Conservative management versus tonsillectomy in adults with recurrent acute tonsillitis in the UK (NATTINA): a multicentre, open-label, randomised controlled trial.

BACKGROUND: Tonsillectomy is regularly performed in adults with acute tonsillitis, but with scarce evidence. A reduction in tonsillectomies has coincided with an increase in acute adult hospitalisation for tonsillitis complications. We aimed to assess the clinical effectiveness and cost-effectiveness of conservative management versus tonsillectomy in patients with recurrent acute tonsillitis. METHODS: This pragmatic multicentre, open-label, randomised controlled trial was conducted in 27 hospitals in the UK. Participants were adults aged 16 years or older who were newly referred to secondary care otolaryngology clinics with recurrent acute tonsillitis. Patients were randomly assigned (1:1) to receive tonsillectomy or conservative management using random permuted blocks of variable length. Stratification by recruiting centre and baseline symptom severity was assessed using the Tonsil Outcome Inventory-14 score (categories defined as mild 0-35, moderate 36-48, or severe 49-70). Participants in the tonsillectomy group received elective surgery to dissect the palatine tonsils within 8 weeks after random assignment and those in the conservative management group received standard non-surgical care during 24 months. The primary outcome was the number of sore throat days collected during 24 months after random assignment, reported once per week with a text message. The primary analysis was done in the intention-to-treat (ITT) population. This study is registered with the ISRCTN registry, 55284102. FINDINGS: Between May 11, 2015, and April 30, 2018, 4165 participants with recurrent acute tonsillitis were assessed for eligibility and 3712 were excluded. 453 eligible participants were randomly assigned (233 in the immediate tonsillectomy group vs 220 in the conservative management group). 429 (95%) patients were included in the primary ITT analysis (224 vs 205). The median age of participants was 23 years (IQR 19-30), with 355 (78%) females and 97 (21%) males. Most participants were White (407 [90%]). Participants in the immediate tonsillectomy group had fewer days of sore throat during 24 months than those in the conservative management group (median 23 days [IQR 11-46] vs 30 days [14-65]). After adjustment for site and baseline severity, the incident rate ratio of total sore throat days in the immediate tonsillectomy group (n=224) compared with the conservative management group (n=205) was 0·53 (95% CI 0·43 to 0·65; <0·0001). 191 adverse events in 90 (39%) of 231 participants were deemed related to tonsillectomy. The most common adverse event was bleeding (54 events in 44 [19%] participants). No deaths occurred during the study. INTERPRETATION: Compared with conservative management, immediate tonsillectomy is clinically effective and cost-effective in adults with recurrent acute tonsillitis. FUNDING: National Institute for Health Research.

Exploring the Effects of Volunteering on the Social, Mental, and Physical Health and Well-being of Volunteers: An Umbrella Review.

Volunteering provides unique benefits to organisations, recipients, and potentially the volunteers themselves. This umbrella review examined the benefits of volunteering and their potential moderators. Eleven databases were searched for systematic reviews on the social, mental, physical, or general health benefits of volunteering, published up to July 2022. AMSTAR 2 was used to assess quality and overlap of included primary studies was calculated. Twenty-eight reviews were included; participants were mainly older adults based in the USA. Although overlap between reviews was low, quality was generally poor. Benefits were found in all three domains, with reduced mortality and increased functioning exerting the largest effects. Older age, reflection, religious volunteering, and altruistic motivations increased benefits most consistently. Referral of social prescribing clients to volunteering is recommended. Limitations include the need to align results to research conducted after the COVID-19 pandemic. (PROSPERO registration number: CRD42022349703). Supplementary Information: The online version contains supplementary material available at 10.1007/s11266-023-00573-z.

Barriers and facilitators to implementing the CURE stop smoking project: a qualitative study.

