Acceptability of digital vending machines to access STI and HIV tests in two UK cities.

OBJECTIVES: Prompt HIV and STI diagnosis and treatment is a public health priority and relies on accessible testing. Technology-based approaches to distribute test kits have the potential to increase access to testing. We evaluated the acceptability and uptake of vending machines in publicly available settings in Brighton and Hove (BH) and Bristol, North Somerset and South Gloucestershire (BNSSG), to distribute HIV rapid self-test and STI self-sample kits. METHODS: Seven machines were installed in BH and four in BNSSG. User characteristics, proportion of kits returned and test results, taken from the machine database and clinic records, combined with online questionnaires completed by self-recruited users and analysed using Stata and SPSS. RESULTS: 2536 kits were dispensed over 12 months (April 2022 to March 2023). The STI self-sample kits were most popular (74% of vends). 78% of kits dispensed were among users aged 16-35 years and 56% identified as male. 68% and 59% of users had either not tested in the last 12 months or never tested for HIV and STIs, respectively. 51% of STI kits were returned via post, lower than the local online service (65%). 208 users completed questionnaires. Convenience, desire for instant access and increased confidentiality were the most common reasons for using machines. 92% of respondents thought the machines were user-friendly and 97% would recommend the service. Concerns about safety and privacy while using the machine were reported by 42% and 66% of respondents. CONCLUSIONS: This study demonstrates that vending machines are an acceptable and effective means of accessing infrequent or never testers in the general population and can act as a horizontal intervention to tackle HIV and STIs. Research is needed to understand optimal machine locations to assure privacy and safety along with the long-term impact on sexual health services.

Engagement in rapid public health research among young people from underserved communities: maximising opportunities and overcoming barriers.

BACKGROUND: Inclusion in public health research of young people from low-income households and those from minority ethnic groups remains low. It is recognised that there is a need to change the way in which research is conducted so that it becomes more inclusive. The aim of this work was to identify novel and innovative ways to maximise recruitment and inclusion of diverse participants when doing co-production within very short time frames for emergency responses. METHOD: We conducted interviews with young people from low-income and minority ethnic backgrounds, and members or leaders of groups or organisations supporting or representing young people from underserved communities. RESULTS: A total of 42 participants took part in an interview. This included 30 young people from low income or minority ethnic backgrounds and 12 community leaders/service providers. Of the 30 young people, 26 participants identified as female and 12 participants identified as being from a minority ethnic background. Participants discussed a number of interrelated barriers to research involvement and identified ways in which barriers may be reduced. Prejudice and discrimination experienced by young people from underserved communities has led to substantial mistrust of educational and governmental establishments. Rigid and unfamiliar research practices further limit the involvement of young people. Four themes were identified as ways of supporting involvement, including: making opportunities available for young people, adaptations to research governance, understanding and acknowledging challenges faced by young people, and ensuring reciprocal benefits. CONCLUSION: This research explored barriers to engagement in rapid public health co-production. Working with communities to co-produce rapid recruitment and research procedures to suit the needs and the context in which young people live is necessary.

Development, acceptability and feasibility of a personalised, behavioural intervention to prevent bacterial skin and soft tissue infections among people who inject drugs: a mixed-methods Person-Based Approach study.

BACKGROUND: Skin and soft tissue infections (SSTI) among people who inject drugs (PWID) are a public health concern. This study aimed to co-produce and assess the acceptability and feasibility of a behavioural intervention to prevent SSTI. METHODS: The Person-Based Approach (PBA) was followed which involves: (i) collating and analysing evidence; (ii) developing guiding principles; (iii) a behavioural analysis; (iv) logic model development; and (v) designing and refining intervention materials. Co-production activities with target group representatives and key collaborators obtained feedback on the intervention which was used to refine its design and content. The intervention, harm reduction advice cards to support conversation between service provider and PWID and resources to support safer injecting practice, was piloted with 13 PWID by four service providers in Bristol and evaluated using a mixed-methods approach. Semi-structured interviews were conducted with 11 PWID and four service providers. Questionnaires completed by all PWID recorded demographic characteristics, SSTI, drug use and treatment history. Interviews were analysed thematically and questionnaires were analysed descriptively. RESULTS: Published literature highlighted structural barriers to safer injecting practices, such as access to hygienic injecting environments and injecting practices associated with SSTI included: limited handwashing/injection-site swabbing and use of too much acidifier to dissolve drugs. Co-production activities and the literature indicated vein care and minimisation of pain as PWID priorities. The importance of service provider-client relationships and non-stigmatising delivery was highlighted through the co-production work. Providing practical resources was identified as important to address environmental constraints to safer injecting practices. Most participants receiving the intervention were White British, male, had a history of SSTI and on average were 43.6 years old and had injected for 22.7 years. The intervention was well-received by PWID and service providers. Intervention content and materials given out to support harm reduction were viewed positively. The intervention appeared to support reflections on and intentions to change injecting behaviours, though barriers to safer injecting practice remained prominent. CONCLUSIONS: The PBA ensured the intervention aligned to the priorities of PWID. It was viewed as acceptable and mostly feasible to PWID and service providers and has transferability promise. Further implementation alongside broader harm reduction interventions is needed.

