Improving oral health and related health behaviours (substance use, smoking, diet) in people with severe and multiple disadvantage: A systematic review of effectiveness and cost-effectiveness of interventions.

BACKGROUND: People experiencing homelessness co-occurring with substance use or offending ('severe and multiple disadvantage' SMD) often have high levels of poor oral health and related health behaviours (particularly, substance use, smoking, poor diet). This systematic review aimed to assess the effectiveness and cost-effectiveness of interventions in adults experiencing SMD to improve oral health and related health behaviours. METHODS AND FINDINGS: From inception to February 2023, five bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus) and grey literature were searched. Two researchers independently screened the search results. Randomized controlled trials (RCTs), comparative studies and economic evaluations were included that reported outcomes on oral health and the related health behaviours. Risk of bias was assessed and results narratively synthesized. Meta-analyses were performed where appropriate. This review was registered with PROSPERO (reg. no: CRD42020202416). Thirty-eight studies were included (published between 1991 and 2023) with 34 studies reporting about effectiveness. Most studies reported on substance use (n = 30). Interventions with a combination of housing support with substance use and mental health support such as contingent work therapy appeared to show some reduction in substance use in SMD groups. However, meta-analyses showed no statistically significant results. Most studies had short periods of follow-up and high attrition rates. Only one study reported on oral health; none reported on diet. Three RCTs reported on smoking, of which one comprising nicotine replacement with contingency management showed improved smoking abstinence at 4 weeks compared to control. Five studies with economic evaluations provided some evidence that interventions such as Housing First and enhanced support could be cost-effective in reducing substance use. CONCLUSION: This review found that services such as housing combined with other healthcare services could be effective in improving health behaviours, particularly substance use, among SMD groups. Gaps in evidence also remain on oral health improvement, smoking, and diet. High quality studies on effectiveness with adequate power and retention are needed to address these significant health challenges in SMD populations.

Physical Activity-Related Practices and Psychosocial Factors of Childcare Educators: A Latent Profile Analysis.

Limited research investigates early childhood education and care (ECEC) educators' involvement in promoting physical activity. The aim was to identify distinct profiles based on physical activity-related practices and psychosocial factors in ECEC educators and examine how they relate to the amount of time allocated to children's physical activity. A secondary analysis of educator-reported survey data from the Play Active study was undertaken. Educators (n = 532) reported on four practices and four psychosocial subscales adapted from the Environment and Policy Evaluation and Observation relating to the provision of physical activity in childcare. Latent profile analysis was used to identify distinct groups of educators based on their practices and psychosocial factors. Logistic regression analysed associations between latent profiles and educator-reported time provided for children's physical activity. Five profiles of educators' physical activity-related practices and psychosocial factors were identified. Profiles with higher practice scores also had higher psychosocial scores. Educators in profiles characterised by higher scores had greater odds of meeting the best practice guidelines for daily time allocated to children for total physical activity and energetic play. This study highlights interventions which address multiple educator behaviour change determinants to improve children's physical activity in childcare.

Factors influencing the commissioning and implementation of health and social care interventions for people with dementia: commissioner and stakeholder perspectives.

BACKGROUND: Despite several interventions demonstrating benefit to people living with dementia and their caregivers, few have been translated and implemented in routine clinical practice. There is limited evidence of the barriers and facilitators for commissioning and implementing health and social care interventions for people living with dementia. The aim of the current study was to explore the barriers and facilitators to commissioning and implementing health and social care interventions for people with dementia, using a dementia friendly exercise and physical activity-based intervention (PrAISED [Promoting Activity, Stability and Independence in Early Dementia and Mild Cognitive Impairment]) as a case study. METHODS: Qualitative semi-structured interviews were conducted with stakeholders from a range of backgrounds including individuals from health and social care, local government, the voluntary and community sector, universities, and research centres in England. The Consolidated Framework for Intervention Research (CFIR) was used to guide the design and analysis. RESULTS: Fourteen participants took part, including commissioning managers, service managers, partnership managers, charity representatives, commercial research specialists, academics/researchers, and healthcare professionals. Data were represented in 33 constructs across the five CFIR domains. Participants identified a need for greater support for people diagnosed with dementia and their caregivers immediately post dementia diagnosis. Key barriers included cost/financing, the culture of commissioning, and available resources. Key facilitators included the adaptability of the intervention, cosmopolitanism/partnerships and connections, external policy and incentives, and the use of already existing (and untapped) workforces. CONCLUSION: Several barriers and facilitators for commissioning and implementing health and social care interventions for people with dementia were identified which need to be addressed. Recommended actions to facilitate the commissioning and implementation of dementia friendly services are: 1) map out local needs, 2) evidence the intervention including effectiveness and cost-effectiveness, 3) create/utilise networks with stakeholders, and 4) plan required resources.

Remote monitoring of patients with rheumatoid arthritis: a mixed methods evaluation across six hospitals in London, UK.