BACKGROUND: The Conversation, Understand, Replace, Experts and evidence-based treatment (CURE) project aims to provide a comprehensive offer of both pharmacotherapy and specialist support for tobacco dependence to all smokers admitted to hospital and after discharge. CURE was recently piloted within a single trust in Greater Manchester, with preliminary evidence suggesting this intervention may be successful in improving patient outcomes. Plans are currently underway to pilot a model based upon CURE in other sites across England. To inform implementation, we conducted a qualitative study, which aimed to identify factors influencing healthcare professionals' implementation behaviour within the pilot site. METHODS: Individual, semi-structured telephone interviews were conducted with 10 purposively sampled health professionals involved in the delivery and implementation of the CURE project pilot. Topic guides were informed by the Theoretical Domains Framework (TDF). Transcripts were analysed in line with the framework method, with data coded to TDF domains to highlight important areas of influence and then mapped to the COM-B to support future intervention development. RESULTS: Eight TDF domains were identified as important areas influencing CURE implementation; 'environmental context and resources' (physical opportunity), 'social influence' (social opportunity), 'goals', 'professional role and identity' and 'beliefs about consequences' (reflective motivation), 'reinforcement' (automatic motivation), 'skills' and 'knowledge' (psychological capability). Most domains had the potential to both hinder and/or facilitate implementation, with the exception of 'beliefs about consequences' and 'knowledge', which were highlighted as facilitators of CURE. Participants suggested that 'environmental context and resources' was the most important factor influencing implementation; with barriers most often related to challenges integrating into the wider healthcare context. CONCLUSIONS: This qualitative study identified multi-level barriers and facilitators to CURE implementation. The use of theoretical frameworks allowed for the identification of domains known to influence behaviour change, and thus can be taken forward to develop targeted interventions to support future service implementation. Future work should focus on discussing these findings with a broad range of stakeholders, to ensure resultant intervention strategies are feasible and practicable within a healthcare context. These findings complement wider evaluative work to support nationwide roll out of NHS funded tobacco dependence treatment services in acute care trusts.

Is Scottish Intercollegiate Guidelines Network guidance for GP management of tonsillitis suitable? A qualitative study.

Background: The Scottish Intercollegiate Guidelines Network (SIGN) developed guidelines for the management of sore throat and indications for tonsillectomy in 1999 to address concerns of unnecessary surgery. Emergency admissions to hospital for tonsillitis have since increased. Adults experience an average of 27 episodes of tonsillitis before undergoing tonsillectomy. We wished to explore the appropriateness of the guidance and/or its implementation in primary care. Aim: To explore the attitudes of GPs to the referral criteria they use when managing adults presenting with acute tonsillitis. Design: Secondary analysis of qualitative data from the NAtional Trial of Tonsillectomy IN Adults (NATTINA) feasibility and process evaluation. Participants and Setting: Twenty-one GPs from practices throughout the UK. Method: In-depth interviews with GPs concerning both the feasibility and process evaluation phases of NATTINA. Analysis was conducted using the framework method. Results: GPs felt it was rarely necessary to refer patients. They were aware of guidelines and would refer if requested by a patient who fulfilled the guidelines criteria and/or who were missing considerable amounts of work. Conclusion: The introduction of the guidelines appears to coincide with what some may have hoped to be a desired effect of reducing adult sore throat referrals and subsequent tonsillectomies by increasing the number of episodes a patient must suffer before the referral threshold is met. GPs may find equipoise for tonsillectomy referral challenging as many patients express a strong preference for surgery. We believe this paper reinforces GP professionalism and patient-centred consultations, and challenges the role of clinical guidelines.

Interventions to reduce the negative effects of alcohol consumption in older adults: a systematic review.