The Effectiveness of Low Dead Space Syringes for Reducing the Risk of Hepatitis C Virus Acquisition Among People Who Inject Drugs: Findings From a National Survey in England, Wales, and Northern Ireland.

Syringes with attached needles (termed fixed low dead space syringes [LDSS]) retain less blood following injection than syringes with detachable needles, but evidence on them reducing blood-borne virus transmission among people who inject drugs (PWID) is lacking. Utilizing the UK Unlinked Anonymous Monitoring cross-sectional bio-behavioral surveys among PWID for 2016/18/19 (n = 1429), we showed that always using fixed LDSS was associated with 76% lower likelihood (adjusted odds ratio  = 0.24, 95% confidence interval [CI]: .08-.67) of recent hepatitis C virus infection (RNA-positive and antibody-negative) among antibody-negative PWID compared to using any syringes with detachable needles.

Using the recommended summary plan for emergency care and treatment (ReSPECT) in care homes: a qualitative interview study.

BACKGROUND: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an advance care planning process designed to facilitate discussion and documentation of preferences for care in a medical emergency. Advance care planning is important in residential and nursing homes. AIM: To explore the views and experiences of GPs and care home staff of the role of ReSPECT in: (i) supporting, and documenting, conversations about care home residents' preferences for emergency care situations, and (ii) supporting decision-making in clinical emergencies. SETTING/PARTICIPANTS: Sixteen GPs providing clinical care for care home residents and 11 care home staff in the West of England. METHODS: A qualitative research design using semi-structured interviews. RESULTS: Participants' accounts described the ReSPECT process as facilitating person-centred conversations about residents' preferences for care in emergency situations. The creation of personalised scenarios supported residents to consider their preferences. However, using ReSPECT was complex, requiring interactional work to identify and incorporate resident or relative preferences. Subsequent translation of preferences into action during emergency situations also proved difficult in some cases. Care staff played an important role in facilitating and supporting ReSPECT conversations and in translating it into action. CONCLUSIONS: The ReSPECT process in care homes was positive for GPs and care home staff. We highlight challenges with the process, communication of preferences in emergency situations and the importance of balancing detail with clarity. This study highlights the potential for a multi-disciplinary approach engaging care staff more in the process.

Evidence of changing sexual behaviours and clinical attendance patterns, alongside increasing diagnoses of STIs in MSM and TPSM.

BACKGROUND: Due to rising numbers of STI diagnosis and increasing prevalence of antimicrobial resistance, we explored trends in STI testing frequency and diagnoses, alongside sexual decision making and attitudes concerning condom use and HIV pre-exposure prophylaxis (PrEP) at a large urban UK sexual health clinic. METHODS: We examined 66 528 electronic patient records covering 40 321 attendees between 2016 and 2019, 3977 of whom were men who have sex with men or trans persons who have sex with men (MSM/TPSM). We also explored responses from MSM/TPSM attendees sent an electronic questionnaire between November 2018 and 2019 (n=1975) examining behaviours/attitudes towards PrEP. We measured trends in STI diagnoses and sexual behaviours including condomless anal intercourse (CAI), using linear and logistic regression analyses. RESULTS: Tests resulting in gonorrhoea, chlamydia or syphilis diagnoses increased among MSM/TPSM from 13.5% to 18.5% between 2016 and 2019 (p<0.001). The average MSM/TPSM STI testing frequency increased from 1.5/person/year to 2.1/person/year (p=0.017). Gay MSM/TPSM had the highest proportions of attendances resulting in diagnoses, increasing from 15.1% to 19.6% between 2016 and 2019 (p<0.001) compared with bisexual/other MSM/TPSM increasing from 6.9% to 14.5% (p<0.001), alongside smaller but significant increases in non-MSM/TPSM from 5.9% to 7.7% (p<0.001).The proportion of MSM/TPSM clinic attendees reporting CAI in the previous 3 months prior to at least one appointment in a given year increased significantly from 40.6% to 45.5% between 2016 and 2019 (p<0.0001) and average number of partners from 3.8 to 4.5 (p=0.002). Of 617 eligible questionnaire responses, 339/578 (58.7%) HIV-negative and 29/39 (74.4%) HIV-positive MSM/TPSM indicated they would be more likely to have CAI with someone on PrEP versus not on PrEP. 358/578 (61.9%) HIV-negative respondents said that PrEP use would make them more likely to have CAI with HIV-negative partners. CONCLUSION: Rising numbers of STI diagnoses among MSM/TPSM are not attributable to increased testing alone. Increased CAI and number of partners may be attributable to evolving sexual decision making among PrEP users and their partners. Proportionally, bisexual/other MSM/TPSM have the steepest increase in STI diagnoses.

