Process evaluation of an integrated community-based intervention for promoting health equity in children in a new residential development area.

BACKGROUND: Reducing health inequities for children from a disadvantaged background is an important task in public health. While intersectoral partnerships are a promising way to achieve this, few studies have examined the factors influencing the success of these interventions. In this study, we conducted a process evaluation of the integrated community-based intervention Präventionskette Freiham that the city of Munich, Germany, has implemented in a new residential development area. The aim was to investigate the implementation process as well as barriers and facilitators. METHODS: Following a mixed methods approach, we collected data from different core groups making up Präventionskette Freiham from April 2020 to August 2022, exploring their perspective on the implementation process. We conducted repeated qualitative interviews with the network coordinators and eleven local professionals from institutions engaged with or relevant for the intervention. We also undertook a focus group with four members of the advisory group representing the three municipal departments guiding the intervention. Ego-centered network maps were drawn by the network coordinators to chart the development of the network. Subsequently, we also conducted an online survey with local network members. RESULTS: At the early stage of the implementation process, the intervention was able to integrate actors from different sectors, serving as a platform for mutual exchange. However, the network produced limited output. According to the interviews, this may be mainly attributable to the early development status of the area. We identified seven topics that may act as facilitators or barriers to implementation of Präventionskette Freiham: (1) availability of resources, (2) political and administrative support, (3) the network coordinators, (4) network-internal processes, (5) trans-institutional cooperation, (6) perceived benefits of engagement, and (7) the output of the network. CONCLUSIONS: The early development status of the area was a challenge for the intervention. This emphasizes the need to carefully consider context when planning and implementing integrated community-based public health interventions in new residential development areas.

Satisfaction with remote consultations in primary care during COVID-19: a population survey of UK adults.

BACKGROUND: Mode of access to primary care changed during the COVID-19 pandemic; remote consultations became more widespread. With remote consultations likely to continue in UK primary care, it is important to understand people's perceptions of remote consultations and identify potential resulting inequalities. AIM: To assess satisfaction with remote GP consultations in the UK during the COVID-19 pandemic and identify demographic variation in satisfaction levels. DESIGN AND SETTING: A cross-sectional survey from the second phase of a large UK-based study, which was conducted during the COVID-19 pandemic. METHOD: In total, 1426 adults who self-reported having sought help from their doctor in the past 6 months completed an online questionnaire (February to March 2021). Items included satisfaction with remote consultations and demographic variables. Associations were analysed using multivariable regression. RESULTS: A novel six-item scale of satisfaction with remote GP consultations had good psychometric properties. Participants with higher levels of education had significantly greater satisfaction with remote consultations than participants with mid-level qualifications (B = -0.82, 95% confidence interval [CI] = -1.41 to -0.23) or those with low or no qualifications (B = -1.65, 95% CI = -2.29 to -1.02). People living in Wales reported significantly higher satisfaction compared with those living in Scotland (B = -1.94, 95% CI = -3.11 to -0.78), although caution is warranted due to small group numbers. CONCLUSION: These findings can inform the use and adaptation of remote consultations in primary care. Adults with lower educational levels may need additional support to improve their experience and ensure equitable care via remote consultations.

Barriers and facilitators to engaging in smoking cessation support among lung screening participants.

INTRODUCTION: Embedded smoking cessation support within lung cancer screening is recommended in the UK; however, little is known about why individuals decline smoking cessation support in this setting. This study identified psychosocial factors that influence smoking cessation and quit motivation among those who declined support for quitting smoking alongside lung cancer screening. METHODS: Qualitative interviews conducted between August 2019 - April 2021 with thirty adults with a smoking history, recruited from the Yorkshire Lung Screening Trial. Participants had declined smoking cessation support. Verbatim interview transcripts were thematically analysed. RESULTS: Fifty percent of participants were male and the majority were from the most deprived groups. Participants reported low motivation and a variety of barriers to stopping smoking. Participants described modifiable behavioural factors that influenced their quit motivation including self-efficacy, perceived effectiveness of stop-smoking services including smoking cessation aids, risk-minimising beliefs, lack of social support, absence of positive influences on smoking and beliefs about smoking/smoking cessation. Broader contextual factors included social isolation and stigma, COVID-19 and comorbid mental and physical health conditions that deterred smoking cessation. CONCLUSIONS: To encourage engagement in smoking cessation support during lung cancer screening, interventions should seek to encourage positive beliefs about the effectiveness of smoking cessation aids and increase confidence in quitting as part of supportive, person-centred care. Interventions should also acknowledge the wider social determinants of health among the lung screening-eligible population. IMPLICATIONS: This study provides an in-depth understanding of the beliefs surrounding smoking and smoking cessation and further potential psychosocial factors that influence those attending lung cancer screening. Many of the barriers to smoking cessation found in the present study are similar to those outside of a lung screening setting however this work offers an understanding of potential facilitators that should be considered in future lung screening programmes.