BACKGROUND: Older individuals are consuming alcohol more frequently yet there is limited evidence on the effectiveness of current interventions. This systematic review aims to investigate interventions that target alcohol use in individuals aged 55 + . METHODS: CINAHL, ERIC, MEDLINE, Science Direct, PsychInfo, SCOPUS, Web of Science and socINDEX were searched using terms devised from the PICO (Population, Intervention, Comparison and Outcome) tool. Studies using pharmaceutical interventions, or those that investigated comorbidities or the use of other substances were excluded. Peer reviewed empirical studies written in the English language that compared the outcomes of alcohol related interventions to standard care were included in this review. Studies were appraised and assessed for quality using the relevant Critical Appraisal Skills Programme checklist. RESULTS: Seven papers were included in this review. Six were conducted in the United States of America and one in Denmark. The interventions were carried out in primary care centres and in community based groups. The studies included in this review showed varying levels of success. Participants showed improvements in at least one area of alcohol consumption or frequency of consumption however, these did not always reach significance. CONCLUSION: Individuals in this age group appear to respond well to interventions aimed at reducing alcohol consumption. However, included studies had limitations, in particular many did not include a clear intervention description; leaving us unable to fully investigate the components required for success. Further research is needed on the effective components of alcohol interventions targeting older people.

Primary care physicians' attitudes to the adoption of electronic medical records: a systematic review and evidence synthesis using the clinical adoption framework.

BACKGROUND: Recent decades have seen rapid growth in the implementation of Electronic Medical Records (EMRs) in healthcare settings in both developed regions as well as low and middle income countries. Yet despite substantial investment, the implementation of EMRs in some primary care systems has lagged behind other settings, with piecemeal adoption of EMR functionality by primary care physicians (PCPs) themselves. We aimed to review and synthesise international literature on the attitudes of PCPs to EMR adoption using the Clinical Adoption (CA) Framework. METHODS: MEDLINE, PsycINFO, and EMBASE were searched from 1st January 1996 to 1st August 2017 for studies investigating PCP attitudes towards EMR adoption. Papers were screened by two independent reviewers, and eligible studies selected for further assessment. Findings were categorised against the CA Framework and the quality of studies assessed against one of three appropriate tools. RESULTS: Out of 2263 potential articles, 33 were included, based in North and South America, Europe, Middle East and Hong Kong. Concerns about the accessibility, reliability and EMR utility exerted an adverse influence on PCPs' attitudes to adoption. However many were positive about their potential to improve clinical productivity, patient safety and care quality. Younger, computer-literate PCPs, based in large/multi-group practices, were more likely to be positively inclined to EMR use than older physicians, less-skilled in technology use, based in solo practices. Adequate training, policies and procedures favourably impacted on PCPs' views on EMR implementation. Financial factors were common system level influencers shaping EMR adoption, from start-up costs to the resources required by ongoing use. CONCLUSIONS: By using the CA Framework to synthesise the evidence, we identified a linked series of factors influencing PCPs attitudes to EMR adoption. Findings underline the need to involve end-users in future implementation programmes from the outset, to avoid the development of an EMR which is neither feasible nor acceptable for use in practice. TRIAL REGISTRATION: PROSPERO CRD42016038790 .

A systematic review of the application of Wilson and Cleary health-related quality of life model in chronic diseases.

BACKGROUND: A conceptual model approach to clarify the elements of health-related quality of life (HRQL), their determinants and causal pathways is needed to aid researchers, health practitioners and policy makers in their bid to improve HRQL outcomes in patients. The aim of this systematic review was to appraise empirical evidence on the performance of the Wilson and Cleary Model of HRQL. METHODS: We conducted a search of MEDLINE, Science Direct, PsyARTICLES and CINAHL databases to identify articles that used Wilson and Cleary model to examine HRQL in chronic diseases. A narrative synthesis was employed in the review of the articles. RESULTS: Evidence supports linkages between adjacent concepts and between non-adjacent concepts of the Wilson and Cleary model indicating that in practice there is a need to examine relationships among constructs - or to consider interventions in terms of - both with and without mediators. Symptoms status has the highest magnitude of relative impact on health-related quality of life. CONCLUSION: The Wilson and Cleary model demonstrated good features suitable for evaluating health-related quality of life in chronic diseases.