Human Immunodeficiency Virus Preexposure Prophylaxis Knowledge, Attitudes and Perceptions of Sexual Health Risk in an Age of Sexually Transmitted Infection Antimicrobial Resistance.

BACKGROUND: Human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) has helped reduce new HIV infections. However, bacterial sexually transmitted infections (STIs) have increased among PrEP users. We examined PrEP knowledge, access, and risk perceptions in an age of antimicrobial resistance (AMR). METHODS: An online anonymous survey was distributed to all cisgender men/transpersons who have sex with men attending a sexual health clinic in Bristol, United Kingdom (October 2018 to November 2019). Interviews with a sample identified at increased risk of HIV were analyzed thematically and integrated with survey data. RESULTS: Five hundred and seventy-eight (95%) of 617 cisgender men/transpersons who have sex with men survey respondents were HIV-negative/unknown, of these, 202 (34.9%) had ever used PrEP. Interviewees (n = 24) reported widespread awareness of and enthusiasm for PrEP. Among nonusers, 39% (146/376) were unaware how to access PrEP, and 27% (103/376) could not access PrEP through the national "impact" trial of whom 79% (81/103) were eligible. The PrEP was described as "life-changing," but expense was the main barrier to use. Sixty-two percent (358/578) of HIV-negative/unknown respondents on PrEP were more likely to have condomless anal intercourse with someone they thought was HIV-negative. Interviewees used PrEP with other risk-reduction strategies. Sexually transmitted infections were seen as "curable" and AMR rarely influenced risk perception or sexual decision making. CONCLUSIONS: The PrEP awareness was high, but purchase cost limited access. PrEP may increase condomless anal intercourse, but interviewees used PrEP as one of many risk-reduction tools. Reduced fear of HIV transmission and testing was highly valued. Sexually transmitted infection AMR was not seen as an immediate threat and did not influence risk perception or sexual decision making.

The introduction of a safety checklist in two UK hospital emergency departments: A qualitative study of implementation and staff use.

AIMS AND OBJECTIVES: To explore the extent to which a checklist designed to support patient safety in hospital Emergency Departments was recognised and used by staff. BACKGROUND: Patient crowding in UK Emergency Departments makes it difficult for staff to monitor all patients for signs of clinical deterioration. An Emergency Department Safety Checklist was developed at a UK hospital to ensure patients are regularly monitored. It was subsequently implemented in six hospitals and recommended for use across the National Health Service in England. METHODS: This was a qualitative study in two UK hospital Emergency Departments. Data collection consisted of sixty-six hours of nonparticipant observation and interviews with twenty-six staff. Observations were sampled across different days and times. Interviews sampled a range of staff. Data were analysed thematically. The study was undertaken in accordance with COREQ guidelines. RESULTS: Staff described the Emergency Department Safety Checklist as a useful prompt and reminder for monitoring patients' vital signs and other aspects of care. It was also reported as effective in communicating patient care status to other staff. However, completing the checklist was also described as a task which could be overlooked during busy periods. During implementation, the checklist was promoted to staff in ways that obscured its core function of maintaining patient safety. CONCLUSIONS: The Emergency Department Safety Checklist can support staff in maintaining patient safety. However, it was not fully recognised by staff as a core component of everyday clinical practice. RELEVANCE TO CLINICAL PRACTICE: The Emergency Department Safety Checklist is a response to an overcrowded environment. To realise the potential of the checklist, emergency departments should take the following steps during implementation: (a) focus on the core function of clinical safety, (b) fully integrate the checklist into the existing workflow and (c) employ a departmental team-based approach to implementation and training.

Reducing Primary Care Attendance Intentions for Pediatric Respiratory Tract Infections.