Alcohol and smoking brief interventions by socioeconomic position: a population-based, cross-sectional study in Great Britain.

BACKGROUND: Alcohol and smoking brief interventions (BIs) in general practice have been shown to be effective in lowering alcohol and smoking-related harm. AIM: To assess prevalence of self-reported BI receipt among increasing or higher-risk drinkers and past-year smokers in England, Scotland, and Wales, and associations between intervention receipt and socioeconomic position. DESIGN & SETTING: Cross-sectional study using data from a monthly population-based survey in England, Scotland, and Wales. METHOD: The study comprised 47 799 participants (15 573 increasing or higher-risk drinkers [alcohol use disorders identification test consumption score ≥5] and 7791 past-year smokers) surveyed via telephone in 2020-2022 (during the COVID-19 pandemic). All data were self-reported. Prevalence of self-reported BI receipt was assessed descriptively; associations between receipt and socioeconomic position were analysed using logistic regression. RESULTS: Among adults in England, Scotland, and Wales, 32.2% (95% confidence interval [CI] = 31.8 to 32.7) reported increasing or higher-risk drinking and 17.7% (95% CI = 17.3 to 18.1) past-year smoking. Among increasing or higher-risk drinkers, 58.0% (95% CI = 57.1 to 58.9) consulted with a GP in the past year, and of these, 4.1% (95% CI = 3.6 to 4.6) reported receiving BIs. Among past-year smokers, 55.8% (95% CI = 54.5 to 57.1) attended general practice in the past year; of these, 41.0% (95% CI = 39.4 to 42.7) stated receiving BIs. There was a tendency for patients from socioeconomically disadvantaged backgrounds to receive more alcohol (adjusted odds ratio [aOR] 1.38, 95% CI = 1.10 to 1.73) or smoking BIs (aOR 1.11, 95% CI = 0.98 to 1.26), but for the latter the results were statistically non-significant. Results did not differ notably by nation within Great Britain. CONCLUSION: BIs in general practice are more common for smoking than for alcohol. A greater proportion of BIs for alcohol were found to be delivered to people who were from socioeconomically disadvantaged backgrounds and who were increasing or higher-risk drinkers.

Technology to improve reliable access to oxygen in Western Uganda: study protocol for a phased implementation trial in neonatal and paediatric wards.

INTRODUCTION: Oxygen is an essential medicine for children and adults. The current systems for its delivery can be expensive and unreliable in settings where oxygen is most needed. FREO2 Foundation Australia has developed an integrated oxygen system, driven by a mains-powered oxygen concentrator, with the ability to switch automatically between low-pressure oxygen storage device and cylinder oxygen in power interruptions. The aim of this study is to assess the clinical impact and cost-effectiveness of expanding this system to 20 community and district hospitals and level IV facilities in Western Uganda. METHODS AND ANALYSIS: This will be a phased implementation with preintervention and postintervention comparison of outcomes. Standardised baseline data collection and needs assessment will be conducted, followed by implementation of the FREO2 Oxygen System in combination with pulse oximetry in 1-2 facilities per month over a 16-month period, with a total 23-month data collection period. The primary outcome will be the proportion of hypoxaemic children receiving oxygen pre and post oxygen system. Secondary outcomes will assess clinical, economic and technical aspects. Pre and post oxygen system primary and secondary outcomes will be compared using regression models and standard tests of significance. Useability will be quantitatively and qualitatively evaluated in terms of acceptability, feasibility and appropriateness, using standardised implementation outcome measure tools. ETHICS AND DISSEMINATION: Ethics approval was obtained from Mbarara University of Science and Technology (MUREC 1/7) and the University of Melbourne (2021-14489-13654-2). Outcomes will be presented to the involved facilities, and to representatives of the Ministry of Health, Uganda. Broader dissemination will include publication in peer-reviewed journals and academic conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12621000241831.