Promoting physical activity with a school-based dance mat exergaming intervention: qualitative findings from a natural experiment.

BACKGROUND: Physical activity is critical to improving health and well-being in children. Quantitative studies have found a decline in activity in the transition from primary to secondary education. Exergames (active video games) might increase physical activity in adolescents. In January 2011 exergame dance mat systems were introduced in to all secondary schools across two local authority districts in the UK. We performed a quasi-experimental evaluation of a natural experiment using a mixed methods design. The quantitative findings from this work have been previously published. The aim of this linked qualitative study was to explore the implementation of the dance mat scheme and offer insights into its uptake as a physical activity intervention. METHODS: Embedded qualitative interviews at baseline and 12 month follow-up with purposively selected physical education teachers (n = 20) and 25 focus groups with a convenience sample of pupils (n = 120) from five intervention schools were conducted. Analysis was informed by sociology of translation approach. RESULTS: At baseline, participants (both teachers and pupils) reported different expectations about the dance mats and how they could be employed. Variation in use was seen at follow-up. In some settings they were frequently used to engage hard to reach groups of pupils. Overall, the dance mats were not used routinely to increase physical activity. However there were other unanticipated benefits to pupils such as improved reaction time, co-ordination and mathematic skills. The use of dance mats was limited in routine physical education classes because of contextual issues (school/government policy) technological failures (batteries/updates) and because of expectations about how and where they could be used. CONCLUSIONS: Our linked quantitative study (previously published) suggested that the dance mats were not particularly effective in increasing physical activity, but the qualitative results (reported here) show that the dance mats were not used routinely enough to show a significant effect on physical activity of the intervention. This research demonstrates the benefit of using mixed methods to evaluate complex physical activity interventions. Those planning any intervention for promoting physical activity in schools need to understand the distinction between physical activity and physical education.

Perceptions of nursery staff and parent views of healthy eating promotion in preschool settings: an exploratory qualitative study.

BACKGROUND: In the UK just over a fifth of all children start school overweight or obese and overweight 2-5 year olds are at least 4 times more likely to become overweight adults. This can lead to serious future health problems. The WHO have recently highlighted the preschool years as a critical time for obesity prevention, and have recommended preschools as an ideal setting for intervention. However, existing evidence suggests that the preschool environment, including the knowledge, beliefs and practices of preschool staff and parents of young children attending nurseries can be a barrier to the successful implementation of healthy eating interventions in this setting. METHODS: This study examined the perceptions of preschool centre staff and parents' of preschool children of healthy eating promotion within preschool settings. The participants were preschool staff working in private and local authority preschool centres in the North East of England, and parents of preschool children aged 3-4 years. Preschool staff participated in semi-structured interviews (n = 16 female, 1 male). Parents completed a mapping activity interview (n = 14 mothers, 1 father). Thematic analysis was applied to interpret the findings. RESULTS: Complex communication issues surrounding preschool centre dietary 'rules' were apparent. The staff were keen to promote healthy eating to families and felt that parents needed 'education' and 'help'. The staff emphasised that school policies prohibited providing children with sugary or fatty snacks such as crisps, cakes, sweets and 'fizzy' drinks, however, some preschool centres appeared to have difficulty enforcing such guidelines. Parents were open to the idea of healthy eating promotion in preschool settings but were wary of being 'told what to do' and being thought of as 'bad parents'. CONCLUSIONS: There is a need to further explore nursery staff members' personal perceptions of health and how food policies which promote healthier food in preschool settings can be embedded and implemented. Family friendly healthy eating strategies and activities which utilise nudge theory should be developed and delivered in a manner that is sensitive to parents' concerns. Preschool settings may offer an opportunity for delivery of such activities.

Impact of financial incentives on alcohol intervention delivery in primary care: a mixed-methods study.

