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SummaryAsset-based approaches are becoming more common within public health interventions; however, due to variations in terminology, it can be difficult to identify asset-based approaches. The study aimed to develop and test a framework that could distinguish between asset-based and deficit-based community studies, whilst acknowledging there is a continuum of approaches. Literature about asset-based and deficit-based approaches were reviewed and a framework was developed based on the Theory of Change model. A scoring system was developed for each of the five elements in the framework based on this model. Measurement of community engagement was built in, and a way of capturing how much the study involved an asset approach. The framework was tested on 13 studies examining community-based interventions to investigate whether it could characterize asset-based versus deficit-based studies. The framework demonstrated how much the principles underpinning asset-based approaches were present and distinguished between studies where the approach was deficit-based to those that had some elements of an asset-based approach. This framework is useful for researchers and policymakers when determining how much of an intervention is asset-based and identifying which elements of asset-based approaches lead to an intervention working.

Purpose Effective cost performance is a crucial criterion measuring successful project management in public-housing projects. This paper aims to analyse the vital underlying factors surrounding the successful cost management process (CMP) outcomes in public housing projects (PHPs). Design/methodology/approach The research was conducted in three stages. The first stage consisted of a detailed literature review to document success factors affecting cost performances and management. In stage two, brainstorming sessions were undertaken with construction experts knowledgeable in cost management practices and have been involved in PHPs. These sessions were used to refine those success factors for the PHPs settings and define their criticality with respect to the CMP stages using interpretive ranking process. In stage three, focus group sessions were performed to validate the interrelationships of the contextualised critical success factors. Findings The top three most critical factors for successful implementation and outcomes at all CMP stages in PHPs settings were found to relate to competencies, team qualities and collaborative practices of the project team. Early contractor involvement and effective construction planning and management also emerged relevant to the process. Practical implications Government project departments, project managers and construction organisations (consultants and contractors) need to commit and mandate continuous development of cost management competencies for all professionals engaged in PHPs. Channels supporting team integration and collaborative practices between design and construction teams are required to increase the likelihood of successful project cost management practice and outcomes in PHPs. Originality/value The research has developed a factor-process relationship model that can be used to improve and evaluate the efficacy of CMP implementation in PHP settings.

Acellular dermal matrix (ADM) is an increasingly popular alloplastic cadaveric dermis used to enhance postmastectomy reconstruction. Acellular dermal matrix can be used as a nipple-shaped cylinder in central pillar nipple reconstruction to help maintain long-term projection. We report a unique presentation of ADM mimicking a retroareolar mass after central pillar neonipple reconstruction. A 49-year-old woman with a history of invasive ductal carcinoma underwent delayed nipple reconstruction after lumpectomy and oncoplastic closure using an inframammary V-Y advancement flap.The nipple reconstruction was performed using pretattoo and articulated tab flaps. A rolled tube of acellular dermal matrix was placed in the central aspect of the neonipple reconstruction for projection. At 4 months postoperative, a screening mammogram and ultrasound noted a new retroareolar mass classified as BIRADS 4 necessitating a breast biopsy. Biopsy revealed portions of fibrous connective tissue consistent with partially incorporated acellular dermal matrix allograft. There was no evidence of malignancy. To mitigate the risk of future radiographic or clinical misinterpretation of ADM in nipple reconstruction, the placement of radiopaque markers such as microclips on the ADM implant could be a useful adjunct. Radiologists and surgeons should include ADM artifact in their differential diagnosis of radiologic imaging when evaluating a new mass in the proximity of prior ADM placement in neonipple reconstruction of the breast.

