Explaining differential socioeconomic effects in population health interventions: development and application of a new tool to classify intervention agentic demand.

BACKGROUND: The agentic demand of population health interventions (PHIs) might influence how interventions work. Highly agentic interventions (eg, information campaigns) rely on recipients noticing and responding to the intervention. Resources required for individuals to benefit from highly agentic interventions have a socioeconomical pattern, thus agentic demand might affect intervention effectiveness and equity. Systematic evidence exploring these associations is missing due to the absence of adequate tools to classify agentic demands. We aimed to develop such a tool and test its application. METHODS: Our iterative development process involved: (1) systematic identification of diet and physical activity PHIs; (2) coding of intervention actors and actions; (3) data synthesis; (4) expert qualitative feedback; and (5) reliability assessment. We searched nine databases for articles published between Jan 1, 2010, and Aug 17, 2020. For all included articles, we coded the actors (people required to act within an intervention) and their actions (what they were required to do for the intervention to have its intended effects). We combined these codes for similar intervention types to develop overarching schematic flow chart diagrams used to identify concepts, and we organised these into a draft tool. After expert feedback, and we assessed inter-rater reliability of the final version. We applied the final tool in a proof-of-concept review, extracting studies from three existing equity-focused systematic reviews on tool category, overall intervention effect, and differential socioeconomic effects and visualised findings. FINDINGS: We identified three concepts affecting agentic demands of intervention components: exposure, two levels (how recipients encounter the intervention); mechanism of action, five levels; and engagement, two levels (how recipients respond to the intervention). We then combined these concepts to form 20 categories that grouped together interventions with similar agentic demands. In the review, we applied the tool to 26 PHIs that included 163 components. Intervention components were concentrated in a small number of categories, and their categorisation was related to intervention equity but not to effectiveness. INTERPRETATION: We present a novel tool to classify the agentic demand of PHIs and demonstrate its feasibility within a systematic review. Linking intervention types to their effect on inequalities enables these factors to be considered when designing or selecting interventions. Users of the tool can avoid implementing intervention types that are likely to widen inequalities or implement them alongside counter-strategies to minimise any adverse equity effects. Applying this tool within future research, policy, and practice to design, select, evaluate, and synthesise evidence from PHIs has the potential to advance our understanding of how interventions work and their effect on socioeconomic inequalities. FUNDING: Public Health Policy Research Unit (PH-PRU), National Institute for Health and Care Research (NIHR) Policy Research Programme.

Parliamentary reaction to the announcement and implementation of the UK Soft Drinks Industry Levy: applied thematic analysis of 2016-2020 parliamentary debates.

OBJECTIVE: The UK Soft Drinks Industry Levy (SDIL) (announced in March 2016; implemented in April 2018) aims to incentivise reformulation of soft drinks to reduce added sugar levels. The SDIL has been applauded as a policy success, and it has survived calls from parliamentarians for it to be repealed. We aimed to explore parliamentary reaction to the SDIL following its announcement until two years post-implementation in order to understand how health policy can become established and resilient to opposition. DESIGN: Searches of Hansard for parliamentary debate transcripts that discussed the SDIL retrieved 186 transcripts, with 160 included after screening. Five stages of Applied Thematic Analysis were conducted: familiarisation and creation of initial codebooks; independent second coding; codebook finalisation through team consensus; final coding of the dataset to the complete codebook; and theme finalisation through team consensus. SETTING: The United Kingdom Parliament. PARTICIPANTS: N/A. RESULTS: Between the announcement (16/03/2016) - royal assent (26/04/2017), two themes were identified 1: SDIL welcomed cross-party 2: SDIL a good start but not enough. Between royal assent - implementation (5/04/2018), one theme was identified 3: The SDIL worked - what next? The final theme identified from implementation until 16/03/2020 was 4: Moving on from the SDIL. CONCLUSIONS: After the announcement, the SDIL had cross-party support and was recognised to have encouraged reformulation prior to implementation. Lessons for governments indicate that the combination of cross-party support and a policy's documented success in achieving its aim can help cement the resilience of it to opposition and threats of repeal.

