Understanding how children and young people with chronic non-cancer pain and their families experience living with pain, pain management and services: a meta-ethnography.

Background: Childhood chronic pain is a widespread public health issue. We need to understand how children with chronic pain and their families experience chronic pain and its management. Objectives: To conduct a meta-ethnography on the experiences and perceptions of children with chronic pain and their families of chronic pain, treatments and services. We investigated how children and their families conceptualise and live with chronic pain; what they think of and want from health and social care services; and what they conceptualise as 'good' pain management. Design: Meta-ethnography with stakeholder and patient and public involvement in the design, search and sampling strategies, analysis and dissemination. Review strategy: comprehensive searches of 12 bibliographic databases and supplementary searches in September 2022, to identify qualitative studies with children aged 3 months to 18 years with chronic non-cancer pain and their families. We included studies with rich explanatory data; appraised methodological limitations using the Critical Appraisal Skills Programme tool; and extracted, analysed and synthesised studies' findings. We used Grading of Recommendations Assessment, Development and Evaluation-confidence in the evidence from reviews of qualitative research to assess confidence in review findings. We integrated findings with 14 Cochrane treatment effectiveness reviews on children's chronic non-cancer pain. Results: We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Studies had minor (n = 24) or moderate (n = 19) methodological limitations. Grading of Recommendations Assessment, Development and Evaluation-confidence in the evidence from reviews of qualitative research assessments of review findings were high (n = 22), moderate (n = 13) or very low confidence (n = 1). Moderate and severe chronic pain had profound adverse impacts on family members' well-being, autonomy and self-identity; family dynamics; parenting approaches; friendships and socialising; children's education and parental paid employment. Most children and families sought a biomedical cure for pain. They experienced difficulties seeking and receiving support from health services to manage pain and its impacts. Consequently, some families repeatedly visited health services. Cochrane reviews of intervention effects and trials did not measure some outcomes important to children and families, for example effects of pain on the family and resolution of pain. Reviews have mainly neglected a biopsychosocial approach when considering how interventions work. Limitations: There were limited data on common pain conditions like migraine/headache, abdominal pain; some rarer conditions; children with learning disabilities and under-fives; siblings; fathers and experiences of treatments/services. We excluded studies on cancer, end-of-life pain and experiences of healthcare professionals. Conclusions: We developed the family-centred theory of children's chronic pain management, integrating health and social care with community support. Future work: Future research should explore families' experiences of services and treatments, including opioids, and social care services; experiences of children with autism and learning disabilities, under 5 years old and with certain common pain conditions. We need development and testing of family-centred interventions and services. Study registration: This study is registered as PROSPERO (CRD42019161455) and Cochrane Pain, Palliative and Supportive Care (623). Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128671) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 17. See the NIHR Funding and Awards website for further award information.

Chronic pain lasting 3 months or more affects at least 8% of children in the UK. It causes difficulties with many aspects of children's lives including relationships, school attendance and use of National Health Services. In the UK, there are few specialist services and a lack of high-quality research for managing children's chronic pain. Our study aimed to locate and pull together existing research on the experiences and views of children with chronic pain and their families. We wanted to find out how they think about and live with chronic pain, and their views and experiences of services and treatments, and what they want to achieve from them. We conducted this study alongside children with chronic pain and their families, charities, healthcare professionals and academic experts. They helped us to conduct the study and to ensure our findings are relevant to children, families and the National Health Service. We pulled together data from 43 studies that best answered our questions. We found that moderate and severe children's chronic pain that was not well managed affected the whole family, including their relationships and social lives. Families found it difficult to get help and a diagnosis from health services. Most families wanted a medical cure for pain. Families had long waits for answers and treatment but gradually realised there may be no cure, so they focused on living well with pain or gave up hope. Children and families from ethnic minority groups or with a learning disability experienced discrimination. Few studies focused on children under 5 years old, children with learning disabilities or experiences of services. Families need a pain management approach tailored to the whole family's needs involving schools, social care and health services. Our findings could improve treatment guidelines, training of health and social care professionals and service design and treatments.