PURPOSE: The aim of this study was to evaluate a theory and evidence-based, parent-targeted online intervention, combining microbiological local syndromic surveillance data, symptom information, and home-care advice, to reduce primary care attendance for self-limiting, low-risk pediatric respiratory tract infections (RTIs). METHODS: The effect of this novel intervention on primary care attendance intentions was evaluated in an online experimental study. A representative sample of mothers (n = 806) was randomly assigned to receive the intervention material before (intervention) or after (control) answering questions concerning attendance intentions for an RTI illness scenario and mediating factors. Both groups provided feedback on the material. Group comparisons, linear regression, and path analyses were conducted. RESULTS: Intervention participants reported lower attendance intentions compared with control participants (d = 0.69, 95% CI, 0.55-0.83), an effect that remained when controlling for demographic and clinical characteristics (B = -1.62, 95% CI, -1.97 to -1.30). The path model highlighted that the intervention effect (B = -0.33, 95% CI, -0.40 to -0.26) was mostly indirect and mediated by infection and antibiotic knowledge, symptom severity concerns, and social norm perceptions concerning attendance. Information on when to attend was rated as the most important intervention component 227 times, followed by symptoms rated 186 times. Information on circulating viruses was rated as least important 274 times. CONCLUSIONS: The intervention was effective in reducing primary care attendance intentions by increasing knowledge, lowering attendance motivation, and reducing the need for additional resources. The contribution of individual intervention components and effects on behavioral outcomes requires further testing.

Acceptability and potential impact of delivering sexual health promotion information through social media and dating apps to MSM in England: a qualitative study.

BACKGROUND: Increasing rates of sexually transmitted infections (STIs) in men-who-have-sex-with-men (MSM) in England is a pressing public health concern. Interventions targeting MSM, including information provision that effectively promotes sexual health, are needed. To support such intervention development, it is necessary to understand acceptable ways of delivering sexual health information. We explored the acceptability and potential uses and impacts of delivering sexual health information to MSM through social media and geosocial networking apps or dating apps. METHODS: Semi-structured interviews were conducted in person or by telephone with 25 MSM resident in England recruited via dating apps and social media advertisements. Interviews explored sexual health information sources, perceptions and uses. Attitudes towards sexual health promotion through social media and dating apps were then discussed. The data were analysed using thematic analysis. RESULTS: Sexual health information delivery through social media and dating apps was considered acceptable. Receiving information when browsing social media was viewed positively by most, as people have time to absorb information. In contrast, concerns were expressed that sharing or commenting on social media sexual health information may lead to judgements and discrimination. While social media reaches a high proportion of the population, dating apps can easily target MSM. However, tensions exist between the ability to provide information at an opportune time through dating apps, when users are connecting with new sexual partners, with the potential to adversely affect the app user's experience. Hypothetical and actual uses and impacts of sexual health information ranged from no impact to reading information, sharing with peers, and increased awareness, to influencing healthcare-seeking, decision-making and risk-taking behaviours. Ensuring that information is engaging, positive in tone, not too clinical, focused on building social norms and delivered by trusted organisations were viewed as important for supporting its use. CONCLUSIONS: Overall, these findings support the development of new interventions that use dating apps and social media for sexual health promotion.

Qualitative evaluation of a pilot educational intervention to increase primary care HIV-testing.

BACKGROUND: UK guidelines recommend a 'routine offer of HIV testing' in primary care where HIV diagnosed prevalence exceeds 2 in 1000. However, current primary care HIV testing rates are low. Efforts to increase primary care HIV testing are needed. To examine how an educational intervention to increase HIV testing in general practice was experienced by healthcare professionals (HCPs) and to understand the perceived impacts on HIV testing. METHOD: Qualitative interviews with general practitioners (GPs) and nurses 3-months after receiving an educational intervention developed from an adapted version of the Medical Foundation for HIV and Sexual Health (MEDFASH) HIV Testing In Practice (TIPs) online educational tool which included training on HIV associated clinical indicator conditions, why, who, and how to test. The intervention was delivered in 19 high-HIV prevalence general practices in Bristol. 27 semi-structured interviews were conducted across 13 practices with 16 GPs, 10 nurses and the sexual health clinician who delivered the intervention. Transcripts were analysed thematically informed by Normalisation Process Theory. RESULTS: HCPs welcomed the opportunity to update their HIV knowledge through a tailored, interactive session. Post-training, HCPs reported increased awareness of HIV indicator conditions, confidence to offer HIV tests and consideration of HIV tests. Continued testing barriers include perceived lack of opportunity. CONCLUSIONS: This qualitative study found that HIV education is perceived as valuable in relation to perceived awareness, confidence, and consideration of HIV testing. However, repetition and support from other strategies are needed to encourage HCPs to offer HIV tests. Future interventions should consider using behaviour change theory to develop a complex intervention that addresses not only HCP capability to offer an HIV test, but also issues of opportunity and motivation.