Nicotine replacement therapy, in the form of nicotine patches, is commonly offered to pregnant women who smoke to help them to stop smoking, but this approach has limited efficacy in this population. Electronic cigarettes (e-cigarettes) are also used by pregnant women who smoke but their safety and efficacy in pregnancy are unknown. Here, we report the results of a randomized controlled trial in 1,140 participants comparing refillable e-cigarettes with nicotine patches. Pregnant women who smoked were randomized to e-cigarettes (n = 569) or nicotine patches (n = 571). In the unadjusted analysis of the primary outcome, validated prolonged quit rates at the end of pregnancy in the two study arms were not significantly different (6.8% versus 4.4% in the e-cigarette and patch arms, respectively; relative risk (RR) = 1.55, 95%CI: 0.95–2.53, P = 0.08). However, some participants in the nicotine patch group also used e-cigarettes during the study. In a pre-specified sensitivity analysis excluding abstinent participants who used non-allocated products, e-cigarettes were more effective than patches (6.8% versus 3.6%; RR = 1.93, 95%CI: 1.14–3.26, P = 0.02). Safety outcomes included adverse events and maternal and birth outcomes. The safety profile was found to be similar for both study products, however, low birthweight (P = 0.01). Other adverse events and birth outcomes were similar in the two study arms. E-cigarettes might help women who are pregnant to stop smoking, and their safety for use in pregnancy is similar to that of nicotine patches. ISRCTN62025374.

Background Short stature, defined as height for age more than 2 standard deviations (SDs) below the population median, is an important indicator of child health. Short stature (often termed stunting) has been widely researched in low- and middle-income countries (LMICs), but less is known about the extent and burden in high-income settings. We aimed to map the prevalence of short stature in children aged 4–5 years in England between 2006 and 2019. Methods and findings We used data from the National Child Measurement Programme (NCMP) for the school years 2006–2007 to 2018–2019. All children attending state-maintained primary schools in England are invited to participate in the NCMP, and heights from a total of 7,062,071 children aged 4–5 years were analysed. We assessed short stature, defined as a height-for-age standard deviation score (SDS) below −2 using the United Kingdom WHO references, by sex, index of multiple deprivation (IMD), ethnicity, and region. Geographic clustering of short stature was analysed using spatial analysis in SaTScan. The prevalence of short stature in England was 1.93% (95% confidence interval (CI) 1.92–1.94). Ethnicity adjusted spatial analyses showed geographic heterogeneity of short stature, with high prevalence clusters more likely in the North and Midlands, leading to 4-fold variation between local authorities (LAs) with highest and lowest prevalence of short stature. Short stature was linearly associated with IMD, with almost 2-fold higher prevalence in the most compared with least deprived decile (2.56% (2.53–2.59) vs. 1.38% (1.35–1.41)). There was ethnic heterogeneity: Short stature prevalence was lowest in Black children (0.64% (0.61–0.67)) and highest in Indian children (2.52% (2.45–2.60)) and children in other ethnic categories (2.57% (2.51–2.64)). Girls were more likely to have short stature than boys (2.09% (2.07–2.10) vs. 1.77% (1.76–1.78), respectively). Short stature prevalence declined over time, from 2.03% (2.01–2.05) in 2006–2010 to 1.82% (1.80–1.84) in 2016–2019. Short stature declined at all levels of area deprivation, with faster declines in more deprived areas, but disparities by IMD quintile were persistent. This study was conducted cross-sectionally at an area level, and, therefore, we cannot make any inferences about the individual causes of short stature. Conclusions In this study, we observed a clear social gradient and striking regional variation in short stature across England, including a North–South divide. These findings provide impetus for further investigation into potential socioeconomic influences on height and the factors underlying regional variation., Joanna Orr and coauthors investigate regional differences in short stature among children in England, between 2006-2019, using a cross-sectional analysis of the National Child Measurement Program data., Author summary Why was this study done? Short height for age can be a sign that there are underlying health conditions or adverse socioeconomic circumstances in young children. Research into children who have short stature in low- and middle-income countries (LMICs) has found numerous associations with poorer lifelong health and education outcomes. The prevalence and characteristics of children with short stature in England have not previously been investigated. What did the researchers do and find? We used data from 7,062,071 children aged 4 and 5 who were measured as part of the National Child Measurement Programme (NCMP) to calculate percentages of children with short stature by region, ethnicity, sex, and area deprivation. We used regional analyses to assess whether there were hotspots of short stature around the country. We found that 1.93% of children had short stature, and this was strongly related to area deprivation, with more deprived areas having higher rates of short stature. Short stature was also less likely in children who were Black African or Caribbean and more likely in Indian children or children whose ethnicity was coded as “Other.” There were various short stature hotspots in England, and most of these were concentrated in the North and Midlands of the country. What do these findings mean? Short stature is relatively uncommon in England. However, short stature is strongly related to area-level deprivation, with children in the most deprived areas nearly twice as likely to be short as children in the least deprived areas. Further investigation into why children in poorer areas are shorter is important.