OBJECTIVES: This study evaluated the scale-up of a remote monitoring (RM) service, capturing monthly Rheumatoid Arthritis Impact of Disease scores and patient-generated text messages, for patients with rheumatoid arthritis (RA; in remission or with low disease activity) attending routine outpatient clinics across six hospitals. We explored patients and staff experiences and implementation outcomes. METHODS: A pragmatic, mixed methods approach was used, with active patient involvement throughout. We undertook a rapid review, analysed service-level data, and conducted a patient survey and patient and staff interviews, informed by the Capability, Opportunity, Motivation, Behaviour (COM-B) and Exploration, Preparation, Implementation, Sustainment (EPIS) theoretical frameworks. RESULTS: The review included 37 articles, covering themes of patient and clinician acceptability, engagement, feasibility and clinical impact. Service-level data (n = 202) showed high levels of patient engagement with the service. The patient survey (n = 155) showed patients felt the service was easy to use, had confidence in it and felt it improved access to care. Patient interview (n = 22) findings mirrored those of the survey. Motivating factors included increased responsiveness and ease of contact with clinical teams. Views from staff interviews (n = 16) were more mixed. Some implementation barriers were specific to roll-out sites. Prioritisation of staff needs was emphasised. CONCLUSION: Patients were positive about the service and engagement was high. Staff views and engagement were more mixed. Results suggest that equal levels of patient and staff engagement are required for sustainability. These findings further our understanding of the implementation challenges to scaling RM interventions for patients with RA in routine care settings.

Factors influencing implementation and sustainability of interventions to improve oral health and related health behaviours in adults experiencing severe and multiple disadvantage: a mixed-methods systematic review.

OBJECTIVES: Among people experiencing severe and multiple disadvantage (SMD), poor oral health is common and linked to smoking, substance use and high sugar intake. Studies have explored interventions addressing oral health and related behaviours; however, factors related to the implementation of these interventions remain unclear. This mixed-methods systematic review aimed to synthesise evidence on the implementation and sustainability of interventions to improve oral health and related health behaviours among adults experiencing SMD. METHODS: Bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature were searched from inception to February 2023. Studies meeting the inclusion criteria were screened and extracted independently by two researchers. Quality appraisal was undertaken, and results were synthesised using narrative and thematic analyses. RESULTS: Seventeen papers were included (published between 1995 and 2022). Studies were mostly of moderate quality and included views from SMD groups and service providers. From the qualitative synthesis, most findings were related to aspects such as trust, resources and motivation levels of SMD groups and service providers. None of the studies reported on diet and none included repeated offending (one of the aspects of SMD). From the quantitative synthesis, no difference was observed in programme attendance between the interventions and usual care, although there was some indication of sustained improvements in participation in the intervention group. CONCLUSION: This review provides some evidence that trust, adequate resources and motivation levels are potentially important in implementing interventions to improve oral health and substance use among SMD groups. Further research is needed from high quality studies and focusing on diet in this population. PROSPERO REGISTRATION NUMBER: CRD42020202416.

Longitudinal effects of dog ownership, dog acquisition, and dog loss on children's movement behaviours: findings from the PLAYCE cohort study.

INTRODUCTION: Regular physical activity is important for children's physical and mental health, yet many children do not achieve recommended amounts of physical activity. Dog ownership has been associated with increased physical activity in children, however, there have been no longitudinal studies examining this relationship. This study used data from the Play Spaces and Environments for Children's Physical Activity (PLAYCE) cohort study to examine the longitudinal effects of dog ownership status on children's movement behaviours. METHODS: Change in dog ownership from preschool (wave 1, age 2-5) to fulltime school (wave 2, age 5-7) was used as a natural experiment with four distinct dog ownership groups: continuing non-dog owners (n = 307), continuing dog owners (n = 204), dog acquired (n = 58), and dog loss (n = 31; total n = 600). Daily movement behaviours, including physical activity, sedentary time, sleep, and screen time, were measured using accelerometry and parent-report surveys. Differences between groups over time and by sex were tested using linear mixed effects regression models. RESULTS: Girls who acquired a dog increased their light intensity activities and games by 52.0 min/day (95%CI 7.9, 96.0) and girls who lost a dog decreased their light intensity activities and games by 62.1 min/day (95%CI -119.3, -4.9) compared to no change among non-dog owners. Girls and boys who acquired a dog increased their unstructured physical activity by 6.8 (95%CI 3.2, 10.3) and 7.1 (95%CI 3.9, 10.3) occasions/week, compared to no changes among non-dog owners. Girls and boys who lost a dog reduced their unstructured physical activity by 10.2 (95%CI -15.0, -5.3) and 7.7 (95%CI -12.0, -3.5) occasions/week. Girls who lost a dog decreased their total physical activity by 46.3 min/day (95%CI -107.5, 14.8) compared to no change among non-dog owners. Continuing dog ownership was typically not associated with movement behaviours. Dog ownership group was not associated with changes in sleep and had mixed associations with screen time. CONCLUSION: The positive influence of dog ownership on children's physical activity begins in early childhood and differs by child sex. Further research should examine the specific contributions dog-facilitated physical activity makes to children's overall physical activity, including the intensity and duration of dog walking and play.