Reducing alcohol harms whilst minimising impact on hospitality businesses: 'Sweetspot' policy options.

BACKGROUND: During COVID-19, hospitality businesses (e.g. bars, restaurants) were closed/restricted whilst off-sales of alcohol increased, with health consequences. Post-covid, governments face lobbying to support such businesses, but many health services remain under pressure. We appraised 'sweetspot' policy options: those with potential to benefit public services and health, whilst avoiding or minimising negative impact on the hospitality sector. METHODS: We conducted rapid non-systematic evidence reviews using index papers, citation searches and team knowledge to summarise the literature relating to four possible 'sweetspot' policy areas: pricing interventions (9 systematic reviews (SR); 14 papers/reports); regulation of online sales (1 SR; 1 paper); place-shaping (2 SRs; 18 papers/reports); and violence reduction initiatives (9 SRs; 24 papers/reports); and led two expert workshops (n = 11). RESULTS: Interventions that raise the price of cheaper shop-bought alcohol appear promising as 'sweetspot' policies; any impact on hospitality is likely small and potentially positive. Restrictions on online sales such as speed or timing of delivery may reduce harm and diversion of consumption from on-trade to home settings. Place-shaping is not well-supported by evidence and experts were sceptical. Reduced late-night trading hours likely reduce violence; evidence of impact on hospitality is scant. Other violence reduction initiatives may modestly reduce harms whilst supporting hospitality, but require resources to deliver multiple measures simultaneously in partnership. CONCLUSIONS: Available evidence and expert views point to regulation of pricing and online sales as having greatest potential as 'sweetspot' alcohol policies, reducing alcohol harm whilst minimising negative impact on hospitality businesses.

A meta-ethnography of how children and young people with chronic non-cancer pain and their families experience and understand their condition, pain services, and treatments.

BACKGROUND: Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them. OBJECTIVES: 1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services? SEARCH METHODS: Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022. SELECTION CRITERIA: To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families. DATA COLLECTION AND ANALYSIS: We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain. MAIN RESULTS: We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work. AUTHORS' CONCLUSIONS: We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

Knowledge, Beliefs, and Behaviors Related to Secondhand Smoke and Smoking in the Home: A Qualitative Study With Men in Malaysia.

INTRODUCTION: Despite the health risks associated with secondhand smoke (SHS) exposure, smoking in the home is common in Malaysia, and almost exclusively a male behavior. AIMS AND METHODS: This study explored male smokers' knowledge, beliefs, and behaviors related to SHS exposure and smoking in the home, to guide future intervention development. Twenty-four men who smoked and lived in Klang Valley, Kuantan, or Kuala Terengganu took part in semi-structured interviews which explored knowledge and beliefs regarding SHS in the home, and associated home-smoking behaviors. Data were managed and analyzed using the framework approach. RESULTS: There was limited knowledge regarding the health risks associated with SHS: the smell of SHS in the home was a more prominent concern in most cases. Many had no rules in place restricting home smoking, and some suggested that smoking in specific rooms and/or near windows meant SHS was not "shared" with other household members. A few fathers had created but not maintained a smoke-free home prior to and/or after their children were born. Desire to smoke in the home conflicted with men's sense of responsibility as the head of the household to protect others and set a good example for their children. CONCLUSIONS: Men's home-smoking behaviors are shaped by a lack of understanding of the health risks associated with SHS exposure. Gaining a broader understanding of the factors that shape men's decisions to create a smoke-free home is important to facilitate the development of culturally appropriate interventions that address their responsibility to protect other household members from SHS exposure. IMPLICATIONS: Our findings highlight the need for public information campaigns in Malaysia to educate men who smoke regarding the health harms associated with SHS in the home and the ways in which SHS travels and lingers in household air. This is important given men's concerns about SHS often focus on the smell of cigarette smoke in the home. Our findings suggest a number of potential avenues for future intervention development, including household and community-level initiatives that could build on men's sense of responsibility as the head of the household and/or their general desire to protect their families.