Engagement With mHealth COVID-19 Digital Biomarker Measurements in a Longitudinal Cohort Study: Mixed Methods Evaluation.

BACKGROUND: The COVID-19 pandemic accelerated the interest in implementing mobile health (mHealth) in population-based health studies, but evidence is lacking on engagement and adherence in studies. We conducted a fully remote study for ≥6 months tracking COVID-19 digital biomarkers and symptoms using a smartphone app nested within an existing cohort of adults. OBJECTIVE: We aimed to investigate participant characteristics associated with initial and sustained engagement in digital biomarker collection from a bespoke smartphone app and if engagement changed over time or because of COVID-19 factors and explore participants' reasons for consenting to the smartphone substudy and experiences related to initial and continued engagement. METHODS: Participants in the Fenland COVID-19 study were invited to the app substudy from August 2020 to October 2020 until study closure (April 30, 2021). Participants were asked to complete digital biomarker modules (oxygen saturation, body temperature, and resting heart rate [RHR]) and possible COVID-19 symptoms in the app 3 times per week. Participants manually entered the measurements, except RHR that was measured using the smartphone camera. Engagement was categorized by median weekly frequency of completing the 3 digital biomarker modules (categories: 0, 1-2, and ≥3 times per week). Sociodemographic and health characteristics of those who did or did not consent to the substudy and by engagement category were explored. Semistructured interviews were conducted with 35 participants who were purposively sampled by sex, age, educational attainment, and engagement category, and data were analyzed thematically; 63% (22/35) of the participants consented to the app substudy, and 37% (13/35) of the participants did not consent. RESULTS: A total of 62.61% (2524/4031) of Fenland COVID-19 study participants consented to the app substudy. Of those, 90.21% (2277/2524) completed the app onboarding process. Median time in the app substudy was 34.5 weeks (IQR 34-37) with no change in engagement from 0 to 3 months or 3 to 6 months. Completion rates (≥1 per week) across the study between digital biomarkers were similar (RHR: 56,517/77,664, 72.77%; temperature: 56,742/77,664, 73.06%; oxygen saturation: 57,088/77,664, 73.51%). Older age groups and lower managerial and intermediate occupations were associated with higher engagement, whereas working, being a current smoker, being overweight or obese, and high perceived stress were associated with lower engagement. Continued engagement was facilitated through routine and personal motivation, and poor engagement was caused by user error and app or equipment malfunctions preventing data input. From these results, we developed key recommendations to improve engagement in population-based mHealth studies. CONCLUSIONS: This mixed methods study demonstrated both high initial and sustained engagement in a large mHealth COVID-19 study over a ≥6-month period. Being nested in a known cohort study enabled the identification of participant characteristics and factors associated with engagement to inform future applications in population-based health research.

Association between weight change and incidence of cardiovascular disease events and mortality among adults with type 2 diabetes: a systematic review of observational studies and behavioural intervention trials.

