Does a local Alcohol Health Champion programme have a measurable impact on health and crime outcomes? A natural experiment evaluation of Communities in Charge of Alcohol (CICA) based on triangulation of methods.

BACKGROUND AND AIM: Drinking alcohol may cause harm to an individual's health and social relationships, while a drinking culture may harm societies as it may increase crime rates and make an area feel less safe. Local councils in Greater Manchester, UK, developed the Communities in Charge of Alcohol (CICA) intervention, in which volunteers were trained to give alcohol-related advice to the public and taught how to influence policies to restrict when, where and how alcohol is sold. As part of a larger study, the aim of the current project is to measure the impact of CICA on health and crime outcomes at the lower super output (LSOA) geographical aggregation. DESIGN: Quantitative evaluation using four time series analytic methods (stepped-wedge design, and comparisons to local controls, national controls and synthetic controls) with findings triangulated across these methods. A cost-benefit analysis was carried out alongside the effectiveness analysis. SETTING AND PARTICIPANTS: The general public in Greater Manchester, UK, between 2010 and 2020. MEASUREMENTS: The primary outcome of interest was alcohol-related hospital admissions. Secondary outcomes were accident and emergency (A&E) attendances, ambulance callouts, recorded crimes and anti-social behaviour incidents. FINDINGS: Triangulation of the results did not indicate any consistent effect on area-level alcohol-related hospital admissions, A&E attendances, ambulance callouts, reported crimes or anti-social behaviour associated with the implementation of CICA. The primary stepped-wedge analysis indicated an increase in alcohol-related hospital admissions following the implementation of CICA of 13.4% (95% confidence interval -3.3%, +30.1%), which was consistent with analyses based on other methods with point estimates ranging from +3.4% to 16.4%. CONCLUSION: There is no evidence of a measurable impact of the Communities in Charge of Alcohol (CICA) programme on area-level health and crime outcomes in Greater Manchester, UK, within 3 years of the programme start. The increase in alcohol-related hospital admissions was likely the result of other temporal trends rather than the CICA programme. Possible explanations include insufficient follow-up time, too few volunteers trained, volunteers being unwilling to get involved in licensing decisions or that the intervention has no direct impact on the selected outcomes.

Tracheoesophageal Voice Therapy in Postlaryngectomy Rehabilitation: A Systematic Review.

BACKGROUND: Following total laryngectomy, surgical voice restoration is considered the optimal modality for re-establishing communication via tracheoesophageal voice. Yet beyond the insertion of a voice prosthesis to elicit voice production, there is suboptimal clinical knowledge of how to rehabilitate the perceptual quality of tracheoesophageal voice. This systematic review will identify and critically evaluate the quality and effectiveness of therapeutic interventions for tracheoesophageal voice. The findings of this review will inform the development of a novel tracheoesophageal voice therapy intervention. STUDY DESIGN: Systematic literature review carried out in accordance with PRISMA guidelines. METHODS: The review protocol was registered with PROSPERO. Eight electronic databases were searched using a prespecified search strategy. Records were independently screened by two reviewers against inclusion and exclusion criteria. Eligible studies were assessed for quality using the PEDro, ROBIN-T, and NHLBI critical appraisal tools. Data was extracted pertaining to participant characteristics and the content, dosage, intensity and outcomes of interventions. RESULTS: 6344 records were identified, of which 38 were included for full-text review. Six studies met the eligibility criteria for inclusion. Voice rehabilitation was not the primary focus in the majority of studies, and the risk of bias was identified across studies. There was significant heterogeneity in the interventions and outcome measures used within studies with insufficient detail provided on intervention content for tracheoesophageal voice. Evidence for the effectiveness of interventions was limited and inconsistent across studies. CONCLUSIONS: This review found that tracheoesophageal voice therapy is an under-researched area of clinical practice. Evidence from the small body of existing studies was not sufficiently robust to inform clinical practice at this time. This review highlights the necessity to develop and test interventions aimed at improving the perceptual quality of tracheoesophageal voice.

Prevalence of swallow, communication, voice and cognitive compromise following hospitalisation for COVID-19: the PHOSP-COVID analysis.