Measuring secondhand smoke in homes in Malaysia: A feasibility study comparing indoor fine particulate (PM2.5) concentrations following an educational feedback intervention to create smoke-free homes during the COVID-19 pandemic.

INTRODUCTION: Extensive regulations have been introduced to reduce secondhand smoke (SHS) exposure among non-smokers in Malaysia. However, there is still a need to encourage behavior change of smokers in relation to making homes smoke-free. This feasibility study aimed to use low-cost air pollution monitors to quantify SHS concentrations in Malaysian households and to explore the practicality of using personalized feedback in educating families to make their homes smoke-free. METHODS: A total of 35 smokers in three states in Malaysia were recruited via snowball and convenience sampling methods. Indoor fine particulate (PM2.5) concentrations in participants' homes were measured for 7 days before and after educational intervention using a pre-defined template, which included personalized air-quality feedback, and information on SHS impacts were given. The feedback was delivered over two 20-minute phone calls or in-person sessions following the completion of the air-quality measurements. Data were corrected for outdoor PM2.5 concentrations from the nearest environmental monitor. RESULTS: Despite the challenges in conducting the project during COVID-19 pandemic, the delivery of the intervention was found to be feasible. Twenty-seven (77%) out of 35 participants completed PM2.5 measurements and received a complete intervention. The median (IQR: 25th -75th percentile concentrations) SHS-PM2.5 concentrations at baseline and follow-up were 18.3 µg/m3 (IQR: 13.3-28.3) and 16.2 µg/m3 (IQR: 10.4 - 25.6), respectively. There was a reduction of SHS-PM2.5 concentrations at follow-up measurement in the houses of 17 participants (63%). The change in corrected indoor PM2.5 concentrations between baseline and follow-up was not statistically significant (Z= -1.01, p=0.29). CONCLUSIONS: This educational intervention, combining the use of a low-cost air particle counter with personalized air-quality feedback, was found to be feasible in the Malaysian setting. It has potential to trigger behavior change among smokers, reducing indoor smoking and consequent SHS concentrations, and increasing smoke-free home implementation. A large-scale trial is needed.

Lockdown and licensed premises: COVID-19 lessons for alcohol policy.

INTRODUCTION: The COVID-19 pandemic necessitated unprecedented changes in alcohol availability, including closures, curfews and restrictions. We draw on new data from three UK studies exploring these issues to identify implications for premises licensing and wider policy. METHODS: (i) Semi-structured interviews (n = 17) with licensing stakeholders in Scotland and England reporting how COVID-19 has reshaped local licensing and alcohol-related harms; (ii) semi-structured interviews (n = 15) with ambulance clinicians reporting experiences with alcohol during the pandemic; and (iii) descriptive and time series analyses of alcohol-related ambulance callouts in Scotland before and during the first UK lockdown (1 January 2019 to 30 June 2020). RESULTS: COVID-19 restrictions (closures, curfews) affected on-trade premises only and licensing stakeholders highlighted the relaxation of some laws (e.g. on takeaway alcohol) and a rise in home drinking as having long-term risks for public health. Ambulance clinicians described a welcome break from pre-pandemic mass public intoxication and huge reductions in alcohol-related callouts at night-time. They also highlighted potential long-term risks of increased home drinking. The national lockdown was associated with an absolute fall of 2.14 percentage points [95% confidence interval (CI) -3.54, -0.74; P = 0.003] in alcohol-related callouts as a percentage of total callouts, followed by a daily increase of +0.03% (95% CI 0.010, 0.05; P = 0.004). DISCUSSION AND CONCLUSIONS: COVID-19 gave rise to both restrictions on premises and relaxations of licensing, with initial reductions in alcohol-related ambulance callouts, a rise in home drinking and diverse impacts on businesses. Policies which may protect on-trade businesses, while reshaping the night-time economy away from alcohol-related harms, could offer a 'win-win' for policymakers and health advocates.