Use of e-cigarettes (vaping) has potential to help pregnant women stop smoking. This study explored factors influencing adherence among participants in the vaping arm of the first trial of vaping for smoking cessation in pregnancy. We conducted semi-structured telephone interviews (n = 28) with women at three-months postpartum. Interviews were analysed using thematic analysis, informed by the Theoretical-Domains Framework, Necessity-Concerns Framework and Perceptions and Practicalities Approach. Interviewees generally reported high levels of vaping. We found that: (1) intervention adherence was driven by four necessity beliefs&mdash, stopping smoking for the baby, and vaping for harm reduction, smoking cessation or as a last resort, (2) necessity beliefs outweighed vaping concerns, such as dependence and safety, (3) adherence was linked to four practicalities themes, acting as barriers and facilitators to vaping&mdash, device and e-liquid perceptions, resources and support, whether vaping became habitual, and social and environmental factors, and (4) intentional non-adherence was rare, unintentional non-adherence was due to device failures, forgetting to vape, and personal circumstances and stress. Pregnant smokers provided with e-cigarettes, and with generally high levels of vaping, had positive beliefs about the necessity of vaping for smoking cessation which outweighed concerns about vaping. Non-adherence was mainly due to unintentional factors.

ObjectivesSmokers are more likely to quit if they use the National Health Service (NHS) Stop Smoking Service (SSS). However, community pharmacies experience low service uptake. The Smoking Treatment Optimisation in Pharmacies (STOP) programme aims to address this problem by enhancing staff training using a theory-based intervention. In this study, we evaluated intervention fidelity using simulated smokers (actors) to assess smoker engagement and enactment of key intervention components by STOP trained staff.DesignAn observational pilot study.SettingsFive community pharmacies in North East London with an NHS SSS.MethodsSix actors, representative of East London’s population, were recruited and trained to complete intervention fidelity assessments. Consenting pharmacy staff from five participating pharmacies received STOP Intervention training. Four weeks after the staff training, the actors visited the participating pharmacies posing as smokers eligible for smoking cessation support. Engagement behaviour by pharmacy staff and enactment of intervention components was assessed using a scoring tool derived from the STOP logic model (scoring range of 0–36), and contemporaneous field notes taken by actors.Results18 of 30 completed assessments were with STOP trained staff (10/18 were counter assistants). Mean score for smoker engagement was 24.4 (SD 9.0) points for trained and 16.9 (SD 7.8) for untrained staff, respectively. NHS SSS leaflets (27/30) were the most common smoking cessation materials seen on pharmacy visits. Most trained counter staff engaged with smokers using leaflets and a few proactively offered appointments with their cessation advisors. Appropriate use of body language was reported on 26/30 occasions alongside the use of key phrases from the STOP training session (n=8). Very few pharmacy staff wore STOP promotional badges (4/30).ConclusionsSTOP training may change client engagement behaviour in pharmacy staff and could improve the uptake of the NHS SSS. A cluster randomised controlled trial is currently in progress to evaluate its effectiveness and cost-effectiveness.Trial registration numberISRCTN16351033.

