Reflections on co-producing an obesity-prevention toolkit for Islamic Religious Settings: a qualitative process evaluation.

BACKGROUND: Islamic leaders, staff, and Muslim parents in the UK are supportive of healthy lifestyle intervention delivery through Islamic Religious Settings. Such interventions are necessary given high obesity rates in British South Asian (40%) compared to White British (32%) children of equivalent age. Co-production can facilitate the development of culturally appropriate health interventions, however it can be theoretically and practically challenging, and evaluation of co-production within an Islamic Religious Setting context is lacking. The aim of this study was to examine the feasibility and acceptability of taking a co-production approach to develop an obesity-prevention toolkit for Islamic Religious Settings. METHODS: An obesity-prevention toolkit for use in Islamic Religious Settings, incorporating physical activity, healthy diet, and organisational change, has been co-produced to be evidence-informed and contextually relevant. A qualitative process evaluation was employed to examine experiences of co-production. Semi-structured interviews (n = 15) and a focus group (n = 5) were conducted with toolkit co-production stakeholders, e.g., subject experts, an Islamic scholar, and Islamic Religious Setting staff. Transcripts were analysed inductively using reflexive thematic analysis. RESULTS: The analysis revealed four major themes regarding stakeholders' experiences of co-producing a childhood obesity-prevention toolkit for Islamic Religious Settings. These themes are: (1) attitudes towards obesity-prevention through Islamic Religious Settings, (2) benefits of co-production including capacity building and ownership (3) negotiating involvement, power, and perspectives within the co-production process, and (4) the complexities of effective communication in co-production. CONCLUSION: This study adds to the evidence-base in support of delivering health promotion through faith settings. Taking a co-production approach to develop an obesity-prevention toolkit for Islamic Religious Settings provided benefit to the toolkit product and local stakeholders. The toolkit is currently being implemented across Bradford, UK and there is potential to adapt the toolkit to other geographical contexts, and for evaluating effectiveness for preventing obesity in British Muslim families.

Study Protocol. Evaluating the life-course health impact of a city-wide system approach to improve air quality in Bradford, UK: A quasi-experimental study with implementation and process evaluation.

BACKGROUND: Air quality is a major public health threat linked to poor birth outcomes, respiratory and cardiovascular disease, and premature mortality. Deprived groups and children are disproportionately affected. Bradford will implement a Clean Air Zone (CAZ) as part of the Bradford Clean Air Plan (B-CAP) in 2022 to reduce pollution, providing a natural experiment. The aim of the current study is to evaluate the impact of the B-CAP on health outcomes and air quality, inequalities and explore value for money. An embedded process and implementation evaluation will also explore barriers and facilitators to implementation, impact on attitudes and behaviours, and any adverse consequences. METHODS: The study is split into 4 work packages (WP). WP1A: 20 interviews with decision makers, 20 interviews with key stakeholders; 10 public focus groups and documentary analysis of key reports will assess implementation barriers, acceptability and adverse or unanticipated consequences at 1 year post-implementation (defined as point at which charging CAZ goes 'live'). WP1B: A population survey (n = 2000) will assess travel behaviour and attitudes at baseline and change at 1 year post-implementation). WP2: Routine air quality measurements will be supplemented with data from mobile pollution sensors in 12 schools collected by N = 240 pupil citizen scientists (4 within, 4 bordering and 4 distal to CAZ boundary). Pupils will carry sensors over four monitoring periods over a 12 month period (two pre, and two post-implementation). We will explore whether reductions in pollution vary by CAZ proximity. WP3A: We will conduct a quasi-experimental interrupted time series analysis using a longitudinal routine health dataset of > 530,000 Bradford residents comparing trends (3 years prior vs 3 years post) in respiratory health (assessed via emergency/GP attendances. WP3B: We will use the richly-characterised Born in Bradford cohort (13,500 children) to explore health inequalities in respiratory health using detailed socio-economic data. WP4: will entail a multi-sectoral health economic evaluation to determine value for money of the B-CAP. DISCUSSION: This will be first comprehensive quasi-experimental evaluation of a city-wide policy intervention to improve air quality. The findings will be of value for other areas implementing this type of approach. TRIAL REGISTRATION: ISRCTN67530835 https://doi.org/10.1186/ISRCTN67530835.

Taking a deep breath: a qualitative study exploring acceptability and perceived unintended consequences of charging clean air zones and air quality improvement initiatives amongst low-income, multi-ethnic communities in Bradford, UK.