Managing COVID-19 Transmission Risks in Bars: An Interview and Observation Study.

OBJECTIVE: Licensed premises face particular challenges to operating safely within COVID-19 restrictions. Following a U.K. national lockdown from March 20, 2020, we studied business practices and behaviors in licensed premises to inform COVID-19 policies. To our knowledge, no previous study worldwide has examined these issues. METHOD: Before premises reopened in Scotland, we conducted in-depth telephone interviews (May-June 2020) with participants from hospitality trade associations, licensed premises, or in related roles (n = 18). Interviews focused on anticipated business practices and challenges relevant to minimizing COVID-19 transmission. Following reopening (July-August 2020), we conducted observations of relevant practices and behaviors in 29 bars purposively sampled for diversity, using a structured schedule. Interviews and observation reports were analyzed thematically. RESULTS: Interviewees generally sought clarity, flexibility, and balance in government guidance on reopening, and they cited commercial and practical challenges to doing so safely. Alcohol consumption was perceived as an additional but potentially manageable challenge. Most observed premises had made physical and operational modifications; however, practices were variable. Observed incidents of concern included close physical interaction between customers and with staff, frequently featuring alcohol intoxication and rarely effectively stopped by staff. CONCLUSIONS: Despite the efforts of bar operators and guidance from government, potentially significant risks of COVID-19 transmission persisted in a substantial minority of observed bars, especially when customers were intoxicated.

A Qualitative Study of Factors Influencing Adherence among Pregnant Women Taking Part in a Trial of E-Cigarettes for Smoking Cessation.

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-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-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.

A cluster feasibility trial to explore the uptake and use of e-cigarettes versus usual care offered to smokers attending homeless centres in Great Britain.

Smoking rates in the UK are at an all-time low but this masks considerable inequalities; prevalence amongst adults who are homeless remains four times higher than the national average. The objective of this trial was to assess the feasibility of supplying free e-cigarette starter kits to smokers accessing homeless centres and to estimate parameters to inform a possible future larger trial. In this feasibility cluster trial, four homeless centres in Great Britain were non-randomly allocated to either a Usual Care (UC) or E-Cigarette (EC) arm. Smokers attending the centres were recruited by staff. UC arm participants (N = 32) received advice to quit and signposting to the local Stop Smoking Service. EC arm participants (N = 48) received an EC starter kit and 4-weeks supply of e-liquid. Outcome measures were recruitment and retention rates, use of ECs, smoking cessation/reduction and completion of measures required for economic evaluation. Eighty (mean age 43 years; 65% male) of the 153 eligible participants who were invited to participate, were successfully recruited (52%) within a five-month period, and 47 (59%) of these were retained at 24 weeks. The EC intervention was well received with minimal negative effects and very few unintended consequences (e.g. lost, theft, adding illicit substances). In both study arm, depression and anxiety scores declined over the duration of the study. Substance dependence scores remained constant. Assuming those with missing follow up data were smoking, CO validated sustained abstinence at 24 weeks was 3/48 (6.25%) and 0/32 (0%) respectively for the EC and UC arms. Almost all participants present at follow-up visits completed data collection for healthcare service and health-related quality of life measures. Providing an e-cigarette starter kit to smokers experiencing homelessness was associated with reasonable recruitment and retention rates and promising evidence of effectiveness and cost-effectiveness.

Implementing pelvic floor muscle training for women with pelvic organ prolapse: a realist evaluation of different delivery models.