AIMS/HYPOTHESIS: Weight loss is often recommended in the treatment of type 2 diabetes. While evidence has shown that large weight loss may lead to diabetes remission and improvement in cardiovascular risk factors, long-term impacts are unclear. We performed a systematic review of studies of weight loss and other weight changes and incidence of CVD among people with type 2 diabetes. METHODS: Observational studies of behavioural (non-surgical and non-pharmaceutical) weight changes and CVD events among adults with type 2 diabetes, and trials of behavioural interventions targeting weight loss, were identified through searches of MEDLINE, EMBASE, Web of Science, CINAHL, and The Cochrane Library (CENTRAL) until 9 July 2019. Included studies reported change in weight and CVD and/or mortality outcomes among adults with type 2 diabetes. We performed a narrative synthesis of observational studies and meta-analysis of trial data. RESULTS: Of 13,227 identified articles, 17 (14 observational studies, three trials) met inclusion criteria. Weight gain (vs no change) was associated with higher hazard of CVD events (HRs [95% CIs] ranged from 1.13 [1.00, 1.29] to 1.63 [1.11, 2.39]) and all-cause mortality (HRs [95% CIs] ranged from 1.26 [1.12, 1.41] to 1.57 [1.33, 1.85]). Unintentional weight loss (vs no change) was associated with higher risks of all-cause mortality, but associations with intentional weight loss were unclear. Behavioural interventions targeting weight loss showed no effect on CVD events (pooled HR [95% CI] 0.95 [0.71, 1.27]; I2 = 50.1%). Risk of bias was moderate in most studies and was high in three studies, due to potential uncontrolled confounding and method of weight assessment. CONCLUSIONS/INTERPRETATION: Weight gain is associated with increased risks of CVD and mortality, although there is a lack of data supporting behavioural weight-loss interventions for CVD prevention among adults with type 2 diabetes. Long-term follow-up of behavioural intervention studies is needed to understand effects on CVD and mortality and to inform policy concerning weight management advice and support for people with diabetes. PROSPERO registration CRD42019127304.

Implementing community-based health promotion in socio-economically disadvantaged areas: a qualitative study.

BACKGROUND: There is a gradient relationship between socio-economic status and health. We investigated the views and perceptions of health promotion service providers regarding factors that affect lack of engagement in public health initiatives by residents in socio-economically disadvantaged (SED) communities. METHODS: We conducted semi-structured interviews with a purposive sample of key providers (n = 15) of community-based health promotion services to elicit their views about engagement-related factors and their experiences of the provision, delivery and impact of health promotion in SED areas. Interviews were analysed using thematic analysis. RESULTS: Failure to (i) recognise within SED communities, socio-cultural norms of health-related behaviour and (ii) communicate to local residents an understanding of complex lifestyle influences appeared to affect adversely service engagement and contribute to the development of negative attitudes towards health promotion. Engagement is more likely when services are delivered within familiar settings, peer support is available, initiatives are organized within existing groups, external incentives are offered and there are options regarding times and locations. Collaborative working between providers and communities facilitates efficient, context-sensitive service delivery. CONCLUSIONS: Knowledge of a local community and its socio-environmental context alongside a collaborative, facilitative and tailored approach to delivery are required to ensure successful engagement of SED communities in health promotion.

The effect of community-based interventions for cardiovascular disease secondary prevention on behavioural risk factors.

Cardiovascular disease (CVD) is the leading cause of death worldwide, and its prevalence is increasing; with limited healthcare resources, secondary prevention programmes outside traditional hospital settings are needed, but their effectiveness is unclear. We aimed to assess the effectiveness of secondary prevention cardiovascular risk reduction programmes delivered in venues situated within the community on modification of behavioural risk factors. We searched five databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane library) to identify trials of health behaviour interventions for adults with CVD in community-based venues. Primary outcomes were changes in physical activity, diet, smoking and/or alcohol consumption. Two reviewers independently assessed articles for eligibility and risk of bias; statistical analysis used Revman v5.3. Of 5905 articles identified, 41 articles (38 studies) (n = 7970) were included. Interventions were mainly multifactorial, educational, psychological and physical activity-based. Meta-analyses identified increased steps/week (Mean Difference (MD): 7480; 95% CI 1,940, 13,020) and minutes of physical activity/week (MD: 59.96; 95% CI 15.67, 104.25) associated with interventions. There was some evidence for beneficial effects on peak VO2, blood pressure, total cholesterol and mental health. Variation in outcome measurements reported for other behavioural risk factors limited our ability to perform meta-analyses. Effective interventions were based in homes, general practices or outpatient settings, individually tailored and often multicomponent with a theoretical framework. Our review identified evidence that interventions for secondary CVD prevention, delivered in various community-based venues, have positive effects on physical activity; such opportunities should be promoted by health professionals.

Reducing the Impact of Immigration Enforcement Policies to Ensure the Health of North Carolinians: Statewide Community-Level Recommendations.