BACKGROUND: Local and national financial incentives were introduced in England between 2008 and 2015 to encourage screening and brief alcohol intervention delivery in primary care. We used routine Read Code data and interviews with General Practitioners (GPs) to assess their impact. METHODS: A sequential explanatory mixed-methods study was conducted in 16 general practices representing 106,700 patients and 99 GPs across two areas in Northern England. Data were extracted on screening and brief alcohol intervention delivery for 2010-11 and rates were calculated by practice incentive status. Semi-structured interviews with 14 GPs explored which factors influence intervention delivery and recording in routine consultations. RESULTS: Screening and brief alcohol intervention rates were higher in financially incentivised compared to non-incentivised practices. However absolute rates were low across all practices. Rates of short screening test administration ranged from 0.05% (95% CI: 0.03-0.08) in non-incentivised practices to 3.92% (95% CI: 3.70-4.14) in nationally incentivised practices. For the full AUDIT, rates were also highest in nationally incentivised practices (3.68%, 95% CI: 3.47-3.90) and lowest in non-incentivised practices (0.17%, 95% CI: 0.13-0.22). Delivery of alcohol interventions was highest in practices signed up to the national incentive scheme (9.23%, 95% CI: 8.91-9.57) and lowest in non-incentivised practices (4.73%, 95% CI: 4.50-4.96). GP Interviews highlighted a range of influences on alcohol intervention delivery and subsequent recording including: the hierarchy of different financial incentive schemes; mixed belief in the efficacy of alcohol interventions; the difficulty of codifying complex conditions; and GPs' beliefs about patient-centred practice. CONCLUSIONS: Financial incentives have had some success in encouraging screening and brief alcohol interventions in England, but levels of recorded activity remain low. To improve performance, future policies must prioritise alcohol prevention work within the quality and outcomes framework, and address the values, attitudes and beliefs that shape how GPs' provide care.

The effect of dance mat exergaming systems on physical activity and health-related outcomes in secondary schools: results from a natural experiment.

BACKGROUND: Exergaming has been proposed as an innovative method for physical activity promotion. However, large effectiveness studies are rare. In January 2011, dance mat systems were introduced in secondary schools in two districts in England with the aim of promoting an innovative opportunity for physical activity. The aim of this natural experiment was to examine the effect of introducing the dance mat exergaming systems on physical activity and health-related outcomes in 11-13 year old students using a non-randomised controlled design and mixed methods. METHODS: Participants were recruited from five schools in intervention districts (n = 280) and two schools in neighbouring control districts (n = 217). Data on physical activity (accelerometer), anthropometrics (weight, BMI and percentage of body fat), aerobic fitness (20-m multistage shuttle run test), health-related quality of life (Kidscreen questionnaire), self-efficacy (children's physical activity self-efficacy survey), school attendance, focus groups with children and interviews with teachers were collected at baseline and approximately 12 months follow-up. RESULTS: There was a negative intervention effect on total physical activity (-65.4 cpm CI: -12.6 to -4.7), and light and sedentary physical activity when represented as a percentage of wear time (Light: -2.3% CI: -4.5 to 0.2; Sedentary: 3.3% CI: 0.7 to 5.9). However, compliance with accelerometers at follow-up was poor. There was a significant positive intervention effect on weight (-1.7 kg, 95% CI: -2.9 to -0.4), BMI (-0.9 kg/m2, 95% CI: -1.3 to -0.4) and percentage of body fat (-2.2%, 95% CI: -4.2 to -0.2). There was also evidence of improvement in some health-related quality of life parameters: psychological well-being (2.5, 95% CI: 0.1 to 4.8) and autonomy and parent relation (4.2, 95% CI: 1.4 to 7.0). CONCLUSIONS: The implementation of a dance mat exergaming scheme was associated with improvement in anthropometric measurements and parameters of health-related quality of life. However, the mechanisms of these benefits are unclear as there was insufficient data from physical activity to draw robust conclusions. Qualitative findings suggest that there was declining support for the initiative over time, meaning that potential benefits may not have been achieved.