BACKGROUND: Pelvic Floor Muscle Training (PFMT) has been shown to be effective for pelvic organ prolapse in women, but its implementation in routine practice is challenging due to lack of adequate specialist staff. It is important to know if PFMT can be delivered by different staff skill mixes, what barriers and facilitators operate in different contexts, what strategies enable successful implementation and what are the underlying mechanisms of their action. PROPEL intervention was designed to maximise the delivery of effective PFMT in the UK NHS using different staff skill mixes. We conducted a realist evaluation (RE) of this implementation to understand what works, for whom, in what circumstances and why. METHODS: Informed by the Realist and RE-AIM frameworks, the study used a longitudinal, qualitative, multiple case study design. The study took place in five, purposively selected, diverse NHS sites across the UK and proceeded in three phases to identify, test and refine a theory of change. Data collection took place at 4 time points over an 18 month implementation period using focus groups and semi-structured interviews with a range of stakeholders including service leads/managers, senior practitioners, newly trained staff and women receiving care in the new service models. Data were analysed using thematic framework approach adapted to identify Context, Mechanism and Outcome (CMO) configurations of the RE. RESULTS: A heightened awareness of the service need among staff and management was a mechanism for change, particularly in areas where there was a shortage of skilled staff. In contrast, the most established specialist physiotherapist-delivered PFMT service activated feelings of role protection and compromised quality, which restricted the reach of PFMT through alternative models. Staff with some level of prior knowledge in women's health and adequate organisational support were more comfortable and confident in new role. Implementation was seamless when PFMT delivery was incorporated in newly trained staff's role and core work. CONCLUSION: Roll-out of PFMT delivery through different staff skill mixes is possible when it is undertaken by clinicians with an interest in women's health, and carefully implemented ensuring adequate levels of training and ongoing support from specialists, multi-disciplinary teams and management.

Solid fuel users' perceptions of household solid fuel use in low- and middle-income countries: A scoping review.

Almost half of the global population is exposed to household air pollution (HAP) from the burning of biomass fuels primarily for cooking, and this has been linked with considerable mortality and morbidity. While alternative cooking technologies exist, sustained adoption of these is piecemeal, indicating that there is insufficient knowledge of understandings of HAP within target communities. To identify potential gaps in the literature, a scoping review was conducted focused on solid fuel users' perceptions of HAP and solid fuel use in low- and middle-income countries. From the initial 14,877 search returns, 56 were included for final analysis. An international multi-disciplinary workshop was convened to develop the research question; six key domains: health; family and community life; home, space, place and roles; cooking and cultural practices, environment; and policy and practice development, were also identified using a Social Ecological Model framework. The review showed a series of disconnects across the domains which highlighted the limited research on perceptions of HAP in the literature. Reviewed studies showed that participants emphasized short-term health impacts of HAP as opposed to longer-term health benefits of interventions and prioritized household security over improved ventilation. There was also a socio-demographic gendered disconnect as although women and children generally have most exposure to HAP, their decision-making power about use of solid fuels is often limited. In the domain of policy and practice, the review identified the importance of community norms and cultural traditions (including taste). Research in this domain, and within the environment domain is however limited and merits further attention. We suggest that interventions need to be locally situated and community-led and a deeper understanding of perceptions of HAP could be obtained using participatory and innovative research methods. Bridging the disconnects and gaps identified in this review is essential if the global disease burden associated with HAP is to be reduced.

Vaping for weight control: Findings from a qualitative study.

INTRODUCTION: Smokers have expressed concern about weight gain once they stop smoking and weight gain is a risk factor associated with smoking relapse. Nicotine in e-cigarettes, as well as vaping behaviour, may support smoking cessation by reducing weight gain. This study explored the factors that influence attitudes towards, and awareness of, e-cigarettes and weight control post smoking cessation. METHODS: Qualitative study involving focus groups with adults in the UK (n = 58) who were either exclusive vapers or dual users. RESULTS: There was limited awareness and/or inclination to vape to prevent weight gain after stopping smoking. Reasons for this centred on: the health gains of stopping smoking outweighing any potential weight gain; a lack of understanding of the appetite supressing effects of nicotine; a belief that vaping could not suppress appetite like a cigarette and could result in craving for certain flavours; concerns about the longer-term effects of e-cigarettes on health and the ethics of promoting vaping as way to support smoking cessation by limiting weight gain, especially for young women. CONCLUSION: Participants in this study do not appear inclined to use e-cigarettes to prevent weight gain after smoking cessation. There is a lack of understanding about why nicotine might help prevent weight gain and a concern that e-cigarette flavours could provoke cravings and that vaping may be unsafe in the long-term.