OBJECTIVE: Identify prevalence of self-reported swallow, communication, voice and cognitive compromise following hospitalisation for COVID-19. DESIGN: Multicentre prospective observational cohort study using questionnaire data at visit 1 (2-7 months post discharge) and visit 2 (10-14 months post discharge) from hospitalised patients in the UK. Lasso logistic regression analysis was undertaken to identify associations. SETTING: 64 UK acute hospital Trusts. PARTICIPANTS: Adults aged >18 years, discharged from an admissions unit or ward at a UK hospital with COVID-19. MAIN OUTCOME MEASURES: Self-reported swallow, communication, voice and cognitive compromise. RESULTS: Compromised swallowing post intensive care unit (post-ICU) admission was reported in 20% (188/955); 60% with swallow problems received invasive mechanical ventilation and were more likely to have undergone proning (p=0.039). Voice problems were reported in 34% (319/946) post-ICU admission who were more likely to have received invasive (p<0.001) or non-invasive ventilation (p=0.001) and to have been proned (p<0.001). Communication compromise was reported in 23% (527/2275) univariable analysis identified associations with younger age (p<0.001), female sex (p<0.001), social deprivation (p<0.001) and being a healthcare worker (p=0.010). Cognitive issues were reported by 70% (1598/2275), consistent at both visits, at visit 1 respondents were more likely to have higher baseline comorbidities and at visit 2 were associated with greater social deprivation (p<0.001). CONCLUSION: Swallow, communication, voice and cognitive problems were prevalent post hospitalisation for COVID-19, alongside whole system compromise including reduced mobility and overall health scores. Research and testing of rehabilitation interventions are required at pace to explore these issues.

Approaches to tracheoesophageal voice rehabilitation: a survey of the UK and Irish speech and language therapists' current practice and beliefs.

BACKGROUND: After total laryngectomy, surgical voice restoration is used to establish communication via tracheoesophageal voice prosthesis. Once voice is established, there is a paucity of information on what speech and language therapists (SLTs) should do to improve tracheoesophageal voice quality to ensure functional communication. No existing surveys or studies investigate this specific question. There is also a disconnect between guidelines, knowledge and clinical practice, whereby clinical guidelines stipulate the requirement for SLT intervention, but do not detail what this entails in the rehabilitation context. AIMS: (1) To advance understanding of current clinical practice beyond voice prosthesis management and care. (2) To explore what approaches are implemented in clinical practice across the UK and Republic of Ireland to rehabilitate tracheoesophageal voice. (3) To investigate the barriers and facilitators to provision of tracheoesophageal voice therapy. METHODS & PROCEDURES: A self-administered 10-min online survey was developed using Qualtrics software and piloted before dissemination. Survey development was informed by the Behaviour Change Wheel to identify barriers, facilitators and additional factors contributing to SLTs' provision of voice therapy to tracheoesophageal speakers. The survey was disseminated via social media and professional networks. Eligibility criteria included SLTs with at least one year post-registration experience and with experience of working with laryngectomy in the past 5 years. Descriptive statistics were used to analyse closed answer questions. Open question responses were analysed using content analysis. OUTCOMES & RESULTS: The survey received 147 responses. Participants were representative of the head and neck cancer SLT workforce. SLTs believe that tracheoesophageal voice therapy is an important aspect of laryngectomy rehabilitation; however, there was a lack of knowledge about therapy approaches and insufficient resources for implementing therapy. SLTs expressed a desire for more training, specific guidelines and a stronger evidence base to inform clinical practice. Some SLTs expressed feelings of frustration and lack of acknowledgement for the specialist skills required to undertake laryngectomy rehabilitation and tracheoesophageal work in general. CONCLUSIONS & IMPLICATIONS: The survey identifies the need for a robust training approach and detailed clinical guidelines to promote consistent practice across the profession. The evidence base within this clinical area is emergent, hence there is a need for increased research and clinical audit to inform practice. Under-resourcing was highlighted, which should be considered in service planning to ensure that adequate staff, access to expert practitioners or time ring-fenced for therapy are available for tracheoesophageal speakers to receive the support they require. WHAT THIS PAPER ADDS: What is already known on this subject Total laryngectomy results in life-altering changes to communication. Clinical guidelines advocate for speech and language therapy intervention; however, there is no clear information on what SLTs should do to optimize tracheoesophageal voice and the evidence base to support practice is lacking. What this study adds to existing knowledge This survey identifies what interventions SLTs provide in clinical practice to rehabilitate tracheoesophageal voice; and it explores the barriers and facilitators that influence the provision of tracheoesophageal voice therapy. What are the potential or actual clinical implications of this work? Specific training, clinical guidelines, increased research and audit are required to support clinical practice in laryngectomy rehabilitation. Service planning should address the under-resourcing of staff, expert practitioners and therapy allocated time.