Habitus of home and traditional drinking: a qualitative analysis of reported middle-class alcohol use.

There is evidence that alcohol consumption among those in middle-class occupations consistently exceeds safe levels, yet there has been little research into why this occurs. This article explores the meanings associated with alcohol use among professional, managerial and clerical workers. Qualitative data were collected from five focus groups of male and female employees aged 21-55 (N =49: 32 male, 17 female). Each focus group was conducted on the premises of a medium-scale or large-scale employer, four public sector and one private sector, in the north-east of England. Using Bourdieu's concepts of 'habitus', 'capitals' and 'fields' we found that, among these middle-class occupational groups, alcohol use was associated with two habitus: a 'home drinking' habitus and a 'traditional drinking' habitus. Those of the home drinking habitus particularly used wine as a source of cultural capital and a means of distinction, whereas those in the traditional habitus consumed lager, beer and spirits to have fun in social settings. A small minority appeared to belong to a third, omnivorous, habitus where a wide range of alcoholic drinks were consumed in a variety of contexts. Existing public health initiatives to reduce alcohol consumption may require modification to accommodate a range of drinking cultures.

Domiciliary Carers' Perspectives on Alcohol Use by Older Adults in Their Care: A Systematic Review and Thematic Synthesis of Qualitative Studies.

As global populations continue to age, alcohol consumption rises, and we strive to age in place, it is important to have an up-to-date understanding of domiciliary carers' perspectives on older adults' alcohol use in their care. Therefore, a systematic review and thematic synthesis of qualitative studies of the unique challenges faced by domiciliary care workers in front line roles regarding older adults' alcohol use was conducted (PROSPERO registration number: CRD42024516660). Eight databases were searched on 22 February 2024 for qualitative studies focusing on older adults' (defined as aged 50 or over) alcohol consumption and domiciliary care. The Critical Appraisal Skills Programme checklist was utilised for quality appraisal. Twenty articles reporting 14 unique studies of mainly medium to low quality were included. Three overarching themes (and associated subthemes) were identified as follows: identification (alcohol problems are common, no assessment for alcohol problems, and additional overt signs of excessive alcohol use), management (to buy or not to buy that is the question, balancing rights and risks, monitor and report but do not intervene, maintaining the vicious circle, home as a barrier to accessing support and services, and more support needed from healthcare professionals), and training (lack of alcohol education). Domiciliary carers are well placed to make every contact count to target alcohol consumption but would benefit from support and resources for alcohol consumption identification and management. Clear guidance on how to manage alcohol consumption to harmoniously balance rights and risks is crucial, particularly when caring for older adults with cognitive difficulties.

Embedding Public Health Practice Amongst Allied Health Professionals: A Rapid Scoping Review of International Approaches.

The UK Allied Health Professions Public Health Strategic Framework outlines their commitment to embed disease prevention and public health into allied health practice roles. Yet there is no clear guidance on how best to embed public health into practice. The aim of this study was to examine international approaches which embed public health practices amongst allied health professionals (AHPs). Given the exploratory nature of this study, a rapid scoping review was conducted. Seventy unique references reporting 69 studies were included representing a breadth of countries, extensive timeline (1987-2022) and different AHPs. Worldwide, AHPs are involved in all four domains of public health outlined in the UK Allied Health Professions Public Health Strategic Framework model. Best practice was evidenced in the form of well-designed studies (n=21) which reported the effectiveness of AHPs public health practice. Nine key success factors for embedding public health approaches within AHP practice were identified. Embedding public health practice should involve interventions targeting AHPs' behaviour change and behaviour change techniques targeting barriers to and facilitators for AHPs' public health practice. Multi/interdisciplinary working, innovative settings/roles, culturally tailored public health interventions along with cultural competence as a core skill should also be encouraged.

Enhancing making every contact count (MECC) training and delivery for the third and social economy (TSE) sector: a strategic behavioural analysis.