The smoking cessation in pregnancy incentives trial (CPIT): study protocol for a phase III randomised controlled trial.

BACKGROUND: Eighty per cent of UK women have at least one baby, making pregnancy an opportunity to help women stop smoking before their health is irreparably compromised. Smoking cessation during pregnancy helps protect infants from miscarriage, still birth, low birth weight, asthma, attention deficit disorder and adult cardiovascular disease. UK national guidelines highlight lack of evidence for effectiveness of financial incentives to help pregnant smokers quit. This includes a research recommendation: within a UK context, are incentives an acceptable, effective and cost-effective way to help pregnant women who smoke to quit? METHODS: The Cessation in Pregnancy Incentives Trial (CPIT) III is a pragmatic, 42-month, multi-centre, parallel-group, individually randomised controlled superiority trial of the effect on smoking status of adding to usual Stop Smoking Services (SSS) support, the offer of up to £400 of financial voucher incentives, compared with usual support alone, to quit smoking during pregnancy. Participants (n = 940) are pregnant smokers (age > 16 years, < 24 weeks pregnant, English speaking), who consent via telephone to take part and are willing to be followed-up in late pregnancy and 6 months after birth. The primary outcome is cotinine/anabasine-validated abstinence from smoking in late pregnancy. Secondary outcomes include engagement with SSS, quit rates at 4 weeks from agreed quit date and 6 months after birth, and birth weight. Outcomes will be analysed by intention to treat, and regression models will be used to compare treatment effects on outcomes. A meta-analysis will include data from the feasibility study in Glasgow. An economic evaluation will assess cost-effectiveness from a UK NHS perspective. Process evaluation using a case-study approach will identify opportunities to improve recruitment and learning for future implementation. Research questions include: what is the therapeutic efficacy of incentives; are incentives cost-effective; and what are the potential facilitators and barriers to implementing incentives in different parts of the UK? DISCUSSION: This phase III trial in Scotland, England and Northern Ireland follows a successful phase II trial in Glasgow, UK. The participating sites have diverse SSS that represent most cessation services in the UK and serve demographically varied populations. If found to be acceptable and cost-effective, this trial could demonstrate that financial incentives are effective and transferable to most UK SSS for pregnant women. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN15236311. Registered on 9 October 2017.

From Global Rights to Local Relationships: Exploring Disconnects in Respectful Maternity Care in Malawi.

Widespread reports of "disrespect and abuse" in maternity wards in low- and middle-income countries have triggered the development of rights-based respectful maternity care (RMC) standards and initiatives. To explore how international standards translate into local realities, we conducted a team ethnography, involving observations in labor wards in government facilities in central Malawi, and interviews and focus groups with midwives, women, and guardians. We identified a dual disconnect between, first, universal RMC principles and local notions of good care and, second, between midwives and women and guardians. The latter disconnect pertains to fraught relationships, reproduced by and manifested in mechanistic care, mutual responsibilization for trouble, and misunderstandings and distrust. RMC initiatives should be tailored to local contexts and midwife-client relationships. In a hierarchical, resource-strapped context like Malawi, promoting mutual love, understanding, and collaboration may be a more productive way to stimulate "respectful" care than the current emphasis on formal rights and respect.

Weighing the options for delivery care in rural Malawi: community perceptions of a policy promoting exclusive skilled birth attendance and banning traditional birth attendants.