Co-design of harm reduction materials for people who inject drugs to implement research findings.

BACKGROUND: Equipment used by people who inject drugs (PWID) either has a needle which is fixed to the syringe or can be detached and replaced. Detachable low dead space syringes (LDSS) have been developed, with less space between the needle and plunger (referred to as dead space) than traditional detachable equipment. This equipment can help protect PWID from harm of infection as less blood is transferred if equipment is shared. Our previous research found that detachable LDSS are likely to be acceptable to PWID, and we produced recommendations for their introduction in needle and syringe programmes (NSP) in the United Kingdom (UK). We held a national stakeholder meeting to discuss how to accelerate the pace and scale of the rollout and uptake of detachable LDSS. This commentary reflects on the involvement of PWID as co-designers of harm reduction materials to implement these research findings in a way that supports the uptake of LDSS equipment by NSP and service users. We present the user-centred design process, peer reflections on the project, and lessons learnt by the team working with the peers. MAIN BODY: Peers and stakeholders translated the research into easy to understand messages following a consultation with NSP across the UK. Working with Linnell Publications over three workshops, peers selected their preferred design style and informed the language, messages, and overall look of the designs. The peers ensured the designs avoided images and language with negative connotations, humour, and unequivocal language. Peers said that they found the process enjoyable and informative-leading to increased awareness of harm reduction practices. The facilitators took steps to ensure the views of the peers were heard throughout. They reflected on the importance of involving PWID meaningfully throughout the project. Without the peers, the designs would be less effective and engaging to their target audience. CONCLUSION: We conclude that placing peers at the heart of this research implementation project was essential to ensure the materials are appropriate and engaging and do not stigmatise or alienate the intended audience unintentionally. We recommend that others planning similar work include peers within the entire project to support their meaningful contribution.

Interventions for preventing or treating malnutrition in homeless problem-drinkers: a systematic review.

BACKGROUND: Excessive drinking leads to poor absorption of nutrients and homeless problem-drinkers often have nutritionally inadequate diets. Depletion of nutrients such as vitamin B1 can lead to cognitive impairment, which can hinder efforts to reduce drinking or engage with services. This review aimed to assess effectiveness of interventions designed to prevent or treat malnutrition in homeless problem-drinkers. METHODS: We systematically searched nine electronic databases and 13 grey literature sources for studies evaluating interventions to improve nutrition in homeless populations, without regional or language restrictions. Screening for inclusion was done in duplicate. One reviewer extracted data and assessed risk of bias, and another checked the extractions. Primary outcomes were nutrition status/deficiency, liver damage, and cognitive function. Secondary outcomes included abstinence, comorbidities, resource use, acceptability and engagement with intervention. Results were synthesised narratively. RESULTS: We included 25 studies (2 Randomised Controlled Trials; 15 uncontrolled before and after; 7 surveys; 1 case-control). Nine studies evaluated educational and support interventions, five food provision, and three supplement provision. Eight studies evaluated a combination of these interventions. No two interventions were the same, and all studies were at high risk of bias. Nutritional status (intake/ deficiency) were reported in 11 studies and liver function in one. Fruit and vegetable intake improved with some education and support interventions (n = 4 studies) but not others (n = 2). Vitamin supplements appeared to improve vitamin deficiency levels in the blood (n = 2). Free or subsidised meals (n = 4) and food packs (n = 1) did not always fulfil dietary needs, but were usually considered acceptable by users. Some multicomponent interventions improved nutrition (n = 3) but acceptability varied (n = 3). No study reported cost effectiveness. CONCLUSIONS: The evidence for any one intervention for improving malnutrition in homeless problem-drinkers was based on single studies at high risk of bias. Various food and supplement provision interventions appear effective in changing nutritional status in single studies. Educational and multicomponent interventions show improved nutritional behaviour in some studies but not others. Further better quality evidence is required before these interventions can be recommended for implementation. Any future studies should seek the end user input in their design and conduct. TRIAL REGISTRATION: Registered with PROSPERO: CRD42015024247 .

Evaluation of an educational intervention to increase HIV-testing in high HIV prevalence general practices: a pilot feasibility stepped-wedged randomised controlled trial.