OBJECTIVE: To enhance Making Every Contact Count (MECC, an opportunistic approach to health promotion), training in the Third and Social Economy (TSE, all groups and organisations primarily working towards social justice, outside of the government or household) by examining the degree to which the behavioural content of MECC training tackled significant factors influencing MECC delivery. METHODS AND MEASURES: A strategic behavioural analysis design. Semi-structured interviews with service providers (n = 15) and users (n = 5) were coded for barriers and facilitators of MECC delivery using the Theoretical Domains Framework (TDF). Existing MECC training was coded for behaviour change techniques (BCTs) and intervention functions (IFs). The degree to which BCTs and IFs addressed the key TDF domains of influences on MECC delivery in the TSE were examined using prespecified tools. RESULTS: Seven key TDF domains of influences in MECC delivery were identified. Overall, only 9/31 linked BCTs were utilised within MECC training, with percentage utilisation of relevant BCTs for each domain ranging from 0% to 66.7%. Training adequately addressed 2/7 key domains. CONCLUSION: The TSE and healthcare share many common key TDF domains, although there are differences in how each are relevant. Limitations and recommendations for MECC training are discussed.

Mapping regional implementation of 'Making Every Contact Count': mixed-methods evaluation of implementation stage, strategies, barriers and facilitators of implementation.

BACKGROUND: The Making Every Contact Count (MECC) programme provides training and materials to support public-facing workers to encourage health-promoting behaviour change by using the day-to-day interactions between organisations and individuals. This project aimed to analyse MECC implementation through a comparative analysis of implementation stage, strategies used for implementation and enablers/barriers of the implementation process within a region in England-the North East and North Cumbria (NENC). METHODS: A mixed-methods process evaluation was conducted applying normalisation process theory and theoretical domains framework. MECC programme documents were reviewed and mapped against specific criteria (eg, implementation strategies). An online mapping survey was conducted to establish current implementation/delivery of MECC within NENC settings (eg, local government, healthcare and voluntary community sector). Qualitative research, using individual interviews and group discussions, was conducted to establish further understanding of MECC implementation. RESULTS: Our findings were informed by reviewing documents (n=5), surveying participants (n=34), interviews (n=18) and group discussions (n=48). Overall, the implementation of MECC within the region was at an early stage, with training mostly delivered between, rather than within, organisations. Qualitative findings highlighted factors that influence stakeholders to implement MECC (eg, organisational goals that were facilitated by MECC implementation, including the prevention agenda), supported resources that facilitate the implementation of MECC (eg, logic models) and enabling factors that promote MECC sustainability across the region (eg, buy-in from leadership and management). CONCLUSIONS: The NENC MECC programme is built around regional leadership that supports the implementation process. This process evaluation identified key influences of MECC implementation across the region. We discuss evidence-based recommendation for policy and practice that can be taken forward to develop targeted strategies to support future MECC implementation. For example, a co-ordinated infrastructure and strategy is needed to combat delivery and implementation issues identified.

"In an ideal world that would be a multiagency service because you need everybody's expertise." Managing hoarding disorder: A qualitative investigation of existing procedures and practices.

Hoarding disorder is characterised by the acquisition of, and failure to discard large numbers of items regardless of their actual value, a perceived need to save the items and distress associated with discarding them, significant clutter in living spaces that render the activities associated with those spaces very difficult causing significant distress or impairment in functioning. To aid development of an intervention for hoarding disorder we aimed to identify current practice by investigating key stakeholders existing practice regarding identification, assessment and intervention associated with people with hoarding disorder. Two focus groups with a purposive sample of 17 (eight male, nine female) stakeholders representing a range of services from housing, health, and social care were audio recorded, transcribed verbatim and analysed thematically. There was a lack of consensus regarding how hoarding disorder was understood and of the number of cases of hoarding disorder however all stakeholders agreed hoarding disorder appeared to be increasing. The clutter image rating scale was most used to identify people who needed help for hoarding disorder, in addition to other assessments relevant to the stakeholder. People with hoarding disorder were commonly identified in social housing where regular access to property was required. Stakeholders reported that symptoms of hoarding disorder were often tackled by enforced cleaning, eviction, or other legal action however these approaches were extremely traumatic for the person with hoarding disorder and failed to address the root cause of the disorder. While stakeholders reported there was no established services or treatment pathways specifically for people with hoarding disorder, stakeholders were unanimous in their support for a multi-agency approach. The absence of an established multiagency service that would offer an appropriate and effective pathway when working with a hoarding disorder presentation led stakeholders to work together to suggest a psychology led multiagency model for people who present with hoarding disorder. There is currently a need to examine the acceptability of such a model.