To address its persistently high maternal mortality, the Malawi government has prioritized strategies promoting skilled birth attendance and institutional delivery. However, in a country where 80% of the population resides in rural areas, the barriers to institutional deliveries are considerable. As a response, Malawi issued Community Guidelines in 2007 that both promoted skilled birth attendance and banned the utilization of traditional birth attendants for routine deliveries. This grounded theory study used interviews and focus groups to explore community actors' perceptions regarding the implementation of this policy and the related affects that arose from its implementation. The results revealed the complexity of decision-making and delivery care-seeking behaviours in rural areas of Malawi in the context of this policy. Although women and other actors seemed to agree that institutional deliveries were safer when complications occurred, this did not necessarily ensure their compliance. Furthermore, implementation of the 2007 Community Policy aggravated some of the barriers women already faced. This innovative bottom-up analysis of policy implementation showed that the policy had further ruptured linkages between community and health facilities, which were ultimately detrimental to the continuum of care. This study helps fill an important gap in research concerning maternal health policy implementation in Low and middle income countries (LMICs), by focusing on the perceptions of those at the receiving end of policy change. It highlights the need for globally promoted policies and strategies to take better account of local realities.

Vaping for weight control: A cross-sectional population study in England.

INTRODUCTION: Concern about weight gain is a barrier to smoking cessation. E-cigarettes may help quitters to control their weight through continued exposure to the appetite-suppressant effects of nicotine and behavioural aspects of vaping. This study explored the views and practices of smokers, ex-smokers and current e-cigarette users relating to vaping and weight control. METHODS: Cross-sectional survey of past-year smokers (n = 1320), current smokers (n = 1240) and current e-cigarette users (n = 394) in England, conducted April-July 2018. Data were weighted to match the English population on key sociodemographic characteristics. RESULTS: Of e-cigarette users, 4.6% (95%CI 2.6-6.6) reported vaping for weight control, and 1.9% (95%CI 0.6-3.2) reported vaping to replace meals/snacks. It was rare for individuals who had smoked in the past year to have heard (8.8%, 95%CI 7.3-10.3) or believe (6.4%, 95%CI 5.1-7.7) that vaping could help control weight. Women (OR = 0.62, 95%CI 0.42-0.93) and older people (OR = 0.30, 95%CI 0.13-0.72) were less likely to have heard the claim and women were less likely to believe it (OR = 0.44, 95%CI 0.27-0.72). However, 13.4% (95%CI 11.3-15.5) and 13.1% (95%CI 11.0-15.2) of current smokers who did not use e-cigarettes said they would be more likely to try e-cigarettes or quit smoking, respectively, if vaping could help control their weight. CONCLUSION: One in 16 English people who have smoked in the last year believe that vaping would prevent weight gain after stopping. One in 22 people who vape are using e-cigarettes for this purpose. However, should evidence emerge that e-cigarettes prevent weight gain, one in eight people who smoke would be tempted to quit smoking and use e-cigarettes.

Women's experiences of receiving care for pelvic organ prolapse: a qualitative study.

BACKGROUND: Pelvic organ prolapse is a common urogenital condition affecting 41-50% of women over the age of 40. To achieve early diagnosis and appropriate treatment, it is important that care is sensitive to and meets women's needs, throughout their patient journey. This study explored women's experiences of seeking diagnosis and treatment for prolapse and their needs and priorities for improving person-centred care. METHODS: Twenty-two women receiving prolapse care through urogynaecology services across three purposefully selected NHS UK sites took part in three focus groups and four telephone interviews. A topic guide facilitated discussions about women's experiences of prolapse, diagnosis, treatment, follow-up, interactions with healthcare professionals, overall service delivery, and ideals for future services to meet their needs. Data were analysed thematically. RESULTS: Three themes emerged relating to women's experiences of a) Evaluating what is normal b) Hobson's choice of treatment decisions, and c) The trial and error of treatment and technique. Women often delayed seeking help for their symptoms due to lack of awareness, embarrassment and stigma. When presented to GPs, their symptoms were often dismissed and unaddressed until they became more severe. Women reported receiving little or no choice in treatment decisions. Choices were often influenced by health professionals' preferences which were subtly reflected through the framing of the offer. Women's embodied knowledge of their condition and treatment was largely unheeded, resulting in decisions that were inconsistent with women's preferences and needs. Physiotherapy based interventions were reported as helping women regain control over their symptoms and life. A need for greater awareness of prolapse and physiotherapy interventions among women, GPs and consultants was identified alongside greater focus on prevention, early diagnosis and regular follow-up. Greater choice and involvement in treatment decision making was desired. CONCLUSIONS: As prolapse treatment options expand to include more conservative choices, greater awareness and education is needed among women and professionals about these as a first line treatment and preventive measure, alongside a multi-professional team approach to treatment decision making. Women presenting with prolapse symptoms need to be listened to by the health care team, offered better information about treatment choices, and supported to make a decision that is right for them.