CHoosing Active Role Models to INspire Girls (CHARMING): protocol for a cluster randomised feasibility trial of a school-based, community-linked programme to increase physical activity levels in 9-10-year-old girls.

BACKGROUND: In the UK, there is evidence that girls' physical activity tends to decline to a greater extent than boys as they enter adolescence. 'Role models' could play a vital role in inspiring girls to become or remain physically active. The CHARMING Programme is a primary school-based community linked role-model programme, co-developed in 2016, with children, parents, schools and wider stakeholders. It involves different types of physical activity delivered for 1-h each week by a community provider and peer role models (e.g. older girls from secondary schools) joining in with the sessions. The programme ultimately aims to increase and sustain physical activity levels among 9-10-year-old girls. This study aims to assess the feasibility and acceptability of the CHARMING Programme and of evaluating it using a randomised trial. METHODS: This study is a feasibility cluster randomised controlled trial, with embedded process evaluation and health economic evaluation. Approximately 90 Year 5 (i.e. 9-10-year-old) girls will be recruited across six primary schools in Mid-South Wales. Participating schools will be allocated to the programme: control on a 2:1 basis; four intervention schools will run the CHARMING Programme and two will continue with usual practice. A survey and accelerometer will be administered at baseline and repeated at 12 months. Interviews and focus groups will be conducted post-intervention delivery. The primary aim is to assess feasibility of a future randomised trial via the recruitment of schools, participants and role models; randomisation; retention; reach; data collection completion rates; programme adherence; and programme fidelity, views on intervention acceptability and programme barriers and facilitators. Secondary aims are to evaluate established physical activity outcome measures for children plus additional health economic outcomes for inclusion in a future full-scale trial. DISCUSSION: The results of this study will inform decisions on whether and how to proceed to a full-scale evaluation of the effectiveness and cost-effectiveness of the CHARMING Programme to improve or sustain physical activity. TRIAL REGISTRATION: ClinicalTrials.gov ISRCTN36223327. Registered March 29, 2021.

Inequalities in Smoking and Quitting-Related Outcomes Among Adults With and Without Children in the Household 2013-2019: A Population Survey in England.

INTRODUCTION: Smoking among those who live with children is an important influence on smoking initiation among children. This study assessed socioeconomic inequalities in smoking and quitting-related outcomes among all adults with and without children in the household. AIMS AND METHODS: Monthly repeat cross-sectional household survey of adults (16+) from 2013-2019 in England (N = 138 583). We assessed the association between cigarette smoking and quitting-related outcomes and having children in the household, and whether these relationships were moderated by occupational social grade (categories AB-E from most to least advantaged). Trends in smoking prevalence among adults with and without children in the household were explored. RESULTS: In adjusted analysis, the association of having children in the household with smoking prevalence depended on social grade: smoking prevalence was between 0.71 (95% confidence interval 0.66-0.77) and 0.93 (0.88-0.98) times lower among social grades AB-D with children in the household relative to those without. Conversely, it was 1.11 (1.05-1.16) times higher among social grade E. Yearly prevalence declined similarly among those with and without children (both prevalence ratio: 0.98, 95% confidence interval 0.97-0.99). Motivation to stop smoking was higher among those with children than those without, but lower among disadvantaged than more advantaged groups. Social grades D-E had greater heavy smoking, but higher prevalence of past-month quit attempts. CONCLUSIONS: Among the most disadvantaged social grade in England, smoking prevalence was higher in those with children in the household than without. To attenuate future smoking-related inequalities, there is an urgent need to target support and address barriers to quitting and promote longer-term quit success. IMPLICATIONS: In the most disadvantaged occupational social grade, having children in the household was associated with higher smoking prevalence compared with not having children. This contrasts with all other social grades in which there was lower comparative smoking prevalence among those with than without children in the household. Without attention this disparity could exacerbate existing and future health inequalities related to smoking.

Socio-Economic Status, Mental Health Difficulties and Feelings about Transition to Secondary School among 10-11 Year Olds in Wales: Multi-Level Analysis of a Cross Sectional Survey.