BACKGROUND: Research indicates that fear of immigration enforcement among Latinos in North Carolina results in limited access to and utilization of health services and negative health consequences. This project developed recommendations to mitigate the public health impact of immigration enforcement policies in North Carolina. METHODS: Our community-based participatory research partnership conducted 6 Spanish-language report-backs (an approach to sharing, validating, and interpreting data) and 3 bilingual forums with community members and public health leaders throughout North Carolina. The goals of these events were to discuss the impact of immigration enforcement on Latino health and develop recommendations to increase health services access and utilization. Findings from the report-backs and forums were analyzed using grounded theory to identify and refine common recommendations. RESULTS: A total of 344 people participated in the report-backs and forums. Eight recommendations emerged: increase knowledge among Latinos about local health services; build capacity to promote policy changes; implement system-level changes among organizations providing health services; train lay health advisors to help community members navigate systems; share Latinos' experiences with policy makers; reduce transportation barriers; increase schools' support of Latino families; and increase collaboration among community members, organizations, health care providers, and academic researchers. LIMITATIONS: Representatives from 16 of 100 North Carolina counties participated. These 16 counties represent geographically diverse regions, and many of these counties have large Latino populations. CONCLUSIONS: Immigration enforcement is a public health issue. Participants proposed developing new partnerships, identifying strategies, and implementing action steps for carrying out recommendations to reduce negative health outcomes among Latinos in North Carolina.

The impact of local immigration enforcement policies on the health of immigrant hispanics/latinos in the United States.

OBJECTIVES: We sought to understand how local immigration enforcement policies affect the utilization of health services among immigrant Hispanics/Latinos in North Carolina. METHODS: In 2012, we analyzed vital records data to determine whether local implementation of section 287(g) of the Immigration and Nationality Act and the Secure Communities program, which authorizes local law enforcement agencies to enforce federal immigration laws, affected the prenatal care utilization of Hispanics/Latinas. We also conducted 6 focus groups and 17 interviews with Hispanic/Latino persons across North Carolina to explore the impact of immigration policies on their utilization of health services. RESULTS: We found no significant differences in utilization of prenatal care before and after implementation of section 287(g), but we did find that, in individual-level analysis, Hispanic/Latina mothers sought prenatal care later and had inadequate care when compared with non-Hispanic/Latina mothers. Participants reported profound mistrust of health services, avoiding health services, and sacrificing their health and the health of their family members. CONCLUSIONS: Fear of immigration enforcement policies is generalized across counties. Interventions are needed to increase immigrant Hispanics/Latinos' understanding of their rights and eligibility to utilize health services. Policy-level initiatives are also needed (e.g., driver's licenses) to help undocumented persons access and utilize these services.

Use of an employment advisory service by cancer survivors.

Employment issues for cancer survivors (CS) were investigated from the perspective of Northern Ireland government general employment advisors. An e-survey was designed and developed based on the results of a scoping search of journal articles, previously validated questionnaires and relevant related surveys; discussions of draft versions of the e-survey and method with lead representatives of stakeholder organizations; and a pilot study with seven prospective respondents. The e-survey and subsequent reminder to employment advisors were distributed internally by the government employment advisory agency. The e-survey was completed by 78/156 (50%) advisors, the majority of whom (74%) received a request for advice in the last year from at least one CS. Most CS used the employment service less than 1 year (52%) or 1 year or more after treatment (32%). Fatigue was the most commonly reported barrier to returning to work (10%) and staying in work (14%), and a supportive employer was the top facilitating factor in returning to (21%) and continuing in (27%), employment. Although most advisors had a positive attitude about a CS's capacity to return to work, half were uncertain about how best to advise cancer survivors.

Children's experiences of care on walking and cycling journeys between home and school in Healthy New Towns: Reframing active school travel.