BACKGROUND: Poor air quality is the one of the biggest causes of early death and illness across the lifespan. In the UK, 28 local authorities with illegal pollution levels have been mandated by the Government to develop plans to rapidly reduce pollution to legal limits. These plans include consideration of implementing one of four of charging 'Clean Air Zone' (CAZ) classes in areas of high pollution which would charge older polluting vehicles a daily charge to enter. While this offers a potential to improve air quality, the extent to which CAZ might impact (for example, economically) on socio-economically deprived groups and local businesses is unclear. AIMS: To explore the acceptability and perceived unintended consequences of a CAZ and other initiatives to improve air quality with seldom-heard communities living in deprived, multi-ethnic areas within the city of Bradford, UK. METHODS: Ten semi-structured focus groups were conducted with people who live in areas of high pollution and deprivation. A total of 87 people participated from a diverse range of ethnic backgrounds with the majority of Pakistani origin. Recorded data were transcribed, coded and analysed using thematic analysis. FINDINGS: As poor air quality was not always visible it was seen as a hidden issue by many, and not prioritised over other more visible environmental issues (e.g. fly-tipping, littering). There was resistance to proposals which included charging private vehicles. Many felt that low-income families did not have the resources to purchase compliant vehicles or pay daily charges, placing a disproportionate burden on them. It was also felt that low-income taxi drivers would be disproportionately affected financially by proposals. Public transport infrastructure was felt to be inadequate. Other traffic management or emission reduction activities were also explored. Views towards these initiatives were more positive if they did not directly affect individuals financially. CONCLUSION: Air quality initiatives such as CAZs were felt to be likely to financially disadvantage communities already living in socio-economic and environmental poverty. Policy makers need to carefully consider appropriate mitigation strategies to ensure that health and economic inequalities are not increased by implementation of CAZ. Given air quality is low priority for some groups, careful engagement and communication will be required to increase acceptance interventions such as CAZs.

Behaviour change intervention for smokeless tobacco cessation: its development, feasibility and fidelity testing in Pakistan and in the UK.

BACKGROUND: People of South Asian-origin are responsible for more than three-quarters of all the smokeless tobacco (SLT) consumption worldwide; yet there is little evidence on the effect of SLT cessation interventions in this population. South Asians use highly addictive and hazardous SLT products that have a strong socio-cultural dimension. We designed a bespoke behaviour change intervention (BCI) to support South Asians in quitting SLT and then evaluated its feasibility in Pakistan and in the UK. METHODS: We conducted two literature reviews to identify determinants of SLT use among South Asians and behaviour change techniques (BCTs) likely to modify these, respectively. Iterative consensus development workshops helped in selecting potent BCTs for BCI and designing activities and materials to deliver these. We piloted the BCI in 32 SLT users. All BCI sessions were audiotaped and analysed for adherence to intervention content and the quality of interaction (fidelity index). In-depth interviews with16 participants and five advisors assessed acceptability and feasibility of delivering the BCI, respectively. Quit success was assessed at 6 months by saliva/urine cotinine. RESULTS: The BCI included 23 activities and an interactive pictorial resource that supported these. Activities included raising awareness of the harms of SLT use and benefits of quitting, boosting clients' motivation and self-efficacy, and developing strategies to manage their triggers, withdrawal symptoms, and relapse should that occur. Betel quid and Guthka were the common forms of SLT used. Pakistani clients were more SLT dependent than those in the UK. Out of 32, four participants had undetectable cotinine at 6 months. Fidelity scores for each site varied between 11.2 and 42.6 for adherence to content - maximum score achievable 44; and between 1.4 and 14 for the quality of interaction - maximum score achievable was 14. Interviews with advisors highlighted the need for additional training on BCTs, integrating nicotine replacement and reducing duration of the pre-quit session. Clients were receptive to health messages but most reported SLT reduction rather than complete cessation. CONCLUSION: We developed a theory-based BCI that was also acceptable and feasible to deliver with moderate fidelity scores. It now needs to be evaluated in an effectiveness trial.

Who shouts the loudest? A qualitative study exploring barriers and enablers to implementing a low emission zone in a Northern UK city.

Pollution is a major cause of ill health globally. Low emission zones (LEZ) have been identified as effective in reducing pollution and are increasing in popularity but remain divisive. Understanding what factors help or hinder implementation is important. In the UK, Clean Air Zones (CAZ, a type of LEZ) are being implemented in several cities. We aimed to identify key barriers and enablers to the implementation of a CAZ in real time, as policy was being developed and implemented in a large Northern city in England, UK. Twenty-five semi-structured interviews were conducted with city stakeholders and implementors approximately 6 months before a CAZ charging non-compliant taxis, buses, heavy goods vehicles and vans was launched. Thematic analysis was used to analyse data. Implementers were required to operate within a tight policy framework. Key enablers included: freedom to adapt the framework to local context, financial support, and cross-sector working. A focus on health was felt to be useful in justifying the policy to the public. Key barriers included conflict and opposition from local industry, politicians, and communities. Implementation of air quality policy which involves traffic restrictions remains controversial. The voices which 'shout the loudest' are often those with negative views, and these can create divisive discourse which shape public opinion and damage confidence of implementers. A systems perspective is needed to understand socio-political contexts which can influence implementation success. We provide recommendations to other areas considering implementing a LEZ.

