How co-locating public mental health interventions in community settings impacts mental health and health inequalities: a multi-site realist evaluation.

BACKGROUND: Public mental health interventions are non-clinical services that aim to promote wellbeing and prevent mental ill health at the population level. In England, the health, social and community system is characterised by complex and fragmented inter-sectoral relationships. To overcome this, there has been an expansion in co-locating public mental health services within clinical settings, the focus of prior research. This study evaluates how co-location in community-based settings can support adult mental health and reduce health inequalities. METHODS: A qualitative multi-site case study design using a realist evaluation approach was employed. Data collection took place in three phases: theory gleaning, parallel testing and refining of theories, and theory consolidation. We collected data from service users (n = 32), service providers (n = 32), funders, commissioners, and policy makers (n = 11), and members of the public (n = 10). We conducted in-depth interviews (n = 65) and four focus group discussions (n = 20) at six case study sites across England, UK, and two online multi-stakeholder workshops (n = 20). Interview guides followed realist-informed open-ended questions, adapted for each phase. The realist analysis used an iterative, inductive, and deductive data analysis approach to identify the underlying mechanisms for how community co-location affects public mental health outcomes, who this works best for, and understand the contexts in which co-location operates. RESULTS: Five overarching co-location theories were elicited and supported. Co-located services: (1) improved provision of holistic and person-centred support; (2) reduced stigma by creating non-judgemental environments that were not associated with clinical or mental health services; (3) delivered services in psychologically safe environments by creating a culture of empathy, friendliness and trust where people felt they were being treated with dignity and respect; (4) helped to overcome barriers to accessibility by making service access less costly and more time efficient, and (5) enhance the sustainability of services through better pooling of resources. CONCLUSION: Co-locating public mental health services within communities impacts multiple social determinants of poor mental health. It has a role in reducing mental health inequalities by helping those least likely to access services. Operating practices that engender inter-service trust and resource-sharing are likely to support sustainability.

Public perspectives on inequality and mental health: A peer research study.

INTRODUCTION: Associations between structural inequalities and health are well established. However, there is limited work examining this link in relation to mental health, or that centres public perspectives. This study explores people's experience and sense-making of inequality in their daily lives, with particular consideration of impacts on mental health. METHODS: We conducted a peer research study. Participants had to live in one of two London Boroughs and have an interest in inequalities and mental health. Using social media, newsletters, local organisations and our peer researchers' contacts, we recruited 30 participants who took photos representing their experience of inequality and discussed them during semi-structured interviews. Data were analysed using reflexive thematic analysis. RESULTS: Three themes were identified in this study: (1) inequalities are unjust, multilayered and intertwined with mental health. Accounts demonstrated a deep understanding of inequalities and their link to mental health outcomes, describing inequalities as 'suffering' and 'not good for anyone'. Financial, housing, immigration and healthcare problems exacerbated poor mental health, with racism, gender-based violence and job loss also contributing factors for both poor mental health and experiences of inequality; (2) inequalities exclude and have far-reaching mental health consequences, impacting personal sense of belonging and perceived societal value and (3) moving forwards-addressing long-standing inequality and poor public mental health necessitated coping and resilience strategies that are often unacknowledged and undervalued by support systems. CONCLUSION: Lived experience expertise was central in this study, creating an innovative methodological approach. To improve public mental health, we must address the everyday, painful structural inequalities experienced by many as commonplace and unfair. New policies and strategies must be found that involve communities, redistributing resources and power, building on a collective knowledge base, to coproduce actions combatting inequalities and improving population mental health. PATIENT OR PUBLIC CONTRIBUTION: This study was peer-led, designed and carried out by researchers who had experiences of poor mental health. Six authors of the paper worked as peer researchers on this study.

Inequalities and Inclusion in Exercise Referral Schemes: A Mixed-Method Multi-Scheme Analysis.

Physical activity prescription, commonly through exercise referral schemes, is an established disease prevention and management pathway. There is considerable heterogeneity in terms of uptake, adherence, and outcomes, but because within-scheme analyses dominate previous research, there is limited contextual understanding of this variance. Both the impact of schemes on health inequalities and best practices for inclusion of at-risk groups are unclear. To address this, we modelled secondary data from the multi-scheme National Referral Database, comprising 23,782 individuals across 14 referral schemes, using a multilevel Bayesian inference approach. Scheme-level local demographics identified over-sampling in uptake; on the basis of uptake and completion data, more inclusive schemes (n = 4) were identified. Scheme coordinators were interviewed, and data were analyzed using a grounded theory approach. Inequalities presented in a nuanced way. Schemes showed promise for engaging populations at greater risk of poor health (e.g., those from more deprived areas or of an ethnic minority background). However, the completion odds were lower for those with a range of complex circumstances (e.g., a mental health-related referral). We identified creative best practices for widening access (e.g., partnership building), maintaining engagement (e.g., workforce diversity), and tailoring support, but recommend changes to wider operational contexts to ensure such approaches are viable.