The Healthy New Town programme in England set out to 'put health into place' by supporting the design and construction of healthy places to live, including by creating safe environments for active travel. To explore the impact of this approach, this study examined how children and their families experienced school journeys in two contrasting Healthy New Towns in England, one an affluent new town in the early stages of construction and the other more economically deprived and established. We undertook photo-elicitation and go-along interviews with 24 children aged 7-12 years and semi-structured interviews with 17 caregivers. We found that experiences of care were important for children's school travel. In the 'deprived' town, opportunities for children to care and to be cared for were enjoyed, facilitated by routes with limited traffic, pockets of 'nature', and possibilities to encounter meaningful others. For families living in a town under construction, the need to negotiate unfinished travel infrastructure, and a sense of being 'in limbo', was experienced as an absence of care by planners and developers. Interventions to promote children's active travel should consider the role of care-full planning in facilitating walking and cycling journeys.

A registered report survey of open research practices in psychology departments in the UK and Ireland.

Open research practices seek to enhance the transparency and reproducibility of research. While there is evidence of increased uptake in these practices, such as study preregistration and open data, facilitated by new infrastructure and policies, little research has assessed general uptake of such practices across psychology university researchers. The current study estimates psychologists' level of engagement in open research practices across universities in the United Kingdom and Ireland, while also assessing possible explanatory factors that may impact their engagement. Data were collected from 602 psychology researchers in the United Kingdom and Ireland on the extent to which they have implemented various practices (e.g., use of preprints, preregistration, open data, open materials). Here we present the summarized descriptive results, as well as considering differences between various categories of researcher (e.g., career stage, subdiscipline, methodology), and examining the relationship between researcher's practices and their self-reported capability, opportunity, and motivation (COM-B) to engage in open research practices. Results show that while there is considerable variability in engagement of open research practices, differences across career stage and subdiscipline of psychology are small by comparison. We observed consistent differences according to respondent's research methodology and based on the presence of institutional support for open research. COM-B dimensions were collectively significant predictors of engagement in open research, with automatic motivation emerging as a consistently strong predictor. We discuss these findings, outline some of the challenges experienced in this study, and offer suggestions and recommendations for future research. Estimating the prevalence of responsible research practices is important to assess sustained behaviour change in research reform, tailor educational training initiatives, and to understand potential factors that might impact engagement.

3-D jobs and health disparities: The health implications of Latino chicken catchers' working conditions.

OBJECTIVES: This study uses qualitative data to describe the tasks performed by chicken catchers, their organization of work, and possible health and safety hazards encountered. METHODS: Twenty-one Latino immigrant chicken catchers for North Carolina poultry-processing plants were interviewed to obtain their perceptions of the job and its hazards. Interviews were recorded and transcribed (n = 10) or detailed notes recorded (n = 11). Transcripts and notes were subjected to qualitative analysis. RESULTS: Chicken catching takes place in a highly contaminated and hazardous work environment. The fast pace of work, low level of control over work intensity, and piece rate compensation all result in high potential for work-related injury and illness, including trauma, electrical shock, respiratory effects, musculoskeletal injuries, and drug use. Workers receive little safety or job training. CONCLUSIONS: Chicken catching is characterized by a work environment and organization of work that promote injury and illness.

Children's experiences of the journey between home and school: A qualitative synthesis using meta-ethnography.

This paper uses meta-ethnography to synthesise qualitative and ethnographic studies of children's (aged 5-13) experiences of socio-material environments on their school journey. Most of the 21 papers (18 studies) identified from the systematic search were from high-income countries and used self-report qualitative methods. Our synthesis shows children can feel vulnerable, but also negotiate journeys and manage risks, enjoy shared and solitary mobility, and explore their material environments. School journeys offer children a place to learn and develop agency within their socio-material environments. Attending to these wider benefits of school journeys, alongside supporting children to develop active modes attuned to the risks associated with these journeys, could improve the reach and impact of active school travel initiatives.

Acceptability and feasibility of an acceptance and commitment therapy-based guided self-help intervention for weight loss maintenance in adults who have previously completed a behavioural weight loss programme: the SWiM feasibility study protocol.