Transition between primary and secondary school represents an important milestone in young people's development. While most young people look forward to this transition, it is a source of anxiety for many. Drawing on a nationally representative survey of 2218 children in 73 schools in Wales, this study aimed to understand the extent to which 10-11 year old children worried about and/or looked forward to their imminent transition to secondary school, the things they worried about and/or looked forward to, and how feelings about transition differed by socioeconomic status, as well as by emotional and behavioural difficulties. About a third of children reported being quite or very worried about transition to secondary school, while approximately two-thirds reported looking forward to it quite a bit or very much. These items were only moderately correlated, with many children both looking forward to and worrying about transition, or neither. Major sources of worry about transition centred around bullying and impact on existing friendships, while forming new friendships or joining existing friends in their new school were key things children looked forward to. Children from poorer backgrounds, attending poorer schools and reporting more emotional difficulties were significantly more likely to report worries about transition. Children from poorer families, and children reporting more emotional difficulties and behavioural difficulties, were less likely to look forward to transition. Interventions to support children in transition to secondary school need to be sensitive to the needs of children from poorer backgrounds and children with mental health difficulties.

The what, why and when of adapting interventions for new contexts: A qualitative study of researchers, funders, journal editors and practitioners' understandings.

BACKGROUND: The adaptation of interventions for new contexts is a rapidly developing research area. To date there is no consensus-based guidance to support decision-making and recommend adaptation processes. The ADAPT study is developing such guidance. This aim of the qualitative component of the study was to explore stakeholders' understandings of adaptation, as to date there has limited consideration of how different concepts and meanings shape decision-making and practice. METHODS: A case study research design was used. Participants/cases were purposefully sampled based on study outcome, study design, expertise, context and country. Semi-structured interviews were conducted with a sample of researchers (n = 23); representatives from research funding panels (n = 6); journal editors (n = 5) and practitioners (n = 3). Data were analysed using the Framework approach. Overarching themes were discussed with the ADAPT study team, with further iterative refinement of subthemes. RESULTS: The results generated four central themes. Four themes related to stakeholders' understanding: 1) definitions of adaptation and related concepts; 2) rationales for undertaking adaptation; 3) the appropriate timing for adaptation; and 4) ensuring fidelity when implementing adapted interventions. CONCLUSION: The findings highlight the lack of clarity around key concepts and uncertainty about central decision-making processes, notably why interventions should be adapted, when and to what extent. This has informed the ADAPT study's guidance, shaping the scope and nature of recommendations to be included and surfacing key uncertainties that require future consideration.

Using Latent Class Analysis to Explore Complex Associations Between Socioeconomic Status and Adolescent Health and Well-Being.

PURPOSE: Research demonstrates a strong socioeconomic gradient in health and well-being. However, many studies rely on unidimensional measures of socioeconomic status (SES) (e.g. educational qualifications, household income), and there is often a more limited consideration of how facets of SES combine to impact well-being. This paper develops a multidimensional measure of SES, drawing on family and school-level factors, to provide more nuanced understandings of socioeconomic patterns in adolescent substance use and mental well-being. METHODS: Data from the Student Health and Wellbeing Survey from Wales, UK was employed. The sample compromised 22,372 students and we used latent class analysis to identify distinct groups using three measures of SES. These classes were then used to estimate mental well-being, internalizing symptoms, and substance use. RESULTS: The five-class solution offered the best fit. Findings indicated distinct classes of families as follows: "nonworking," "deprived working families," "affluent families in deprived schools," "lower affluence," and "higher affluence." There was a clear relationship among the classes and mental well-being, internalizing symptoms, smoking, and cannabis use; alcohol was the exception to this. CONCLUSIONS: The identification of these classes led to a fuller understanding of the health and well-being effects of SES, showing clearer patterning in health behaviors that often is not captured in research. The implications for adolescent health and well-being are discussed, including considerations for future research.

Smoking, distress and COVID-19 in England: Cross-sectional population surveys from 2016 to 2020.