Background and aims Covid-19 is a global pandemic that requires a global and integrated response of all national medical and healthcare systems. Covid-19 exposed the need for timely response and data sharing on fast spreading global pandemics. In this study, we investigate the scientific research response from the early stages of the pandemic, and we review key findings on how the early warning systems developed in previous epidemics responded to contain the virus. Methods We conducted data mining of scientific literature records from the Web of Science Core Collection, using the topics Covid-19, mortality, immunity, and vaccine. The individual records are analysed in isolation, and the analysis is compared with records on all Covid-19 research topics combined. The data records are analysed with commutable statistical methods, including R Studio, Bibliometrix package, and the Web of Science data mining tool. Results From historical analysis of scientific data records on viruses, pandemics and mortality, we identified that Chinese universities have not been leading on these topics historically. However, during the early stages of the Covid-19 pandemic, the Chinese universities are strongly dominating the research on these topics. Despite the current political and trade disputes, we found strong collaboration in Covid-19 research between the US and China. From the analysis on Covid-19 and immunity, we wanted to identify the relationship between different risk factors discussed in the news media. We identified few different clusters, containing references to exercise, inflammation, smoking, obesity and many additional factors. From the analysis on Covid-19 and vaccine, we discovered that although the USA is leading in volume of scientific research on Covid-19 vaccine, the leading 3 research institutions (Fudan, Melbourne, Oxford) are not based in the USA. Hence, it is difficult to predict which country would be first to produce a Covid-19 vaccine. Conclusions We analysed the conceptual structure maps with factorial analysis and multiple correspondence analysis (MCA), and identified multiple relationships between keywords, synonyms and concepts, related to Covid-19 mortality, immunity, and vaccine development. We present integrated and corelated knowledge from 276 records on Covid-19 and mortality, 71 records on Covid-19 and immunity, and 189 records on Covid-19 vaccine., Highlights • We analysed scientific research records on Covid-19 with computable statistical methods. • We present visualisations of interrelationships between scientific research data records on Covid-19. • We compare the coverage of research on Covid 19 mortality, immunity, and vaccine development by organisations and countries. • Despite political disagreements, countries (US and China) are still collaborating in Covid-19 research.

Background: Smoking is one of the greatest threats to public health worldwide. We integrated phenome-wide association study (PheWAS) and Mendelian randomization (MR) approaches to explore causal effects of genetically predicted smoking intensity across the human disease spectrum. Methods: We conducted PheWAS case-control analyses in 152,483 ever smokers of White-British ancestry, aged 39–73 years. Disease diagnoses were based on hospital inpatient and mortality registrations. Smoking intensity was instrumented by four genetic variants, and disease risks estimated for one cigarette per day heavier intakes. Associations passing the FDR threshold (p

BACKGROUND: Although there is clear evidence of genetic contributions to susceptibility to nicotine addiction, it has proved difficult to identify causal alleles and pathways from studies in humans. Mutagenesis in model species generates strong phenotypes not present in wildtype populations and can be used to identify biological mechanisms underlying quantifiable behaviours. We tested the hypothesis that a forward genetic screen for nicotine preference in zebrafish can predict loci and biological mechanisms influencing human smoking behaviour. METHODS: A population-based forward genetic screen of ethylnitrosurea- mutagenized zebrafish was used to identify lines of fish showing altered nicotine preference. Immunohistochemical, behavioral and quantitative PCR analyses were used to characterize mutant larvae. Focussed SNP analysis of the homologous human locus in cohorts from the UK and a Finnish Twin study assessed the predictive validity of the zebrafish data for human smoking behavior. RESULTS: We show nicotine preference is heritable in fish as in humans and identify loss-of-function mutations in the zebrafish Slit3 gene as associated with increased nicotine preference. Slit3 mutant larval fish showed altered sensitivity of habituation to acoustic startle to dopaminergic antagonists and increased Drd2 and Drd3 mRNA expression. Dopaminergic neuronal pathfinding was unaffected. Analysis of the SLIT3 locus in two independent human cohorts identified 2 genetic markers that predict level of cigarette consumption and likelihood of cessation. CONCLUSION: These findings suggest a role for SLIT3 signaling in development of dopaminergic pathways affecting behaviours associated with nicotine dependence and confirm the translational relevance of the zebrafish model in exploring complex human behaviors.