INTRODUCTION: The cost-effectiveness and long-term health impact of behavioural weight management programmes depends on post-treatment weight-loss maintenance. Growing evidence suggests that interventions using acceptance and commitment therapy (ACT) could improve long-term weight management. We developed an ACT-based, guided self-help intervention to support adults who have recently completed a behavioural weight loss programme. This study will assess the feasibility and acceptability of this type of intervention and findings will inform the development of a full-scale trial. METHODS AND ANALYSIS: This is a pragmatic, randomised, single-blind, parallel group, two-arm, feasibility study with an embedded process evaluation. We will recruit and randomise 60 adults who have recently completed a behavioural weight loss programme to the ACT-based intervention or standard care, using a computer-generated sequence with 2:1 allocation stratified by diabetes status and sex. Baseline and 6-month measurements will be completed using online questionnaires. Qualitative interviews will be conducted with a subsample of participants and coaches about their experiences at 3 (mid-intervention) and 6 (postintervention) months. Feasibility and acceptability of the intervention, and a full-scale trial will be assessed using a number of outcomes, including adherence to, and engagement with the intervention, recruitment and retention rates, proportion of missing data for each outcome measure, participants' experiences of the intervention and study, and coaches' experiences of delivering intervention support. Quantitative and qualitative findings will be integrated and summarised to contribute to the interpretation of the main feasibility evaluation findings. Value of information methods will be used to estimate the decision uncertainty associated with the intervention's cost-effectiveness and determine the value of a definitive trial. ETHICS AND DISSEMINATION: Ethical approval was received from Cambridge South Research Ethics Committee on 15/03/2021 (21/EE/0024). This protocol (V.2) was approved on 19 April 2021. Findings will be published in peer-reviewed scientific journals and communicated to other stakeholders as appropriate. TRIAL REGISTRATION NUMBER: ISRCTN12685964.

Development of a Web-Based, Guided Self-help, Acceptance and Commitment Therapy-Based Intervention for Weight Loss Maintenance: Evidence-, Theory-, and Person-Based Approach.

BACKGROUND: The long-term impact and cost-effectiveness of weight management programs depend on posttreatment weight maintenance. There is growing evidence that interventions based on third-wave cognitive behavioral therapy, particularly acceptance and commitment therapy (ACT), could improve long-term weight management; however, these interventions are typically delivered face-to-face by psychologists, which limits the scalability of these types of intervention. OBJECTIVE: The aim of this study is to use an evidence-, theory-, and person-based approach to develop an ACT-based intervention for weight loss maintenance that uses digital technology and nonspecialist guidance to minimize the resources needed for delivery at scale. METHODS: Intervention development was guided by the Medical Research Council framework for the development of complex interventions in health care, Intervention Mapping Protocol, and a person-based approach for enhancing the acceptability and feasibility of interventions. Work was conducted in two phases: phase 1 consisted of collating and analyzing existing and new primary evidence and phase 2 consisted of theoretical modeling and intervention development. Phase 1 included a synthesis of existing evidence on weight loss maintenance from previous research, a systematic review and network meta-analysis of third-wave cognitive behavioral therapy interventions for weight management, a qualitative interview study of experiences of weight loss maintenance, and the modeling of a justifiable cost for a weight loss maintenance program. Phase 2 included the iterative development of guiding principles, a logic model, and the intervention design and content. Target user and stakeholder panels were established to inform each phase of development, and user testing of successive iterations of the prototype intervention was conducted. RESULTS: This process resulted in a guided self-help ACT-based intervention called SWiM (Supporting Weight Management). SWiM is a 4-month program consisting of weekly web-based sessions for 13 consecutive weeks followed by a 4-week break for participants to reflect and practice their new skills and a final session at week 18. Each session consists of psychoeducational content, reflective exercises, and behavioral experiments. SWiM includes specific sessions on key determinants of weight loss maintenance, including developing skills to manage high-risk situations for lapses, creating new helpful habits, breaking old unhelpful habits, and learning to manage interpersonal relationships and their impact on weight management. A trained, nonspecialist coach provides guidance for the participants through the program with 4 scheduled 30-minute telephone calls and 3 further optional calls. CONCLUSIONS: This comprehensive approach facilitated the development of an intervention that is based on scientific theory and evidence for supporting people with weight loss maintenance and is grounded in the experiences of the target users and the context in which it is intended to be delivered. The intervention will be refined based on the findings of a planned pilot randomized controlled trial.