Changes in the prevalence of psychological distress among smokers during the COVID-19 pandemic in England may exacerbate existing health inequalities. This study examined the prevalence of psychological distress among smokers following the onset of the pandemic compared with previous years. Cross-sectional data came from a representative survey of smokers (18+) in England (n = 2,927) between April-July in 2016, 2017 and 2020. Logistic regressions estimated the associations between past-month distress across 2016/2017 and 2020, and age. Weighted proportions, chi-squared statistics and stratified logistic regression models were used to compare the distributions of moderate and severe distress, respectively, within socio-demographic and smoking characteristics in 2016/2017 and 2020. Between the combined April-July 2016 and 2017 sample and April-July 2020 the prevalence of moderate and severe distress among past-year smokers increased (2016/2017: moderate 20.66%, 19.02-22.43; severe 8.23%, 7.16-9.47; 2020: moderate 28.79%, 95%CI 26.11-31.60; OR = 2.08, 95%CI 1.34-3.25; severe 11.04%, 9.30-13.12; OR = 2.16, 1.13-4.07). While there was no overall evidence of an interaction between time period and age, young (16-24 years) and middle-age groups (45-54 years) may have experienced greater increases in moderate distress and older age groups (65+ years) increases in severe distress. There were increases of moderate distress among more disadvantaged social grades and both moderate and severe distress among women and those with low cigarette addiction. Between April-July 2016/2017 and April-July 2020 in England there were increases in both moderate and severe distress among smokers. The distribution of distress among smokers differed between 2016/2017 and 2020 and represents a widening of inequalities.

The SPECTRUM Consortium: a new UK Prevention Research Partnership consortium focussed on the commercial determinants of health, the prevention of non-communicable diseases, and the reduction of health inequalities.

The main causes of non-communicable diseases (NCDs), health inequalities and health inequity include consumption of unhealthy commodities such as tobacco, alcohol and/or foods high in fat, salt and/or sugar. These exposures are preventable, but the commodities involved are highly profitable. The economic interests of 'Unhealthy Commodity Producers' (UCPs) often conflict with health goals but their role in determining health has received insufficient attention. In order to address this gap, a new research consortium has been established. This open letter introduces the SPECTRUM ( S haping  Public h Ealth poli Cies  To  Reduce ineq Ualities and har M)Consortium: a multi-disciplinary group comprising researchers from 10 United Kingdom (UK) universities and overseas, and partner organisations including three national public health agencies in Great Britain (GB), five multi-agency alliances and two companies providing data and analytic support. Through eight integrated work packages, the Consortium seeks to provide an understanding of the nature of the complex systems underlying the consumption of unhealthy commodities, the role of UCPs in shaping these systems and influencing health and policy, the role of systems-level interventions, and the effectiveness of existing and emerging policies. Co-production is central to the Consortium's approach to advance research and achieve meaningful impact and we will involve the public in the design and delivery of our research. We will also establish and sustain mutually beneficial relationships with policy makers, alongside our partners, to increase the visibility, credibility and impact of our evidence. The Consortium's ultimate aim is to achieve meaningful health benefits for the UK population by reducing harm and inequalities from the consumption of unhealthy commodities over the next five years and beyond.

An assessment of symptom burden in inflammatory bowel diseases to develop a patient preference-weighted symptom score.

PURPOSE: Inflammatory bowel disease (IBD) patients experience diverse symptoms and the impact of these different symptoms varies substantially. Current disease activity measures do not account for the relative importance of the different symptoms and severity levels. In this study, we aimed to quantify the relative importance of different symptoms for IBD patients and to develop a patient preference-weighted symptom (PWS) score to assess symptom burden in IBD. METHODS: We performed a choice-based conjoint analysis (CBCA) survey with 129 IBD patients to estimate the relative importance of four common IBD symptoms: stool frequency, abdominal pain, blood in stools, and urgency. We then developed the PWS score using the preferences obtained from the CBCA, which we validated against existing measures. RESULTS: CBCA revealed that urgency was the most important symptom to patients, followed by abdominal pain and blood in stools. Urgency associated with incontinence received particularly high scores and was perceived to be more than 3 times as important as urgency without incontinence. Our results confirmed that different symptoms are not equally bothersome, and we showed that the relation between symptom-level and importance is not linear. The PWS score, which we developed using these estimates was highly correlated with existing disease activity measures. CONCLUSIONS: We quantified the relative importance of four common IBD symptoms and developed the PWS score for IBD, which takes the relative importance of different symptoms and symptom-levels into account. The PWS score can be used to obtain a patient-centered assessment of symptom burden.

Testing the "Zero-Sum Game" Hypothesis: An Examination of School Health Policies and Practices and Inequalities in Educational Outcomes.