BACKGROUND: HIV-infected patients often present to primary care several times with HIV-indicator conditions before diagnosis but the opportunity to test by healthcare professionals (HCPs) is frequently missed. Current HIV testing rates in primary care are low and educational interventions to facilitate HCPs to increase testing and awareness of HIV are needed. METHOD: We implemented a pilot feasibility stepped-wedged randomised controlled trial of an educational intervention in high HIV prevalence practices in Bristol. The training delivered to HCPs including General Practitioners (GP) aimed to increase HIV testing and included why, who, and how to test. The intervention was adapted from the Medical Foundation for HIV and Sexual Health HIV Testing in Practice (MEDFASH) educational tool. Questionnaires assessed HCP feedback and perceived impacts of the intervention. HIV testing rates were compared between control and intervention practices using 12 monthly laboratory totals. RESULTS: 169 HCPs (from 19 practices) received the educational intervention. 127 (75%) questionnaires were completed. Delivery of the intervention was received positively and was perceived as valuable for increasing awareness, confidence and consideration of testing, with HCPs gaining more awareness of HIV testing guidelines. The main pre-training HIV testing barrier reported by GPs was the patient not considering themselves at risk, whilst for nurses it was a concern about embarrassing or offending the patient. Most HCPs reported the intervention addressed these barriers. The HIV testing rate increased more in the control than in the intervention practices: mean difference 2.6 (95% CI 0.5,4.7) compared with 1.9 (- 0.5,4.3) per 1000 patients, respectively. The number of HIV tests across all practices increased from 1154 in the first 6 months to 1299 in the second 6 months, an annual increase in testing rate of 2.0 (0.7,3.4) from 16.3 to 18.3 per 1000 patients. CONCLUSION: There was a small increase in HIV testing rates over the study period, but this could not be attributed to the educational intervention. More effective and sustainable programmes tailored to each practice context are needed to change testing culture and HCP behaviour. Repeated training, supported by additional measures, such as testing prompts, may be needed to influence primary care HIV testing.

The Antibiotic Guardian campaign: a qualitative evaluation of an online pledge-based system focused on making better use of antibiotics.

BACKGROUND: The Antibiotic Guardian Campaign was developed to increase commitment to reducing Antimicrobial Resistance (AMR), change behaviour and increase knowledge through an online pledge system for healthcare professionals and members of the public to become Antibiotic Guardians (AG). This qualitative evaluation aimed to understand AG experiences of the campaign and perceived impact on behaviour. METHODS: Ninety-four AGs (48 via a survey and 46 who had agreed to future contact) were invited to participate in a telephone semi-structured interview. The sample was based on self-identification as a healthcare professional or a member of the public, pledge group (e.g. adults, primary care prescribers etc.), pledge and gender. Interviews explored how participants became aware of the campaign, reasons for joining, pledge choices, responses to joining and views about the campaign's implementation. Interviews were analysed using the Framework Method. RESULTS: Twenty-two AGs (10 healthcare professionals and 12 members of the public) were interviewed. AGs became aware of the campaign through professional networks and social media, and were motivated to join by personal and professional concern for AMR. Choice of pledge group and pledge were attributed to relevance and potential impact on AMR and the behaviour of others through pledge enactment and promotion of the campaign. Most AGs could not recall their pledge unprompted. Most felt they fulfilled their pledge, although this reflected either behaviour change or the pledge reinforcing pre-existing behaviour. The campaign triggered AGs to reflect on AMR related behaviour and reinforced pre-existing beliefs. Several AGs promoted the campaign to others. Responding collectively as part of the campaign was thought to have a greater impact than individual action. However, limited campaign visibility was observed and the campaign was perceived to have restricted ability to reach those unaware of AMR. CONCLUSIONS: AGs were motivated to reduce AMR and most felt they fulfilled their pledges although for many this appeared to be through reinforcement of existing behaviours. We recommend that the campaign engages those without pre-existing knowledge of AMR by increasing its visibility, capitalising on the diffusion of its message and including more awareness-raising content for those with limited AMR knowledge.

How parents perceive screen viewing in their 5-6 year old child within the context of their own screen viewing time: a mixed-methods study.