Individual Characteristics Associated with Active Travel in Low and High Income Groups in the UK.

Active travel (AT) has gained increasing attention as a way of addressing low levels of physical activity. However, little is known regarding the relationship between income and AT. The aim of this study was to investigate characteristics associated with undertaking AT in an adult population and by low- and high-income groups. Data collected from the Physical Activity and the Rejuvenation of Connswater (PARC) study in 2017 were used. Participants were categorised into socio-economic groups according to their weekly household income, and were categorised as participating in 'no' AT or 'some' AT and 'sufficient' AT. Multivariable logistic regression explored characteristics associated with AT in the full cohort, and the low- and high-income groups separately. Variables associated with AT in the low-income group were body mass index (BMI), physical activity self-efficacy, marital status, long term illness, difficulty walking and housing tenure. For the high-income group, BMI, marital status, housing tenure and education were associated with AT. For both income groups, there were consistent positive associations with the action/maintenance phase of the stage of change model across all AT categories. The findings suggest that population sub-groups may benefit from targeted initiatives to support engagement in AT and prevent further widening of inequalities.

The impact of adult behavioural weight management interventions on mental health: A systematic review and meta-analysis.

There is good evidence that behavioural weight management interventions improve physical health; however, the impact on mental health remains unclear. We evaluated the impact of behavioural weight management interventions on mental health-related outcomes in adults with overweight or obesity at intervention-end and 12 months from baseline. Eligible studies were randomized controlled trials (RCTs) or cluster RCTs of adult behavioural weight loss interventions reporting affect, anxiety, binge eating, body image, depression, emotional eating, quality of life, self-esteem and stress. We searched seven databases from inception to 7 May 2019 and included 43 articles reporting 42 RCTs. Eighteen studies were deemed to be at high risk of bias. We conducted random-effects meta-analyses, stratified analyses and meta-regression using Stata. Interventions generated greater improvements than comparators for depression, mental health-related quality of life and self-efficacy at intervention-end and 12 months from baseline. There was no difference between groups for anxiety, overall quality of life, self-esteem or stress at intervention-end. There was insufficient evidence to assess the impact on anxiety, binge eating, body image, emotional eating, affect, life satisfaction, self-esteem or stress at intervention-end and/or 12 months from baseline. Although evidence suggests that interventions benefit some aspects of mental health, high-quality, transparently reported RCTs measuring a range of mental health outcomes over longer durations are required to strengthen the evidence base.

Cognitive and behavioural strategies employed to overcome "lapses" and prevent "relapse" among weight-loss maintainers and regainers: A qualitative study.

While many behavioural weight management programmes are effective in the short-term, post-programme weight regain is common. Overcoming "lapses" and preventing "relapse" has been highlighted as important in weight-loss maintenance, but little is known on how this is achieved. This study aimed to compare the cognitive and behavioural strategies employed to overcome "lapses" and prevent "relapse" by people who had regained weight or maintained weight-loss after participating in a weight management programme. By investigating differences between groups, we intended to identify strategies associated with better weight-loss maintenance. Semi-structured interviews were conducted with 26 participants (58% female) recruited from the 5-year follow-up of the Weight Loss Referrals for Adults in Primary Care (WRAP) trial (evaluation of a commercial weight-loss programme). Participants who had lost ≥5% baseline weight during the active intervention were purposively sampled according to 5-year weight trajectories (n = 16 'Regainers', n = 10 'Maintainers'). Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Key differences in strategies were that Maintainers continued to pay attention to their dietary intake, anticipated and planned for potential lapses in high-risk situations, and managed impulses using distraction techniques. Regainers did not report making plans, used relaxed dietary monitoring, found distraction techniques to be ineffective and appeared to have difficulty navigating food within interpersonal relationships. This study is one of the longest qualitative follow-ups of a weight loss trial to date, offering unique insights into long-term maintenance. Future programmes should emphasize strategies focusing on self-monitoring, planning and managing interpersonal relationships to help participants successfully maintain weight-loss in the longer-term.