A methodological systematic review of meta-ethnography conduct to articulate the complex analytical phases.

BACKGROUND: Decision making in health and social care requires robust syntheses of both quantitative and qualitative evidence. Meta-ethnography is a seven-phase methodology for synthesising qualitative studies. Developed in 1988 by sociologists in education Noblit and Hare, meta-ethnography has evolved since its inception; it is now widely used in healthcare research and is gaining popularity in education research. The aim of this article is to provide up-to-date, in-depth guidance on conducting the complex analytic synthesis phases 4 to 6 of meta-ethnography through analysis of the latest methodological evidence. METHODS: We report findings from a methodological systematic review conducted from 2015 to 2016. Fourteen databases and five other online resources were searched. Expansive searches were also conducted resulting in inclusion of 57 publications on meta-ethnography conduct and reporting from a range of academic disciplines published from 1988 to 2016. RESULTS: Current guidance on applying meta-ethnography originates from a small group of researchers using the methodology in a health context. We identified that researchers have operationalised the analysis and synthesis methods of meta-ethnography - determining how studies are related (phase 4), translating studies into one another (phase 5), synthesising translations (phase 6) and line of argument synthesis - to suit their own syntheses resulting in variation in methods and their application. Empirical research is required to compare the impact of different methods of translation and synthesis. Some methods are potentially better at preserving links with the context and meaning of primary studies, a key principle of meta-ethnography. A meta-ethnography can and should include reciprocal and refutational translation and line of argument synthesis, rather than only one of these, to maximise the impact of its outputs. CONCLUSION: The current work is the first to articulate and differentiate the methodological variations and their application for different purposes and represents a significant advance in the understanding of the methodological application of meta-ethnography.

Improving reporting of meta-ethnography: the eMERGe reporting guidance.

AIMS: The aim of this study was to provide guidance to improve the completeness and clarity of meta-ethnography reporting. BACKGROUND: Evidence-based policy and practice require robust evidence syntheses which can further understanding of people's experiences and associated social processes. Meta-ethnography is a rigorous seven-phase qualitative evidence synthesis methodology, developed by Noblit and Hare. Meta-ethnography is used widely in health research, but reporting is often poor quality and this discourages trust in and use of its findings. Meta-ethnography reporting guidance is needed to improve reporting quality. DESIGN: The eMERGe study used a rigorous mixed-methods design and evidence-based methods to develop the novel reporting guidance and explanatory notes. METHODS: The study, conducted from 2015 to 2017, comprised of: (1) a methodological systematic review of guidance for meta-ethnography conduct and reporting; (2) a review and audit of published meta-ethnographies to identify good practice principles; (3) international, multidisciplinary consensus-building processes to agree guidance content; (4) innovative development of the guidance and explanatory notes. FINDINGS: Recommendations and good practice for all seven phases of meta-ethnography conduct and reporting were newly identified leading to 19 reporting criteria and accompanying detailed guidance. CONCLUSION: The bespoke eMERGe Reporting Guidance, which incorporates new methodological developments and advances the methodology, can help researchers to report the important aspects of meta-ethnography. Use of the guidance should raise reporting quality. Better reporting could make assessments of confidence in the findings more robust and increase use of meta-ethnography outputs to improve practice, policy, and service user outcomes in health and other fields. This is the first tailored reporting guideline for meta-ethnography. This article is being simultaneously published in the following journals: Journal of Advanced Nursing, Psycho-oncology, Review of Education, and BMC Medical Research Methodology.