'A priori' external contextual factors and relationships with process indicators: a mixed methods study of the pre-implementation phase of 'Communities in Charge of Alcohol'.

BACKGROUND: It is widely recognised that complex public health interventions roll out in distinct phases, within which external contextual factors influence implementation. Less is known about relationships with external contextual factors identified a priori in the pre-implementation phase. We investigated which external contextual factors, prior to the implementation of a community-centred approach to reducing alcohol harm called 'Communities in Charge of Alcohol' (CICA), were related to one of the process indicators: numbers of Alcohol Health Champions (AHCs) trained. METHODS: A mixed methods design was used in the pre-implementation phase of CICA. We studied ten geographic communities experiencing both high levels of deprivation and alcohol-related harm in the North West of England. Qualitative secondary data were extracted from pre-implementation meeting notes, recorded two to three months before roll-out. Items were coded into 12 content categories using content analysis. To create a baseline 'infrastructure score', the number of external contextual factors documented was counted per area to a maximum score of 12. Descriptive data were collected from training registers detailing training numbers in the first 12 months. The relationship between the baseline infrastructure score, external contextual factors, and the number of AHCs trained was assessed using non-parametric univariable statistics. RESULTS: There was a positive correlation between baseline infrastructure score and total numbers of AHCs trained (Rs = 0.77, p = 0.01). Four external contextual factors were associated with significantly higher numbers of lay people recruited and trained: having a health care provider to coordinate the intervention (p = 0.02); a pool of other volunteers to recruit from (p = 0.02); a contract in place with a commissioned service (p = 0.02), and; formal volunteer arrangements (p = 0.03). CONCLUSIONS: Data suggest that there were four key components that significantly influenced establishing an Alcohol Health Champion programme in areas experiencing both high levels of deprivation and alcohol-related harm. There is added value of capturing external contextual factors a priori and then testing relationships with process indicators to inform the effective roll-out of complex interventions. Future research could explore a wider range of process indicators and outcomes, incorporating methods to rate individual factors to derive a mean score. TRIAL REGISTRATION: ISRCTN81942890, date of registration 12/09/2017.

Determinants of nutrition practice and food choice in UK construction workers.

The workplace is considered an effective setting for health and wellbeing interventions, including programmes focusing on nutrition, and provides opportunities to tailor programmes to meet the specific needs of industry and employees. This study explored nutrition practices amongst construction workers and managers to inform the design of a nutrition intervention. Five focus groups were conducted on three construction sites: two with managers (n = 11) and three with workers (n = 27). Construction workers and managers identified several unhealthy nutrition-related behaviours, including high consumption of convenient and fast foods, excessive coffee, alcohol, energy drinks and low fruit and vegetable intake. These behaviours were often attributed to high workloads, long working hours and physically demanding jobs. Snacking and skipping meals were repeatedly reported, attributed to short breaks and poor accessibility to food outlets. The nutritional quality of meals differed between individuals (homemade vs fast food), depending on the type of sites (temporary vs permanent) and site location. Nutrition knowledge, establishing routines, meal planning and preparation were recognized as important in sustaining healthy nutrition habits. However, meal preparation depended on the facilities available, which differed between managers and workers, highlighting the complex relationship between the workplace context and eating behaviours. Construction workers were interested in learning about nutrition and improving their eating habits through nutrition intervention. However, they highlighted that better cooking and storage facilities on site, together with fewer job demands and longer break times, would enhance the sustainability of the intervention and their ability to make healthier food choices.