IntroductionAssessing the fidelity of complex behavioural interventions and examining the contextual reasons why such interventions succeed, or fail are important activities but challenging and rarely reported. The Smoking Treatment Optimisation in Pharmacies (STOP) trial is a cluster randomised trial evaluating the effectiveness of a complex intervention to optimise the National Health Service (NHS) Stop Smoking Service delivered in community pharmacies. This complex intervention comprises a training package for pharmacy staff involving motivational interviewing and communication skills aimed at increasing smoking cessation knowledge and proactive client engagement. We report on a process evaluation which was planned alongside the trial to offer findings that will assist in the interpretation of the main trial results and help inform potential implementation in community pharmacy settings on a wider scale.Methods and analysisQuantitative data on recruitment and retention process of pharmacies, pharmacy staff and service users has been collected during the trial along with data on dose and fidelity of the intervention delivery from participating intervention arm pharmacies to identify potential implementation issues. Simulated client data on behaviour change skills and display of intervention materials from both control and intervention pharmacies is being assessed. These data will be combined with qualitative data; including adviser-smoker consultation recordings that provide a snapshot of behaviour skills delivery by stop smoking advisers and semi-structured interviews with pharmacy staff and services users from the intervention arm.DiscussionPublished protocols for process evaluations of complex health interventions are still rare despite increasing funding for this work to facilitate understanding of trial outcomes from an implementation perspective. This mixed methods protocol will contribute to the developing literature around the conduct of process evaluation and the value they add to health services research.Trial registration numberISRCTN16351033.Strengths and limitations of this studyA planned mixed methods process evaluation that draws together data from different sources to help explain the trial results and establish the feasibility of scaling this complex intervention up in community pharmacy settings.A strength is the use of a previously tested mystery shopping method to assess fidelity of skills performance at the pharmacy counterThe process evaluation relies on willing pharmacy staff and service users involved in the trial to collect some of the data, which may introduce bias.This paper also provides a detailed example of how to use the MRC framework for process evaluation of complex interventions to design an extensive process evaluation within trial settings.

Objectives Review, compare and critically assess digital technology responses to the COVID-19 pandemic around the world. The specific point of interest in this research is on predictive, preventive and personalized interoperable digital healthcare solutions. This point is supported by failures from the past, where the separate design of digital health solutions has led to lack of interoperability. Hence, this review paper investigates the integration of predictive, preventive and personalized interoperable digital healthcare systems. The second point of interest is the use of new mass surveillance technologies to feed personal data from health professionals to governments, without any comprehensive studies that determine if such new technologies and data policies would address the pandemic crisis. Method This is a review paper. Two approaches were used: A comprehensive bibliographic review with R statistical methods of the COVID-19 pandemic in PubMed literature and Web of Science Core Collection, supported with Google Scholar search. In addition, a case study review of emerging new approaches in different regions, using medical literature, academic literature, news articles and other reliable data sources. Results Most countries’ digital responses involve big data analytics, integration of national health insurance databases, tracing travel history from individual’s location databases, code scanning and individual’s online reporting. Public responses of mistrust about privacy data misuse differ across countries, depending on the chosen public communication strategy. We propose predictive, preventive and personalized solutions for pandemic management, based on social machines and connected devices. Solutions The proposed predictive, preventive and personalized solutions are based on the integration of IoT data, wearable device data, mobile apps data and individual data inputs from registered users, operating as a social machine with strong security and privacy protocols. We present solutions that would enable much greater speed in future responses. These solutions are enabled by the social aspect of human-computer interactions (social machines) and the increased connectivity of humans and devices (Internet of Things). Conclusion Inadequate data for risk assessment on speed and urgency of COVID-19, combined with increased globalization of human society, led to the rapid spread of COVID-19. Despite an abundance of digital methods that could be used in slowing or stopping COVID-19 and future pandemics, the world remains unprepared, and lessons have not been learned from previous cases of pandemics. We present a summary of predictive, preventive and personalized digital methods that could be deployed fast to help with the COVID-19 and future pandemics.