Impact of adult weight management interventions on mental health: a systematic review and meta-analysis protocol.

INTRODUCTION: The effects of interventions targeting weight loss on physical health are well described, yet the evidence for mental health is less clear. It is essential to better understand the impact of weight management interventions on mental health to optimise care and minimise risk of harm. We will assess the effect of behavioural weight management interventions on mental health in adults with overweight and obesity. METHODS AND ANALYSIS: The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. We will include behavioural weight management interventions with a diet and/or physical activity component focusing on weight loss for adults with a body mass index ≥25 kg/m2. Randomised controlled trials (RCTs) and cluster RCTs will be the only eligible study designs. Outcomes of interest will be related to mental health. The following databases were searched from inception to 07 May 2019: MEDLINE, Embase, Cochrane database (CENTRAL), PsycINFO, ASSIA, AMED and CINAHL. The search strategy was based on four concepts: (1) adults, defined as ≥18 years, with overweight/obesity, defined as BMI ≥25kg/m², (2) weight management interventions, (3) mental health outcomes and (4) study design. The search was restricted to English-language published papers, with no other restrictions applied. Two stage screening for eligibility will be completed by two independent reviewers, with two independent reviewers completing data extraction and risk of bias assessment. Data permitting, a random-effects meta-analysis of outcomes, subgroup analyses and meta-regression will be conducted. If not appropriate, narrative synthesis and 'levels of evidence' assessment will be completed. ETHICS AND DISSEMINATION: Ethical approval is not required as primary data will not be collected. The completed systematic review will be disseminated in a peer-reviewed journal, at conferences and contribute towards the lead author's PhD thesis. PROSPERO REGISTRATION NUMBER: CRD42019131659.

Third-wave cognitive behaviour therapies for weight management: A systematic review and network meta-analysis.

This systematic review and network meta-analysis synthesized evidence on the effects of third-wave cognitive behaviour therapies (3wCBT) on body weight, and psychological and physical health outcomes in adults with overweight or obesity. Studies that included a 3wCBT for the purposes of weight management and measured weight or body mass index (BMI) pre-intervention and ≥ 3 months post-baseline were identified through database searches (MEDLINE, CINAHL, Embase, Cochrane database [CENTRAL], PsycINFO, AMED, ASSIA, and Web of Science). Thirty-seven studies were eligible; 21 were randomized controlled trials (RCT) and included in the network meta-analyses. Risk of bias was assessed using RoB2, and evidence quality was assessed using GRADE. Random-effects pairwise meta-analysis found moderate- to high-quality evidence suggesting that 3wCBT had greater weight loss than standard behavioural treatment (SBT) at post-intervention (standardized mean difference [SMD]: -0.09, 95% confidence interval [CI]: -0.22, 0.04; N = 19; I2 = 32%), 12 months (SMD: -0.17, 95% CI: -0.36, 0.02; N = 5; I2 = 33%), and 24 months (SMD: -0.21, 95% CI: -0.42, 0.00; N = 2; I2 = 0%). Network meta-analysis compared the relative effectiveness of different types of 3wCBT that were not tested in head-to-head trials up to 18 months. Acceptance and commitment therapy (ACT)-based interventions had the most consistent evidence of effectiveness. Only ACT had RCT evidence of effectiveness beyond 18 months. Meta-regression did not identify any specific intervention characteristics (dose, duration, delivery) that were associated with greater weight loss. Evidence supports the use of 3wCBT for weight management, specifically ACT. Larger trials with long-term follow-up are needed to identify who these interventions work for, their most effective components, and the most cost-effective method of delivery.