BACKGROUND: Few studies have examined parental perceptions of their child's screen-viewing (SV) within the context of parental SV time. This study qualitatively examined parents' perceptions of their 5-6-year-old child's SV within the context of their own quantitatively measured SV. METHODS: A mixed-methods design employed semi-structured telephone interviews, demographic and SV questionnaires, objectively-measured physical activity and sedentary time. Deductive content analysis was used to explore parents' perceptions of, and concerns about, their child's SV, and management of their child's SV. Comparisons were made between parent-child dyads reporting low (<2-h per day) versus high SV time. RESULTS: Fifty-three parents were interviewed (94.3% mothers), with 52 interviews analysed. Fifteen parent-child dyads (28.8%) exceeded the 2-h SV threshold on both weekdays and weekend days; 5 parent-child dyads (9.6%) did not exceed this threshold. The remaining 32 dyads reported a combination of parent or child exceeding/not exceeding the SV threshold on either weekdays or weekend days. Three main themes distinguished the 15 parent-child dyads exceeding the SV threshold from the 5 dyads that did not: 1) parents' personal SV-related views and behaviours; 2) the family SV environment; and 3) setting SV rules and limits. Parents in the dyads not exceeding the SV threshold prioritized and engaged with their children in non-SV behaviours for relaxation, set limits around their own and their child's SV-related behaviours, and described an environment supportive of physical activity. Parents in the dyads exceeding the SV threshold were more likely to prioritise SV as a shared family activity, and described a less structured SV environment with minimal rule setting, influenced their child's need for relaxation time. CONCLUSIONS: The majority of parents in this study who exceeded the SV threshold expressed minimal concern and a relaxed approach to managing SV for themselves and their child(ren), suggesting a need to raise awareness amongst these parents about the time they spend engaging in SV. Parents may understand their SV-related parenting practices more clearly if they are encouraged to examine their own SV behaviours. Designing interventions aimed to create environments that are less supportive of SV, with more structured approaches to SV parenting strategies are warranted.

Community readiness for adolescents' overweight and obesity prevention is low in urban South Africa: a case study.

BACKGROUND: South Africa is undergoing epidemiological and nutrition transitions with associated increases in the incidence of overweight, obesity and diet-related chronic diseases. With the emergence of the nutrition transition in South Africa, there is an urgent need for interventions to prevent overweight and obesity in children and adolescents as risk factors for chronic diseases in adolescence may track throughout later life. This research explored the potential for faith-based organisations (FBOs) to be used as community organisations for overweight and obesity prevention interventions in adolescents by assessing the readiness of religious leaders to engage in such interventions. METHODS: Surveys and focus group discussions (FGDs) were conducted with 51 religious leaders in Johannesburg and Soweto. The Community Readiness Model (CRM) survey was chosen to determine the stage of readiness of this community regarding overweight and obesity prevention. Six different dimensions were assessed in the CRM (community efforts, knowledge of efforts, leadership, community climate, knowledge of the issue, resources). The surveys were scored according to the CRM protocol. The survey data were supplemented with findings from FGDs. Thematic analysis was used to analyse the FGDs. RESULTS: The mean community readiness score was 2.57 ± 0.76 which equates with the "denial/resistance stage". The mean readiness score for resources was the highest of all the dimensions (3.77 ± 0.28), followed by knowledge of the issue (3.20 ± 0.51). The lowest score was seen for community knowledge of efforts (1.77 ± 1.50), followed by community climate (2.00 ± 0.64). FGDs helped interpret the CRM scores. FGDs showed that religious leaders were enthusiastic and recognised that their role was not limited solely to spiritual guidance and mentoring, but also to physical well-being. CONCLUSIONS: Religious leaders recognised that they act as role models within the community and thus have a role to play in improving adolescent health. They have some knowledge about the overweight/obesity issue and some of the resources could be made available to support overweight/obesity prevention-related initiatives. However, the low community knowledge of efforts and the negative prevailing attitude of the community towards overweight and obesity highlight the need to increase awareness of this issue prior to implementing initiatives on overweight and obesity prevention.

Using self-determination theory to promote adolescent girls' physical activity: Exploring the theoretical fidelity of the Bristol Girls Dance Project.