Inequities and inequalities in outdoor walking groups: a scoping review.

BACKGROUND: Outdoor walking groups are widely-used programmes aimed at improving physical activity and health outcomes. Despite being promoted as accessible and inclusive, emerging work highlights participation biases based on gender, age and socioeconomic status, for example. To explicate the impact of outdoor walking groups on physical activity inequities, we conducted a scoping review of published outdoor walking group literatures. Specifically, we critically examined: (a) equity integration strategies; (b) intervention reach; (c) effectiveness; and (d) potential social determinants of engagement relating to the World Health Organization's conceptual framework. METHODS: Arksey and O'Malley's scoping review protocol was used to develop a comprehensive search strategy and identify relevant academic and grey literatures, which were screened using pre-defined inclusion and exclusion criteria. Data were organised by Cochrane PROGRESS-Plus equity characteristics and a narrative summary was presented for each thematic area. FINDINGS: Sixty-two publications were included. Key findings were: (a) some evidence of targeted intervention trials. Large-scale national programmes were tailored to regional activity and health needs, which may contribute toward addressing inequities. However, participant demographics seldom informed reported analyses; (b) participation was more likely among white, more socioeconomically advantaged, middle-to-older aged, female and able-bodied adults; (c) positive physical and psychological outcomes were unlikely to extend along social gradients; and (d) interventions primarily addressed intermediary determinants (e.g. psychosocial barriers; material resource). Social capital (e.g. friend-making) was identified as potentially important for addressing physical activity inequalities. CONCLUSIONS: The published literature on outdoor walking groups leaves unanswered questions regarding participation inequalities, with implications for future physical activity promotion. Currently, participation in outdoor walking groups is typically more prevalent among advantaged subpopulations. We make recommendations for research and practice to address these issues, as well as aid the translation of existing knowledge into practice. We advocate increased focus on the social determinants of engagement. A more consistent approach to collecting and analysing participant socio-demographic data is required. Our findings also support recommendations that appropriate tailoring of universal programmes to community needs and embedding strategies to increase social cohesion are important in developing equitable programmes.

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.

Seven-year itch: the UK Government's difficult relationship with the food and drink industry since Healthy Lives, Healthy People: A Call to Action on Obesity in England (2011).

OBJECTIVE: Unhealthy food and drink consumption is associated with a range of physical and mental health concerns. In response, public health policies have been developed targeting a reduction in obesity in particular. In the present commentary we argue that government-industry partnerships have reduced the effectiveness of resultant policies and explore why. DESIGN: Perspectives of authors. SETTING: UK.ParticipantsPopulations in the UK; UK Government. RESULTS: Industry involvement has presented three interrelated challenges for the UK Government: (i) balancing collaboration while maintaining appropriate distance from industry stakeholders; (ii) resultant production of 'watertight' and effective legislation or intervention; and (iii) actual or perceived limited sanctioning or bargaining power. CONCLUSIONS: Industry involvement in public health policy making has led to weak action. Support with policy implementation (rather than development) and genuine 'buy-in' from industry could accelerate the pace of public health improvement.

Assessing the feasibility of using uniaxial accelerometers with an online support platform in the delivery of a community-based exercise referral scheme.

Exercise referral schemes are established within community-based health care; however, they have been criticized for failing to evidence long-term behavior change relative to usual care. As such, recent reviews have called for refinement of their delivery with a focus on embedded strategies targeting client motivation. This research letter presents findings from an initial pilot trial conducted within Wales' National Exercise Referral Scheme (NERS), examining the feasibility of using validated physical activity monitoring devices and an accompanying online platform within standard scheme delivery. 30 individuals referred to generic or cardiovascular pathways were offered the system; of these 17 agreed to participate. Common reasons for declining were clustered into lack of technology literacy or access, condition severity, or fear of costs associated with losing the device. Analysis of follow-up interviews after 4 weeks of use indicated that while participants found the monitoring devices practical and informative, only a minority (n = 4) were using the system in full. Crucially, the system element most aligned with contemporary theories of motivation (the online portal) was not used as expected. In addition, feedback from exercise referral professionals indicated that there were demands for support from clients, which might be mitigated by more effective independent system use. Recommendations for larger scale trials using similar systems include consideration of targeted patient groups, equity of access, and providing adequate technological support that is currently beyond the capacity of the NERS system.