BACKGROUND: Health and education are intrinsically linked, while both are significantly patterned by socioeconomic status throughout the life course. Nevertheless, the impact of promoting health via schools on education is seen by some as a "zero-sum game"; ie, focusing resources on health improvement activity distracts schools from their core business of educating pupils, potentially compromising educational attainment. There is emerging evidence that school health improvement interventions may beneficially influence both health and attainment. However, few studies have examined the relationship between school health improvement activity and socioeconomic inequalities in educational attainment. METHODS: Wales-wide, school-level survey data on school health policies and practices was linked with routinely collected data on academic attainment. Primary outcomes included attendance and academic attainment at age 14 (Key Stage 3) and 16 (Key Stage 4). Linear regression models were constructed separately for high and low Free School Meal (FSM) schools, adjusting for confounders. Interaction terms were fitted to test whether there was an interaction between FSM, health improvement activity, and outcomes. RESULTS: There were positive associations between almost all school health variables and KS3 attainment among high, but not low FSM schools. Similarly, for attendance, there were positive associations of several health variables among high but not low FSM schools. There were no associations for KS4 attainment. CONCLUSIONS: Our findings did not support the "zero-sum game" hypothesis; in fact, among more deprived schools there was a tendency for better attendance and attainment at age 14 in schools with more embedded health improvement action.

Socioeconomic status, mental wellbeing and transition to secondary school: Analysis of the School Health Research Network/Health Behaviour in School-aged Children survey in Wales.

Young people's wellbeing is often lowest where they assume a relatively low position within their school's socioeconomic hierarchy, for example, among poorer children attending more affluent schools. Transition to secondary school is a period during which young people typically enter an environment which is more socioeconomically diverse than their primary school. Young people joining a school with a higher socioeconomic status intake relative to their primary school may assume a relatively lowered position within their school's socioeconomic hierarchy, experiencing a detriment to their wellbeing as a consequence. This article draws on data from 45,055 pupils in Years 7 and 8, from 193 secondary schools in Wales, who completed the 2017 Student Health Research Network (SHRN) Student Health and Wellbeing (SHW) survey. Pupils reported which primary school they previously attended, and survey data on wellbeing were linked to publicly available data on the free school meal entitlement of schools attended. In cross-classified linear mixed-effects models, with primary and secondary school as levels, mental wellbeing varied significantly according to both primary and secondary school attended. A higher school-level deprivation was associated with worse mental wellbeing in both cases. Mental wellbeing was significantly predicted by the relative affluence of a child's primary and secondary school, with movement to a secondary school of higher overall socioeconomic status associated with lowered wellbeing. These findings highlight transition to secondary school as a key point in which socioeconomic inequality in wellbeing may widen, and thus as an important focal point for intervention to reduce health inequalities.

Systematic review of behavioural smoking cessation interventions for older smokers from deprived backgrounds.

INTRODUCTION: The associations between smoking prevalence, socioeconomic group and lung cancer outcomes are well established. There is currently limited evidence for how inequalities could be addressed through specific smoking cessation interventions (SCIs) for a lung cancer screening eligible population. This systematic review aims to identify the behavioural elements of SCIs used in older adults from low socioeconomic groups, and to examine their impact on smoking abstinence and psychosocial variables. METHOD: Systematic searches of Medline, EMBASE, PsychInfo and CINAHL up to November 2018 were conducted. Included studies examined the characteristics of SCIs and their impact on relevant outcomes including smoking abstinence, quit motivation, nicotine dependence, perceived social influence and quit determination. Included studies were restricted to socioeconomically deprived older adults who are at (or approaching) eligibility for lung cancer screening. Narrative data synthesis was conducted. RESULTS: Eleven studies met the inclusion criteria. Methodological quality was variable, with most studies using self-reported smoking cessation and varying length of follow-up. There were limited data to identify the optimal form of behavioural SCI for the target population. Intense multimodal behavioural counselling that uses incentives and peer facilitators, delivered in a community setting and tailored to individual needs indicated a positive impact on smoking outcomes. CONCLUSION: Tailored, multimodal behavioural interventions embedded in local communities could potentially support cessation among older, deprived smokers. Further high-quality research is needed to understand the effectiveness of SCIs in the context of lung screening for the target population. PROSPERO REGISTRATION NUMBER: CRD42018088956.