In this article, we conduct data mining to discover the countries, universities and companies, produced or collaborated the most research on Covid-19 since the pandemic started. We present some interesting findings, but despite analysing all available records on COVID-19 from the Web of Science Core Collection, we failed to reach any significant conclusions on how the world responded to the COVID-19 pandemic. Therefore, we increased our analysis to include all available data records on pandemics and epidemics from 1900 to 2020. We discover some interesting results on countries, universities and companies, that produced collaborated most the most in research on pandemic and epidemics. Then we compared the results with the analysing on COVID-19 data records. This has created some interesting findings that are explained and graphically visualised in the article.

SNP in the vitamin D receptor (VDR) gene is associated with risk of lower respiratory infections. The influence of genetic variation in the vitamin D pathway resulting in susceptibility to upper respiratory infections (URI) has not been investigated. We evaluated the influence of thirty-three SNP in eleven vitamin D pathway genes (DBP, DHCR7, RXRA, CYP2R1, CYP27B1, CYP24A1, CYP3A4, CYP27A1, LRP2, CUBN and VDR) resulting in URI risk in 725 adults in London, UK, using an additive model with adjustment for potential confounders and correction for multiple comparisons. Significant associations in this cohort were investigated in a validation cohort of 737 children in Manchester, UK. In all, three SNP in VDR (rs4334089, rs11568820 and rs7970314) and one SNP in CYP3A4 (rs2740574) were associated with risk of URI in the discovery cohort after adjusting for potential confounders and correcting for multiple comparisons (adjusted incidence rate ratio per additional minor allele ≥1·15, Pfor trend ≤0·030). This association was replicated for rs4334089 in the validation cohort (Pfor trend=0·048) but not for rs11568820, rs7970314 or rs2740574. Carriage of the minor allele of the rs4334089 SNP in VDR was associated with increased susceptibility to URI in children and adult cohorts in the United Kingdom.

A survey of amidation reagents demonstrating DIC-HOPO, DMT-MM, COMU-collidine, TPTU-NMI, EEDQ, CDI and EDC-Oxyma to be effective for the coupling of carboxylic acids with amines in the presence of water and the absence of problematic dipolar aprotic solvents is reported. DMT-MM was shown to provide the best yields for the coupling of a secondary amine, TPTU-NMI and COMU-collidine for aniline, whilst the combination of DIC with HOPO afforded the broadest substrate scope and the highest yields for a sterically demanding carboxylic acid.

We explored the potential of asthma apps to support self-management and identified preferred features that enable users to live with asthma. We recruited patients from five UK practices and social media; observed their usage of our app, administered a questionnaire and interviewed a purposive sample of patients and professionals to explore preferred features. Thematic analysis of interview was synthesised with quantitative data. A total of 111 patients used our app for 3 months. We interviewed 15 patients and 16 professionals. Participants were interested in a broad range of self-management support strategies, including action plans, monitoring with feedback, allergy/weather warnings and tailor-made running coaching. Professionals wanted to integrate patients’ logs with practice records, though were concerned about data overload and risk of patient dependency. We propose a paradigm shift - from apps developed to provide features that are easy to implement technologically, to an approach in which apps are designed to deliver theoretically grounded preferred components.

Background NHS community pharmacies provide effective smoking cessation services; however, there is scope for increasing throughput and improving quit rates. This trial examines whether the Smoking Treatment Optimisation in Pharmacies (STOP) intervention can improve smoker engagement to increase service throughput, retention and quitting. Methods This study is a pragmatic, cluster randomised controlled trial in 60 pharmacies in England and Wales. All workers in intervention pharmacies are offered STOP training while control pharmacies provide usual care. The STOP intervention, based on behavioural and organisational theories, comprises educational sessions for staff and environmental prompts in the pharmacy. Intervention fidelity is assessed by actors visiting pharmacies posing as smokers. The primary outcome is throughput, defined as the number of smokers who join the programme, set a firm quit date and undergo at least one stop smoking treatment session, and is measured using routinely collected data. Secondary outcomes include retention and quit rates at 4 weeks and continuous abstinence at 6 months verified by salivary cotinine. Cost-effectiveness is estimated using quality-adjusted life years and the probability that the intervention is effective at different levels of willingness to pay is calculated. Discussion The trial will generate evidence to inform the public health smoking cessation strategy in England and Wales, and may help to shape service commissioning decisions. The STOP intervention model may help inform the undertaking of a range of health behaviour change tasks in community pharmacies. Trial registration ClinicalTrials.gov, ISRCTN16351033. Retrospectively registered on 21 March 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3368-6) contains supplementary material, which is available to authorized users.