"I Genuinely Believe This Is the Most Stigmatised Group within the Social Care Sector"-Health and Social Care Professionals' Experiences of Working with People with Alcohol-Related Brain Damage: A Qualitative Interview Study.

Appropriate diagnosis, treatment and care contribute to better service engagement, improvements to wellbeing, cost savings and reductions in morbidity and mortality for people with alcohol-related brain damage. In Northeast England, large amounts of alcohol are consumed; this is reflected in the number of alcohol-related deaths in the region. However, the pathway for people with alcohol-related brain damage to receive diagnosis, treatment and care is unknown and could be unwittingly influenced by stigma. Qualitative, in-depth, semi-structured interviews were completed with 25 health and social care professionals from organizations involved with people with alcohol-related brain damage recruited via snowball sampling. Interviews were recorded, transcribed verbatim, coded, and analysed. People with alcohol-related brain damage were found to be stigmatised by both society and professionals, inhibiting their entry into services. Therefore, alcohol-related brain damage remains underdiagnosed and misdiagnosed. There was found to be no dedicated service; silos with revolving doors and underfunded generic care with long waiting lists typically exclude those with alcohol-related or neurological problems. Reducing stigmatising processes associated with alcohol-related brain damage could counteract professionals' reluctance to provide care.

Understanding the challenges and impact of training on referral of postnatal women to a community physical activity programme by health professionals: A qualitative study using the COM-B model.

OBJECTIVE: To understand the value of training for health professionals for improving their ability to effectively refer postnatal women to a targeted community physical activity programme. The study also sought to understand challenges to effective referral of postnatal women from deprived areas. DESIGN, SETTING AND PARTICIPANTS: Semi-structured interviews were conducted in January-February 2020 with early years practitioners (n = 4), health visitors (n = 1) and community midwives (n = 2) who had participated in a training workshop implemented as part of a targeted community physical activity referral programme for postnatal women from deprived areas in the North East of England. Two follow up interviews were also conducted with one midwife and one early years practitioner during the Covid-19 pandemic. Data were analysed thematically and the Capability, Opportunity, Motivation, Behaviour (COM-B) model was employed to facilitate identification of the impact of training and the challenges in referral from the health professionals' perspective. FINDINGS: The training increased capability to refer by improving knowledge and confidence of health professionals in being able to give appropriate guidance to postnatal women about physical activity without having to refer to other professionals. Health professionals reported adequate opportunities to engage with postnatal women, were motivated to refer and perceived this to be part of their role. The timing and method of message delivery were key contexts for perceived successful referral, particularly for midwives who wanted to ensure the messaging began in the antenatal period. Low staffing levels, limited interprofessional collaboration and finding strategies to engage women from deprived areas were key challenges to effective delivery of physical activity messages. These challenges were exacerbated during Covid-19, with increased mental health issues amongst postnatal women. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Training health professionals for physical activity messaging can be a useful way to increase capability, opportunity, and motivation to refer to physical activity interventions for postnatal women in deprived areas to potentially increase physical wellbeing and reduce postnatal depression. The COM-B is a relevant framework to underpin training. A clearly identified referral pathway and staffing issues need to be addressed to improve referrals by health professionals.