School-Based Interventions to Support Healthy Indoor and Outdoor Environments for Children: A Systematic Review.

Environmental exposures are associated with children's health. Schools are often urban exposure 'hotspots' for pollution, noise, lack of green space and un-walkable built environments. The aim of this systematic review was to explore the impact of school-based interventions on the modification of indoor and outdoor stressors related to the built and natural environment on children's exposure and health. A systematic review of seven databases was performed. We included quantitative studies on children aged 5-12, which reported intervention delivered within school settings aimed at addressing key environmental exposures including air pollution, green spaces, traffic noise or active travel; and reported physical and mental health, physical activity or active travel behavior. The quality of studies was assessed and interventions were described using a standardized framework. A narrative synthesis approach was used to describe the findings. Thirty-nine papers were included on three main intervention types: improve indoor air quality by the increase of ventilation rates in classrooms; increase children's green time or greening schools, and multicomponent interventions to increase active travel to school by changes in pedestrian facilities. No eligible intervention to reduce traffic noise at school was found. Increasing ventilation rates improved short-term indoor air quality in classrooms, but the effect on cognitive performance was inconsistent. Greening schools and increasing children's green time have consistent positive effects on cognition and physical activity, but not in behavior. Multi-component interventions can increase walking and cycling after three years. Overall, the studies were rated as having poor quality owing to weak study designs. We found modest evidence that school-based built and natural environment interventions can improve children's exposure and health.

A randomised controlled feasibility trial of an early years language development intervention: results of the 'outcomes of Talking Together evaluation and results' (oTTer) project.

BACKGROUND: Early language difficulties are associated with poor school readiness and can impact lifelong attainment. The quality of the early home language environment is linked to language outcomes. However, few home-based language interventions have sufficient evidence of effectiveness in improving preschool children's language abilities. This study reports the first stage in the evaluation of a theory-based programme, Talking Together (developed and delivered by BHT Early Education and Training) given over 6 weeks to families in the home setting. We aimed to test the feasibility and acceptability of delivering Talking Together in the Better Start Bradford community prior to a definitive trial, using a two-armed randomised controlled feasibility study. METHODS: Families from a single site within the Better Start Bradford reach area were randomly allocated (1:1) to the Talking Together intervention or a wait list control group. Child language and parent-level outcome measures were administered before randomisation (baseline), pre-intervention (pre-test), 2 months post-intervention start (post-test), and 6 months post-intervention start (follow-up). Routine monitoring data from families and practitioners were also collected for eligibility, consent, protocol adherence, and attrition rates. Descriptive statistics on the feasibility and reliability of potential outcome measures were analysed alongside qualitative feedback on trial design acceptability. Pre-defined progression-to-trial criteria using a traffic light system were assessed using routine monitoring data. RESULTS: Two-hundred and twenty-two families were assessed for eligibility; of these, 164 were eligible. A total of 102 families consented and were randomised (intervention: 52, waitlist control: 50); 68% of families completed outcome measures at 6-month follow-up. Recruitment (eligibility and consent) reached 'green' progression criteria; however, adherence reached 'amber' and attrition reached 'red' criteria. Child- and parent-level data were successfully measured, and the Oxford-CDI was identified as a suitable primary outcome measure for a definitive trial. Qualitative data not only indicated that the procedures were largely acceptable to practitioners and families but also identified areas for improvement in adherence and attrition rates. CONCLUSIONS: Referral rates indicate that Talking Together is a much-needed service and was positively received by the community. A full trial is feasible with adaptations to improve adherence and reduce attrition. TRIAL REGISTRATION: ISRCTN registry ISRCTN13251954. Retrospectively registered 21 February 2019.

The art of Patient and Public Involvement: exploring ways to research and reduce air pollution through art-based community workshops - a reflective paper.

In this reflective paper we outline and discuss our art-based Patient and Public Involvement (PPI) approach.  This exercise held two broad objectives. Firstly, to assist policy makers in understanding the types of interventions communities will find acceptable to address the problem of poor air quality, and secondly, to ascertain community views about our research plans to explore the impact of the planned interventions on neighbourhoods.  We reflect on both our approach and the emergent conversations from the PPI activity.  Attendees contributed to the process and stressed the importance of not burdening poor neighbourhoods with costly charges as that would ameliorate one health problem but generate others as a consequence of additional financial burden.  Equally, they stressed the need to conduct research on matters which they could connect with such as the impact of clean air plans on young children and how information about air pollution is disseminated in their neighbourhoods as and when research findings emerge.  This paper offers a conceptual analysis of the art-based PPI method and uniquely draws a connection to the philosophical traditions of Ludwig Wittgenstein.  Specifically, we demonstrate how art is conducive to creating a dialogue which is specifically helpful for PPI purposes for both researchers and implementers, and conversely, why traditional conversational approaches may have fallen short of the adequacy mark in this regard.