Background The prevalence of viral hepatitis (hepatitis B virus and hepatitis C virus) in migrants is higher than among the general population in many high-income countries. We aimed to determine whether incentivising and supporting primary-care physicians in areas with a high density of migrants increases the numbers of adult migrants screened for viral hepatitis. Methods HepFREE was a multicentre, open, cluster-randomised controlled trial in general practices in areas of the UK with a high density of migrants (Bradford, Yorkshire, and northeast and southeast London). Participants were adult patients (aged 18 years or older) in primary care, who had been identified as a first or second generation migrant from a high-risk country. General practices were randomly assigned (1:2:2:2:2) to an opportunistic screening (control) group or to one of four targeted screening (interventional) groups: standard (ie, hospital-based) care and a standard invitation letter; standard care and an enhanced invitation letter; community care and a standard invitation letter; or community care and an enhanced invitation letter. In control screening, general practitioners (GPs) were given a teaching session on viral hepatitis and were asked to test all registered migrants. In the intervention, GPs were paid a nominal sum for setting up searches of records, reimbursed for signed consent forms, and supported by a dedicated clinician. Patients who were eligible for testing and tested positive for viral hepatitis in the intervention groups were eligible to enrol in a second embedded trial of community versus hospital based care. The primary outcomes were the proportion of patients eligible for screening, the proportion of those eligible who were sent an invitation letter in the intervention groups, the uptake of viral hepatitis screening (in the intention-to-treat population), the proportion of patients who tested positive for viral hepatitis, the proportion who complied with treatment, and the cost-effectiveness of the intervention. This trial is registered with ISRCTN, number ISRCTN54828633. Findings Recruitment and testing ran from Oct 31, 2013, to Feb 4, 2017, and each practice recruited for 18 consecutive calendar months. We approached 70 general practices in three areas with a high density of migrants, of which 63 general practices agreed to participate. Five practices withdrew and 58 practices were randomly assigned: eight to control and 50 to an intervention. In control practices, 26 046 (38·4%) of 67 820 patients who were initially registered were eligible for testing, as were 152 321 (43·3%) of 351 710 patients in the interventional groups in London and Bradford. Of 51 773 randomly selected eligible patients in the intervention groups in London and Bradford, letters were sent to 43 585 (84·2%) patients. In the eight control general practices, screening was taken up by 543 (1·7%) of 31 738 eligible participants, which included 5692 newly registered patients. However, in the 50 general practices that used the intervention, screening was taken up by 11 386 (19·5%) of 58 512 eligible participants (including 6739 newly registered patients; incidence rate ratio 3·70, 95% CI 1·30–10·51; p=0·014) and this intervention was cost-effective. 720 (4·5%) of 15 844 patients who received a standard letter versus 1032 (3·7%) of 28 095 patients who received the enhanced letter were tested (0·70, 0·38–1·31; p=0·26). In the control group, 17 patients tested positive for viral hepatitis, as did 220 patients (one with a co-infection) in the intervention groups. In the embedded study, 220 patients were randomly assigned to either hospital-based care or community care; 80 (87·9%) of 91 patients in the hospital setting complied with treatment versus 105 (81·4%) of 129 patients in the community setting. The intervention was cost-effective at willingness to pay thresholds in excess of £8540. One serious adverse event (thyroiditis) was noted. Interpretation Screening migrants for viral hepatitis in primary care is effective if doctors are incentivised and supported. Community care is expensive and there is no evidence that this offers benefits in this setting or that bespoke invitation letters add value. We suggest that bespoke invitation letters should not be used, and we suggest that outreach, community-based services for migrants should not be developed.