Evaluation of a pharmacy supported e-cigarette smoking cessation intervention in Northwest England.

BACKGROUND: Cigarette smoking cessation has been described as the world's most important public health intervention. Electronic cigarettes are a relatively new tool for assisting smoking cessation but there is a lack of data on their efficacy. This article reports on a pharmacy supported e-cigarette smoking cessation intervention undertaken in a metropolitan area in the north of England. METHODS: Longitudinal mixed-methods evaluation incorporating analysis of secondary data, interviews with service users, and interviews with service providers at 3-month and 12-month follow-up, with an additional text message survey of service users at 12-month follow-up. RESULTS: The four-week follow-up data suggest that for every twenty people given an e-cigarette, six quit smoking tobacco and three people cut their cigarette intake by more than five cigarettes per day. Long-term follow-up results were positive but only a small number of participants were still engaged with the study at 12 months. Service users and providers spoke positively about the combination of e-cigarettes and pharmacy support. CONCLUSIONS: E-cigarette distribution combined with pharmacy support appears to be an agreeable and effective intervention for smoking cessation, but further data are needed on long-term quit rates and health effects.

"Now, with a bit more knowledge, I understand why I'm asking those questions." midwives' perspectives on their role in the Greater Manchester health and social care partnership's programme to reduce alcohol exposed pregnancies.

OBJECTIVE: To understand midwives' perspectives regarding the effect of a programme of activities aimed at reducing alcohol exposed pregnancies at two NHS Trusts in Greater Manchester. The programme included new protocols for screening, a referral pathway for specialist support and alcohol training for midwives. DESIGN AND PARTICIPANTS: Semi-structured interviews were conducted with 6 midwives working in antenatal care at the two Trusts over the telephone and via video conferencing. A review of the literature provided insight into contemporary midwifery practice. The Theory of Planned Behaviour was used to inform the interview schedule design. Data analysis used a Framework Approach and drew on a priori themes from the literature review. FINDINGS: Participating midwives described objective screening practice using a validated tool on multiple antenatal occasions and were confident to discuss alcohol. Participants were cognisant of local and national policies and guidelines. Discussing alcohol was viewed as important and part of the midwife's role, beliefs which supported participants' intention to practice in line with new protocols. Maternal under-reporting and denial of alcohol consumption was a key barrier to providing effective care. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The professional practice of participants was more in keeping with the Chief Medical Officer's recommendations than that reported in recent research from the UK and other high-income countries. However, from this small study it is not possible to attribute this directly to the local Reducing Alcohol Exposed Pregnancies programme. Training to prepare midwives to elicit more accurately details of maternal alcohol consumption may improve the efficacy of the programme.

Translating Ultrasound into Clinical Practice for the Assessment of Swallowing and Laryngeal Function: A Speech and Language Pathology-Led Consensus Study.

Ultrasound (US) has an emerging evidence base for the assessment of swallowing and laryngeal function. Accessibility and technological advances support the use of US as a clinical assessment tool; however, there is insufficient evidence to support its translation into clinical practice. This study aimed to establish consensus on the priorities for translation of US into clinical practice for the assessment of swallowing and laryngeal function. Nominal Group Technique (NGT) was used as a formal method of consensus development. Clinicians and academics, all members of an international US working group, were invited to participate in the study. Two NGT meetings were held, where participants silently generated and then shared ideas. Participants anonymously ranked items. Rankings were aggregated before participants re-ranked items in order of priority. Discussions regarding rankings were recorded and transcribed to inform analysis. Member-checking with participants informed the final analysis. Participants (n = 15) were speech and language pathologists, physiotherapists and sonographers representing six countries. Fifteen items were identified and prioritised 1-13 (including two equally ranked items). Reliability, validity and normative data emerged as key areas for research while development of training protocols and engagement with stakeholders were considered vital to progressing US into practice. Analysis revealed common themes that might be addressed together in research, in addition to the ranked priority. A measured approach to the translation of US into clinical practice will enable effective implementation of this tool. Priorities may evolve as clinical and professional contexts shift, but this study provides a framework to advance research and clinical practice in this field.

A mixed methods analysis evaluating an alcohol health champion community intervention: How do newly trained champions perceive and understand their training and role?