Acceptability and Feasibility of Implementing Accelorometry-Based Activity Monitors and a Linked Web Portal in an Exercise Referral Scheme: Feasibility Randomized Controlled Trial.

BACKGROUND: Exercise referral schemes (ERSs) are recommended for patients with health conditions or risk factors. Evidence points to the initial effectiveness and cost-effectiveness of such schemes for increasing physical activity, but effects often diminish over time. Techniques such as goal setting, self-monitoring, and personalized feedback may support motivation for physical activity and maintenance of effects. Wearable technologies could provide an opportunity to integrate motivational techniques into exercise schemes. However, little is known about acceptability to exercise referral populations or implementation feasibility within exercise referral services. OBJECTIVE: To determine the feasibility and acceptability of implementing an activity-monitoring device within the Welsh National ERS to inform a decision on whether and how to proceed to an effectiveness trial. METHODS: We conducted a feasability randomized controlled trial with embedded mixed-methods process evaluation and an exploratory economic analysis. Adults (N=156) were randomized to intervention (plus usual practice; n=88) or usual practice only (n=68). Usual practice was a 16-week structured exercise program. The intervention group additionally received an accelerometry-based activity monitor (MyWellnessKey) and associated Web platform (MyWellnessCloud). The primary outcomes were predefined progression criteria assessing acceptability and feasibility of the intervention and proposed evaluation. Postal questionnaires were completed at baseline (time 0:T0), 16 weeks (T1), and 12 months after T0 (T2). Routine data were accessed at the same time-points. A subsample of intervention participants and scheme staff were interviewed following the initiation of intervention delivery and at T2. RESULTS: Participants were on average aged 56.6 (SD 16.3) years and mostly female (101/156, 64.7%) and white (150/156, 96.2%). Only 2 of 5 progression criteria were met; recruitment and randomization methods were acceptable to participants, and contamination was low. However, recruitment and retention rates (11.3% and 67.3%, respectively) fell substantially short of target criteria (20% and 80%, respectively), and disproportionally recruited from the least deprived quintile. Only 57.4% of intervention participants reported receipt of the intervention (below the 80% progression threshold). Less than half reported the intervention to be acceptable at T2. Participant and staff interviews revealed barriers to intervention delivery and engagement related to the device design as well as context-specific technological challenges, all of which made it difficult to integrate the technology into the service. Routinely collected health economic measures had substantial missing data, suggesting that other methods for collecting these should be used in future. CONCLUSIONS: To our knowledge, this is the first study to evaluate short- and long-term feasibility and acceptability of integrating wearable technologies into community-based ERSs. The findings highlight device- and context-specific barriers to doing this in routine practice, with typical exercise referral populations. Key criteria for progression to a full-scale evaluation were not met. TRIAL REGISTRATION: ISRCTN Registry ISRCTN85785652; http://www.isrctn.com/ISRCTN85785652.

Socio-Economic Inequalities in Adolescent Summer Holiday Experiences, and Mental Wellbeing on Return to School: Analysis of the School Health Research Network/Health Behaviour in School-Aged Children Survey in Wales.

The socioeconomic inequalities found in child and adolescent mental wellbeing are increasingly acknowledged. Although interventions increasingly focus on school holidays as a critical period for intervention to reduce inequalities, no studies have modelled the role of summer holiday experiences in explaining socioeconomic inequalities in wellbeing. For this study, we analysed survey data of 103,971 adolescents from 193 secondary schools in Wales, United Kingdom, which included measures of family affluence, experiences during the summer holidays (hunger, loneliness, time with friends and physical activity) and mental wellbeing and internalising symptoms on return to school. Structural equation modelling was used to analyse the data. Although family affluence retained a direct inverse association with student mental wellbeing (r = -0.04, p < 0.001), 65.2% of its association with mental wellbeing was mediated by the experiences over the summer holidays. FAS score was not directly associated with the student's self-reports of internalising symptoms (r = 0.00, p > 0.05). Of all summer holiday experiences, the strongest mediational pathway was observed for reports of loneliness. Although more structural solutions to poverty remain essential, school holiday interventions may have significant potential for reducing socioeconomic inequalities in mental health and wellbeing on young people's return to school through reducing loneliness, providing nutritious food and opportunities for social interaction.