessible, cost-effective approaches to address modifiable risk factors, such as physical inactivity, hypertension and being overweight. The objective of this study was to evaluate the quality of apps for supporting lifestyle change following a TIA or ‘minor’ stroke. Methods Systematic searches of Google Play and the Apple Store were carried out to identify mobile apps released between 1 November 2019 and 1 October 2021. Keywords were used including stroke, TIA, lifestyle, prevention and recovery. Quality was assessed using the Mobile Application Rating Scale (MARS). Common components were identified with the Behaviour Change Technique (BCT) Taxonomy. Descriptive statistics were used to summarize the performance results for each app. Results Searches identified 2545 potential apps. Thirty remained after removing duplicates and screening titles and descriptions. Six were eligible after full review of their content. All apps included at least one BCT (range: 1–16 BCTs). The most frequent BCTs included ‘information about health consequences’ ( n = 5/6), ‘verbal or visual communication from a credible source’ ( n = 4/6) and ‘action planning’ ( n = 4/6). The mean MARS score was 2.57/5 (SD: 0.51; range: 1.78–3.36). No apps were of ‘good’ overall quality (scoring more than 4/5). Conclusions This is the first review of mobile health interventions for this population. Only a small number of apps were available. None were targeted specifically at people with a TIA or ‘minor’ stroke. Overall quality was low. Further work is needed to develop and test accessible, user designed, and evidence-informed digital interventions in this population.

BackgroundMental ill-health presents a major public health problem. A potential part solution that is receiving increasing attention is computer-delivered psychological therapy, particularly during the COVID-19 pandemic as health care systems moved to remote service delivery. However, computerized cognitive behavioral therapy (cCBT) requires active engagement by service users, and low adherence may minimize treatment effectiveness. Therefore, it is important to investigate the acceptability of cCBT to understand implementation issues and maximize potential benefits. ObjectiveThis study aimed to produce a critical appraisal of published reviews about the acceptability of cCBT for adults. MethodsAn umbrella review informed by the Joanna Briggs Institute (JBI) methodology identified systematic reviews about the acceptability of cCBT for common adult mental disorders. Acceptability was operationalized in terms of uptake of, dropping out from, or completion of cCBT treatment; factors that facilitated or impeded adherence; and reports about user, carer, and health care professional experience and satisfaction with cCBT. Databases were searched using search terms informed by relevant published research. Review selection and quality appraisal were guided by the JBI methodology and the AMSTAR tool and undertaken independently by 2 reviewers. ResultsThe systematic searches of databases identified 234 titles, and 9 reviews (covering 151 unique studies) met the criteria. Most studies were comprised of service users with depression, anxiety, or specifically, panic disorder or phobia. Operationalization of acceptability varied across reviews, thereby making it difficult to synthesize results. There was a similar number of guided and unguided cCBT programs; 34% of guided and 36% of unguided users dropped out; and guidance included email, telephone, face-to-face, and discussion forum support. Guided cCBT was completed in full by 8%-74% of the participants, while 94% completed one module and 67%-84% completed some modules. Unguided cCBT was completed in full by 16%-66% of participants, while 95% completed one module and 54%-93% completed some modules. Guided cCBT appeared to be associated with adherence (sustained via telephone). A preference for face-to-face CBT compared to cCBT (particularly for users who reported feeling isolated), internet or computerized delivery problems, negative perceptions about cCBT, low motivation, too busy or not having enough time, and personal circumstances were stated as reasons for dropping out. Yet, some users favored the anonymous nature of cCBT, and the capacity to undertake cCBT in one’s own time was deemed beneficial but also led to avoidance of cCBT. There was inconclusive evidence for an association between sociodemographic variables, mental health status, and cCBT adherence or dropping out. Users tended to be satisfied with cCBT, reported improvements in mental health, and recommended cCBT. Overall, the results indicated that service users’ preferences were important considerations regarding the use of cCBT. ConclusionsThe review indicated that “one size did not fit all” regarding the acceptability of cCBT and that individual tailoring of cCBT is required in order to increase population reach, uptake, and adherence and therefore, deliver treatment benefits and improve mental health.

Rationale Clinical trials are the gold standard for testing interventions. COVID-19 has further raised their public profile and emphasised the need to deliver better, faster, more efficient trials for patient benefit. Considerable overlap exists between data required for trials and data already collected routinely in electronic healthcare records (EHRs). Opportunities exist to use these in innovative ways to decrease duplication of effort and speed trial recruitment, conduct and follow-up.Approach The National Institute of Health Research (NIHR), Health Data Research UK and Clinical Practice Research Datalink co-organised a national workshop to accelerate the agenda for ‘data-enabled clinical trials’. Showcasing successful examples and imagining future possibilities, the plenary talks, panel discussions, group discussions and case studies covered: design/feasibility; recruitment; conduct/follow-up; collecting benefits/harms; and analysis/interpretation.Reflection Some notable studies have successfully accessed and used EHR to identify potential recruits, support randomised trials, deliver interventions and supplement/replace trial-specific follow-up. Some outcome measures are already reliably collected; others, like safety, need detailed work to meet regulatory reporting requirements. There is a clear need for system interoperability and a ‘route map’ to identify and access the necessary datasets. Researchers running regulatory-facing trials must carefully consider how data quality and integrity would be assessed. An experience-sharing forum could stimulate wider adoption of EHR-based methods in trial design and execution.Discussion EHR offer opportunities to better plan clinical trials, assess patients and capture data more efficiently, reducing research waste and increasing focus on each trial’s specific challenges. The short-term emphasis should be on facilitating patient recruitment and for postmarketing authorisation trials where research-relevant outcome measures are readily collectable. Sharing of case studies is encouraged. The workshop directly informed NIHR’s funding call for ambitious data-enabled trials at scale. There is the opportunity for the UK to build upon existing data science capabilities to identify, recruit and monitor patients in trials at scale.