Globally, alcohol harm is recognised as one of the greatest population risks and reducing alcohol harm is a key priority for the UK Government. The Communities in Charge of Alcohol (CICA) programme took an asset-based approach in training community members across nine areas to become alcohol health champions (AHCs); trained in how to have informal conversations about alcohol and get involved with alcohol licensing. This paper reports on the experiences of AHCs taking part in the training through the analysis of: questionnaires completed pre- and post-training (n = 93) and semi-structured interviews with a purposive sample of five AHCs who had started their role. Questionnaires explored: characteristics of AHCs, perceived importance of community action around alcohol and health, and confidence in undertaking their role. Following training AHCs felt more confident to talk about alcohol harms, give brief advice and get involved in licensing decisions. Interviews explored: AHCs' experiences of the training, barriers and facilitators to the adoption of their role, and how they made sense of their role. Four overarching themes were identified through thematic analysis taking a framework approach: (a) perceptions of AHC training; (b) applying knowledge and skills in the AHC role; (c) barriers and facilitators to undertaking the AHC role; and (d) sustaining the AHC role. Findings highlight the challenges in establishing AHC roles can be overcome by combining the motivation of volunteers with environmental assets in a community setting: the most important personal asset being the confidence to have conversations with people about a sensitive topic, such as alcohol.

How can communities influence alcohol licensing at a local level? Licensing officers' perspectives of the barriers and facilitators to sustaining engagement in a volunteer-led alcohol harm reduction approach.

Despite the World Health Organization's assertion that communities need to become involved in reducing alcohol harm, evidence of community engagement in alcohol licensing decision-making in England remains limited. The evaluation of the Communities in Charge of Alcohol (CICA) programme offers policymakers, Licensing authorities and public health practitioners, evidence regarding a specific volunteer-led, place-based approach, designed to enable community engagement in licensing with the aim of reducing localised alcohol harm. This study explored factors affecting the sustainable involvement of volunteers in alcohol licensing decision-making from six licensing officers' perspectives, through semi-structured interviews. Routinely collected crime, disorder, and hospital admissions data were reviewed for further context as proxy indicators for alcohol-related harm. Licensing officers perceived sustainable engagement to be impacted by: (i) the extent of alignment with statutory requirements and local political support; (ii) the ability of licensing officers to operationalise CICA and support local assets, and; (iii) the opportunity for, and ability of, volunteers to raise licensing issues. The perspectives of licensing officers indicate complexities inherent in seeking to empower residents to engage in licensing decision-making at a community level. These relate to statutory and political factors, funding, social norms regarding engagement in licensing decision-making, and the need for networks between critical actors including responsible authorities and communities. The evidence indicates that after increasing community capacity to influence alcohol availability decision-making at a local level, communities continue to struggle to influence statutory processes to affect alcohol availability where they live and work. More understanding of how to enable effective community engagement is required.

Shielding, hospital admission and mortality among 1216 people with total laryngectomy in the UK during the COVID-19 pandemic: A cross-sectional survey from the first national lockdown.