Chain Event Graphs (CEGs) are recent probabilistic graphical modelling tools that have proved successful in modelling scenarios with context-specific independencies. Although the theory underlying CEGs supports appropriate representation of structural zeroes, the literature so far does not provide an adaptation of the vanilla CEG methods for a real-world application presenting structural zeroes also known as the non-stratified CEG class. To illustrate these methods, we present a non-stratified CEG representing a public health intervention designed to reduce the risk and rate of falling in the elderly. We then compare the CEG model to the more conventional Bayesian Network model when applied to this setting.

BackgroundApps can potentially support asthma self-management; however, attracting downloads and encouraging on-going adherence are challenging.ObjectivesWe observed the impact of different recruitment strategies and app features on adoption and continued use.MethodsPractice nurses in five practices in Lothian/Oxford approached adults with active asthma to try out a prototype app. We also advertised the app via social media (Asthma UK; AUK Centre for Applied Research). We observed patients’ download and retention rates and sent pre- and post-trial questionnaires. We sampled 15 patients for interviews before and after using our app for 1 month to explore motivations, triggers and barriers to adoption and usage. Interviews were transcribed and analysed thematically with reference to the Fogg behaviour model.ResultsSocial media attracted 87 users, but only 15 (17%) used the app for 30 days. Practices recruited 24 patients, 13 (54%) continued for 30 days. Successful adoption was dependent on ease of downloading and sufficient motivation. Some patients needed technological assistance with downloading the app and starting to use the features. Adherence was dependent on motivation derived from a sense that the healthcare professional and/or researcher was interested in the results, and that using an app to support their self-management could improve their asthma control.ConclusionSocial media attracted more downloads in a short time. However, most patients stopped using the app within a month. Practices attracted fewer downloads, but patents adhered longer to the app. Dual promotion strategies (social media with practice support) may be the optimal approach to encourage adoption and adherence to telehealth.

BackgroundLow emission zones (LEZ) are an increasingly common, but unevaluated, intervention aimed at improving urban air quality and public health. We investigated the impact of London's LEZ on air quality and children's respiratory health.MethodsWe did a sequential annual cross-sectional study of 2164 children aged 8–9 years attending primary schools between 2009–10 and 2013–14 in central London, UK, following the introduction of London's LEZ in February, 2008. We examined the association between modelled pollutant exposures of nitrogen oxides (including nitrogen dioxide [NO2]) and particulate matter with a diameter of less than 2·5 μm (PM2·5) and less than 10 μm (PM10) and lung function: postbronchodilator forced expiratory volume in 1 s (FEV1, primary outcome), forced vital capacity (FVC), and respiratory or allergic symptoms. We assigned annual exposures by each child's home and school address, as well as spatially resolved estimates for the 3 h (0600–0900 h), 24 h, and 7 days before each child's assessment, to isolate long-term from short-term effects.FindingsThe percentage of children living at addresses exceeding the EU limit value for annual NO2 (40 μg/m3) fell from 99% (444/450) in 2009 to 34% (150/441) in 2013. Over this period, we identified a reduction in NO2 at both roadside (median −1·35 μg/m3 per year; 95% CI −2·09 to −0·61; p=0·0004) and background locations (−0·97; −1·56 to −0·38; p=0·0013), but not for PM10. The effect on PM2·5 was equivocal. We found no association between postbronchodilator FEV1 and annual residential pollutant attributions. By contrast, FVC was inversely correlated with annual NO2 (−0·0023 L/μg per m3; −0·0044 to −0·0002; p=0·033) and PM10 (−0·0090 L/μg per m3; −0·0175 to −0·0005; p=0·038).InterpretationWithin London's LEZ, a smaller lung volume in children was associated with higher annual air pollutant exposures. We found no evidence of a reduction in the proportion of children with small lungs over this period, despite small improvements in air quality in highly polluted urban areas during the implementation of London's LEZ. Interventions that deliver larger reductions in emissions might yield improvements in children's health.FundingNational Institute for Health Research Biomedical Research Centre at Guy's and St Thomas' National Health Service (NHS) Foundation Trust and King's College London, NHS Hackney, Lee Him donation, and Felicity Wilde Charitable Trust.