Abstract Background Empowerment for people with dementia (PWD) is not well defined within the research literature and we feel that this is an important area for development. It is important to seek, consult, and co-produce such a definition with PWD who are more actively involved in their communities post diagnosis (e.g. no longer the ‘long goodbye’). This study seeks to combine academic literature review methods with participatory/co-production methods in order to address this gap. We feel this approach also adds to developing methodologies in the field of co-production and user involvement. Methods We use a unique approach toward a definition of empowerment for PWD. Phase 1 - A scoping review of medical/health, social care and social policy-based databases to identify any previous literature that may have defined empowerment exclusively for PWD. Based on this literature, we collected a list of terms relating to empowerment for PWD. Phase 2 – Using empowerment key terms set on cards formulated from Phase 1 across three co-production workshops, academic team members, and nine members of Dementia NI (an organisation founded and led by people with dementia) we reviewed the findings of this search and co-produced an agreed definition they felt best described empowerment for them. Results Phase 1 and 2 led to a definition of empowerment relevant to PWD. This shared understanding of empowerment was defined by PWD as ‘A confidence building process whereby PWD are respected, have a voice and are heard, are involved in making decisions about their lives and have the opportunity to create change through access to appropriate resources’. Conclusions The strength of this research lies in addressing the current confusion and arbitrariness of empowerment within the context of dementia. This coproduced work also provides evidence for not only the possibility, but also the added value of involving PWD in research in terms of unique insights afforded by their lived experiences.

PURPOSE: The main objective of this systematic review was to identify whether mass and small media interventions improve knowledge and attitudes about cancer, cancer screening rates, and early detection of cancer in Asia. METHODS: The review was conducted according to a predefined protocol. Medline, EMBASE, CINAHL, Web of Science, Cochrane Library, and Google Scholar were searched in September 2017, and data extraction and rating of methodologic study quality (according to Joanna Briggs Institute rating procedures) were performed independently by reviewers. RESULTS: Twenty-two studies (reported across 24 papers) met the inclusion criteria. Most studies (n = 21) were conducted in high or upper-middle income countries; targeted breast (n = 11), cervical (n = 7), colorectal (n = 3), or oral (n = 2) cancer; and used small media either alone (n = 15) or in combination with mass media and other components (n = 5). Studies regarding cancer screening uptake were of medium to high quality and mainly reported positive outcomes for cervical cancer and mixed results for breast and colorectal cancer. The methodologic strength of research that investigated change in cancer-related knowledge and the cost effectiveness of interventions, respectively, were weak and inconclusive. CONCLUSION: Evidence indicated that small media campaigns seemed to be effective in terms of increasing screening uptake in Asia, in particular cervical cancer screening. Because of the limited number of studies in Asia, it was not possible to be certain about the effectiveness of mass media in improving screening uptake and the effectiveness of campaigns in improving cancer-related knowledge.

Abstract Background Insufficient physical activity (PA) is a major public health issue. Whilst PA is an important contributor to disease prevention, engagement in PA decreases with age, particularly among women in socio-economically disadvantaged areas. Research using existing support networks to engage ‘hard to reach’ populations in PA interventions is sparse. We developed and tested the feasibility of a PA-promoting intervention for older women within existing community groups in socio-economically disadvantaged areas. Methods The Medical Research Council guidelines for complex interventions were used to guide the intervention’s development. We recruited participants (n = 40) from older (aged ≥50 years) women’s groups from four different community centres. A 12-week programme was delivered during existing sessions, informed by Social Practice Theory. The sessions provided education about PA, social support in the form of a PA ‘buddy’, group discussion and follow-up telephone calls, as well as printed information about local opportunities to participate in PA. The main uncertainties tested were rates of participant recruitment, retention, and completion of assessments of PA by accelerometry and of mental health using the Hospital Anxiety and Depression Scale (HADS). Intervention acceptability was assessed by questionnaire, and focus group interviews elicited participants’ views about the intervention. Qualitative data were subjected to framework analysis. Results The recruitment rate was high; 87% (n = 40/46) of women consented to participate, and 78% (n = 31) attended all education sessions. Uptake of follow-up telephone calls and PA ‘buddies’ was low. Few participants provided valid accelerometer data, but 63% (n=25) completed the HADS questionnaire at all time points. The printed materials and education sessions were viewed positively; telephone calls and ‘buddy’ support were not valued. Participants believed that organised group activities would lead to increased PA engagement, and whilst participants disliked wearing a waist accelerometer, they thought that regular PA feedback would facilitate necessary goal-setting. Conclusions High recruitment and retention rates suggest that use of existing social support groups is an acceptable and attractive method of delivering a PA intervention to this population. A randomised controlled trial of the intervention appears feasible, but its design requires refinement of the social support component, facilitation of goal-setting and reconsideration of the assessment of PA. Trial registration ClinicalTrials.gov, NCT02880449. Registered on 26 August 2016.