OBJECTIVES: To report the theory-based process evaluation of the Bristol Girls' Dance Project, a cluster-randomised controlled trial to increase adolescent girls' physical activity. DESIGN: A mixed-method process evaluation of the intervention's self-determination theory components comprising lesson observations, post-intervention interviews and focus groups. METHOD: Four intervention dance lessons per dance instructor were observed, audio recorded and rated to estimate the use of need-supportive teaching strategies. Intervention participants (n = 281) reported their dance instructors' provision of autonomy-support. Semi-structured interviews with the dance instructors (n = 10) explored fidelity to the theory and focus groups were conducted with participants (n = 59) in each school to explore their receipt of the intervention and views on the dance instructors' motivating style. RESULTS: Although instructors accepted the theory-based approach, intervention fidelity was variable. Relatedness support was the most commonly observed need-supportive teaching behaviour, provision of structure was moderate and autonomy-support was comparatively low. The qualitative findings identified how instructors supported competence and developed trusting relationships with participants. Fidelity was challenged where autonomy provision was limited to option choices rather than input into the pace or direction of lessons and where controlling teaching styles were adopted, often to manage disruptive behaviour. CONCLUSION: The successes and challenges to achieving theoretical fidelity in the Bristol Girls' Dance Project may help explain the intervention effects and can more broadly inform the design of theory-based complex interventions aimed at increasing young people's physical activity in after-school settings.

From the concrete to the intangible: understanding the diverse experiences and impacts of new transport infrastructure.

BACKGROUND: Changes to the environment that support active travel have the potential to increase population physical activity. The Cambridgeshire Guided Busway is an example of such an intervention that provides new traffic-free infrastructure for walking, cycling and public transport. This qualitative investigation explored the diverse experiences of new transport infrastructure and its impacts on active travel behaviours. METHODS: Thirty-eight adult participants from the Commuting and Health in Cambridge natural experimental study were purposively selected according to their demographic and travel behaviour change characteristics and invited to participate in semi-structured interviews between February and June 2013. A mixed-method, following-a-thread approach was used to construct two contrasting vignettes (stories) to which the participants were asked to respond as part of the interviews. Inductive thematic qualitative analysis of the interview data was performed with the aid of QSR NVivo8. RESULTS: Perceptions of the busway's attributes were important in shaping responses to it. Some participants rarely considered the new transport infrastructure or described it as unappealing because of its inaccessibility or inconvenient routing. Others located more conveniently for access points experienced the new infrastructure as an attractive travel option. Likewise, the guided buses and adjacent path presented ambiguous spaces which were received in different ways, depending on travel preferences. While new features such as on board internet access or off-road cycling were appreciated, shortcomings such as overcrowded buses or a lack of path lighting were barriers to use. The process of adapting to the environmental change was discussed in terms of planning and trialling new behaviours. The establishment of the busway in commuting patterns appeared to be influenced by whether the anticipated benefits of change were realised. CONCLUSIONS: This study examined the diverse responses to an environmental intervention that may help to explain small or conflicting aggregate effects in quantitative outcome evaluation studies. Place and space features, including accessibility, convenience, pleasantness and safety relative to the alternative options were important for the acceptance of the busway. Our findings show how environmental change supporting active travel and public transport can encourage behaviour change for some people in certain circumstances.

Effect and cost of an after-school dance programme on the physical activity of 11-12 year old girls: The Bristol Girls Dance Project, a school-based cluster randomised controlled trial.

BACKGROUND: The aim of this study was to examine the effectiveness and cost of an after-school dance intervention at increasing the physical activity levels of Year 7 girls (age 11-12). METHODS: A cluster randomised controlled trial was conducted in 18 secondary schools. Participants were Year 7 girls attending a study school. The Bristol Girls Dance Project (BGDP) intervention consisted of up to forty, 75-minute dance sessions delivered in the period immediately after school by experienced dance instructors over 20-weeks. The pre-specified primary outcome was accelerometer assessed mean minutes of weekday moderate to vigorous physical activity (MVPA) at time 2 (52 weeks are T0 baseline assessments). Secondary outcomes included accelerometer assessed mean minutes of weekday MVPA at time 1 (while the intervention was still running) and psychosocial outcomes. Intervention costs were assessed. RESULTS: 571 girls participated. Valid accelerometer data were collected from 549 girls at baseline with 508 girls providing valid accelerometer data at baseline and time 2. There were no differences between the intervention and control group for accelerometer assessed physical activity at either time 1 or time 2. Only one third of the girls in the intervention arm met the pre-set adherence criteria of attending two thirds of the dance sessions that were available to them. Instrumental variable regression analyses using complier average causal effects provided no evidence of a difference between girls who attended the sessions and the control group. The average cost of the intervention was £73 per girl, which was reduced to £63 when dance instructor travel expenses were excluded. CONCLUSION: This trial showed no evidence that an after-school dance programme can increase the physical activity of Year 7 girls. The trial highlighted the difficulty encountered in maintaining attendance in physical activity programmes delivered in secondary schools. There is a need to find new ways to help adolescent girls to be physically active via identifying ways to support and encourage sustained engagement in physical activity over the life course. TRIAL REGISTRATION: ISRCTN52882523.