BACKGROUND: People with a total laryngectomy (PTL) rely on a permanent opening in their neck (stoma) to breathe. This altered anatomy may increase susceptibility to contracting and transmitting SARS-CoV-2. AIMS: To report on (1) the frequency and characteristics of PTL who tested positive for COVID-19, (2) the receipt of advice regarding shielding and patient self-reports of shielding, (3) hospital admissions and length of stay, and (4) mortality rates in this group during the first UK national lockdown. METHODS & PROCEDURES: This is a cross-sectional survey and case note review. National Health Service (NHS) centres providing care to PTL were invited to participate via the Royal College of Speech and Language Therapists' (RCSLT) Head & Neck Clinical Excellence Networks and through social media. PTL were reviewed by their speech and language therapist either in person or via telehealth between 30 March and 30 September 2020. Data were collected within the time frame covered by the Control of Patient Information (COPI) notice issued for COVID-19 and included information on COVID-19 testing, shielding, hospital admissions, length of stay and deaths. Information was submitted to the lead NHS site using a custom designed data-capture worksheet. Analysis was performed using descriptive statistics, including proportions and frequency counts. Pearson's Chi squared tests were used to compare categorical data using a 5% significance level. OUTCOMES & RESULTS: Data were obtained from 1216 PTL from 26 centres across the UK. A total of 81% were male; mean age was 70 years (28-97 years). Of the total group, 12% received a COVID-19 test. A total of 24 (2% of total sample) tested positive for COVID-19. Almost one-third of PTL (32%) received a government letter or were advised to shield by a healthcare professional. During the data collection time frame, 12% had a hospital admission (n = 151) with a median length of stay of 1 day (1-133 days), interquartile range (IQR) = 17 days. A total of 20 of these admissions (13%) had tested positive for COVID-19 with a median length of stay of 26 days, IQR = 49 days. The overall mortality was 4% (41 patients), with eight deaths occurring within 28 days of testing positive for COVID-19. CONCLUSIONS & IMPLICATIONS: This study highlighted the lack of routine national data for neck-breathers with which to compare the current findings. Greater testing in the community is necessary to understand the prevalence of COVID-19 in PTL and if this group is indeed more susceptible. The potential for nasopharyngeal and tracheal aspirates to show differing results when testing for COVID-19 in neck-breathers requires further investigation. WHAT THIS PAPER ADDS: What is already known on the subject? People with total laryngectomy (PTL) have an altered anatomy for breathing and speaking. The presence of a neck stoma poses an additional virus entry point aside from the nose, mouth and conjunctiva. This could increase the susceptibility to COVID-19 for PTL. What this paper adds? This is the first national audit to provide data on shielding, hospital admissions and mortality for patients with total laryngectomy in the UK over the pandemic. The overall mortality in PTL over the first lockdown did not appear to be higher than the "best case" estimates from previous years. However, one in three PTL who acquired COVID-19 and were admitted to hospital, died within 28 days of testing positive. These findings are relevant to the current care and management of PTL over the pandemic but also highlights important knowledge gaps. What are the potential or actual clinical implications of this work? This study highlights gaps in the collection of baseline information on hospital admissions, length of stay and mortality for people with laryngectomy in the UK, restricting comparisons between the current data and historical data. The need for further research on whether neck-breathers should be tested via both nasopharyngeal and tracheal aspirates is important not just currently, but also in case of any future respiratory epidemics.

A qualitative systematic review and thematic synthesis exploring the impacts of clinical academic activity by healthcare professionals outside medicine.

BACKGROUND: There are increasing opportunities for healthcare professionals outside medicine to be involved in and lead clinical research. However, there are few roles within these professions that include time for research. In order to develop such roles, and evaluate effective use of this time, the range of impacts of this clinical academic activity need to be valued and understood by healthcare leaders and managers. To date, these impacts have not been comprehensively explored, but are suggested to extend beyond traditional quantitative impact metrics, such as publications, citations and funding awards. METHODS: Ten databases, four grey literature repositories and a naïve web search engine were systematically searched for articles reporting impacts of clinical academic activity by healthcare professionals outside medicine. Specifically, this did not include the direct impacts of the research findings, rather the impacts of the research activity. All stages of the review were performed by a minimum of two reviewers and reported impacts were categorised qualitatively according to a modified VICTOR (making Visible the ImpaCT Of Research) framework. RESULTS: Of the initial 2704 identified articles, 20 were eligible for inclusion. Identified impacts were mapped to seven themes: impacts for patients; impacts for the service provision and workforce; impacts to research profile, culture and capacity; economic impacts; impacts on staff recruitment and retention; impacts to knowledge exchange; and impacts to the clinical academic. CONCLUSIONS: Several overlapping sub-themes were identified across the main themes. These included the challenges and benefits of balancing clinical and academic roles, the creation and implementation of new evidence, and the development of collaborations and networks. These may be key areas for organisations to explore when looking to support and increase academic activity among healthcare professionals outside medicine. The modified VICTOR tool is a useful starting point for individuals and organisations to record the impact of their research activity. Further work is needed to explore standardised methods of capturing research impact that address the full range of impacts identified in this systematic review and are specific to the context of clinical academics outside medicine.

An asset-based community development approach to reducing alcohol harm: Exploring barriers and facilitators to community mobilisation at initial implementation stage.

Globally there is a need to engage communities in actions to reduce alcohol harm. This paper reports on the initial implementation phase of an asset-based community development (ABCD) approach to reducing alcohol harm in ten pre-identified areas across Greater Manchester (UK). This qualitative study highlights the experiences of stakeholders responsible for, or engaged in, implementation. Findings show that it is challenging to recruit sufficient volunteers in a specific, small area/community, which may limit the ability to build health assets. Wider policy and organisational factors that should be understood prior to implementing a place-based volunteer-led health promotion programme are also identified. TRIAL REGISTRATION: https://www.isrctn.com/ISRCTN81942890.

Patient advocacy in head and neck cancer: Realities, challenges and the role of the multi-disciplinary team.

This paper explores the concept of advocacy in head and neck cancer. We define inherent challenges in the development and success of advocacy within this context and offer ways to embed it within clinical practice. We outline what advocacy is, ways in which it may benefit people with head and neck cancer and the engagement required from healthcare professionals to facilitate advocacy to improve outcomes.

Developing a scale: Adolescents' health choices related rights, duties and responsibilities.

BACKGROUND: Adolescents' health choices have been widely researched, but the ethical basis of these choices, namely their rights, duties, and responsibilities, have been disregarded and scale is required to measure these. OBJECTIVE: To describe the development of a scale that measures adolescents' rights, duties, and responsibilities in relation to health choices and document the preliminary scale testing. RESEARCH DESIGN: A multi-phase development method was used to construct the Health Rights Duties and Responsibilities (HealthRDR) scale. The concepts and content were defined through document analysis, a systematic literature review, and focus groups. The content validity and clarity of the items were evaluated by expert panel of 23 adolescents, school nurses, and researchers. We calculated the content validity index and the content validity ratio at on item and scale levels. Preliminary testing was conducted with 200 adolescents aged 15-16 years. Descriptive statistics, Cronbach's alpha correlation, and statistics for the item-analysis were calculated. ETHICAL CONSIDERATIONS: Ethical approval and permission were obtained according to national legislation and responsible research practice was followed. Informed consent was obtained from the participants and the parents were informed about the study. FINDINGS: The Health Rights Duties and Responsibilities scale comprises of four sub-scales with 148 items: 15 on health choices, 36 on rights, 47 on duties, and 50 on responsibilities. The items had a 0.93 content validity index and a 0.85 content validity ratio. Cronbach's alpha correlation coefficient was 0.99 for the total scale and the individual sub-scales scores were health choices (0.93), rights (0.97), responsibilities (0.99), and duties (0.98). DISCUSSION: The findings are discussed in light of the ethical concepts and validity and reliability of the developed scale. CONCLUSION: The Health Rights Duties and Responsibilities scale defines and understands adolescents' rights, duties, and responsibilities in relation to health choices and has good content validity. Further testing and refinement of the concepts are needed.

Long-Term Health Outcomes Associated With an Exercise Referral Scheme: An Observational Longitudinal Follow-Up Study.

BACKGROUND: Exercise referral schemes (ERSs) support inactive adults, who have chronic health conditions, to become physically active. Uncertainty exists regarding the effectiveness of ERSs, with few studies evaluating their long-term impact. The aims of this study were to evaluate the long-term impact (12 mo) of participation in an ERS on self-reported physical activity (PA) and a range of health-related outcomes. METHODS: Data were analyzed for participants of a 24-week ERS who attended a week 52 follow-up between July 2015 and 2017. PA and health-related outcomes collected at weeks 1, 24, and 52 were analyzed using the Friedman test and Wilcoxon signed-ranks test. RESULTS: A total of 273 participants attended the week 52 follow-up. Self-reported PA significantly increased by a median of 636 MET minutes at week 52. There were also significant improvements in body mass index, systolic blood pressure, mental well-being, and health-related quality of life. CONCLUSIONS: For every 8 participants referred to this 24-week ERS, 1 participant went on to show long-term improvements in at least 1 health indicator. The evidence base requires further long-term evaluations to confirm these findings across a range of ERS providers. Changes in self-reported PA would be supported by the inclusion of device-based measurment of PA.