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

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

Alcohol Prevention in Urgent and Emergency Care (APUEC): Development and Evaluation of Workforce Digital Training on Screening, Brief Intervention, and Referral for Treatment.

Excessive alcohol consumption carries a significant health, social and economic burden. Screening, brief intervention and referral to treatment (SBIRT) is one approach to identifying patients with excessive alcohol consumption and providing interventions to help them reduce their drinking. However, healthcare workers in urgent and emergency care settings do not routinely integrate SBIRT into clinical practice and raise a lack of training as a barrier to SBIRT delivery. Therefore, "Alcohol Prevention in Urgent and Emergency Care" (APUEC) training was developed, delivered, and evaluated. APUEC is a brief, stand-alone, multimedia, interactive digital training package for healthcare workers. The aim of APUEC is to increase positive attitudes, knowledge, confidence and skills related to SBIRT through the provision of (a) education on the impact of alcohol and the role of urgent and emergency care in alcohol prevention, and (b) practical guidance on patient assessment, delivery of brief advice and making referral decisions. Development involved collaborative-participatory design approaches and a rigorous six-step ASPIRE methodology (involving n = 28 contributors). APUEC was delivered to healthcare workers who completed an online survey (n = 18) and then participated in individual qualitative interviews (n = 15). Analysis of data was aligned with Levels 1-3 of the Kirkpatrick Model of Training Evaluation. Survey data showed that all participants (100%) found the training useful and would recommend it to others. Insights from the qualitative data showed that APUEC digital training increases healthcare workers' perceived knowledge, confidence and skills related to alcohol prevention in urgent and emergency care settings. Participants viewed APUEC to be engaging and relevant to urgent and emergency care workers. This digital training was perceived to be useful for workforce skills development and supporting the implementation of SBIRT in clinical practice. While the impact of APUEC on clinician behaviour and patient outcomes is yet to be tested, APUEC digital training could easily be embedded within education and continuing professional development programmes for healthcare workers and healthcare trainees of any discipline. Ultimately, this may facilitate the integration of SBIRT into routine care and contribute to population health improvement.

International evidence on lived experiences of trauma during homelessness and effects on mental health including substance use: a co-produced qualitative systematic review.

BACKGROUND: Trauma is an experience (physical or emotional) that is life-threatening, harmful, or out of the ordinary and has lasting effects on mental health and wellbeing. Much of the information about trauma within homeless populations focuses on events in childhood. Using coproduction principles, we aimed to synthesise qualitative evidence exploring the impact of trauma during adulthood homelessness on mental health, including substance use. METHODS: In this qualitative systematic review, we searched ASSIA, CINAHL, Cochrane, EMBASE, MEDLINE, Proquest theses and dissertations, PsychInfo, Scopus, and Web of Science for studies published from inception until Sept 6, 2022, alongside grey literature from relevant websites. Search terms were developed based on the PICO framework. No language, date, or geographical limits were applied. Any qualitative research reporting experiences of trauma and its impact on mental health during homelessness in adults was eligible. We extracted relevant data (eg, methodology, sample characteristics, homelessness, and findings). People with lived experience of homelessness were provided with bespoke training by the lead researcher. They contributed to refining the review aims, screening, coding, and theme development. Quality was assessed using the CASP Qualitative Studies Checklist. FINDINGS: We included 26 qualitative papers, including 876 adults experiencing homelessness between ages 18 and 70 years (448 [51%] women and 428 [49%] men). All papers focused on urban settings. Eight papers were from the USA, five from Canada, four from the UK and Australia, three from Brazil, and one from Ethiopia and Iran. A framework synthesis of these 26 papers identified three preliminary themes. People experiencing homelessness make sense of trauma in three ways: internalised understanding, relationality to others, and with a survival lens. Coping strategies for managing feelings of fear, anxiety, and depression included substance use, self-rationalisation, and strategies to feel safe. Finally, when people experienced repeated trauma, they became either dissociated, and accepted their situation, or resilient, wishing to change their circumstances. INTERPRETATION: Further evidence is needed in rural or coastal regions, where people experiencing homelessness may face greater isolation. Trauma rarely takes place in isolation, and often previous experiences of trauma shape how people experiencing homelessness make sense of trauma and cope with it. Support to address coping with the effects of trauma should focus on ensuring people do not become desensitised and prevent deterioration of mental health and substance use. The strength of this review is its coproduction with people with lived experience. Single person data extraction with secondary checks was a limitation. FUNDING: National Institute for Health and Care Research (NIHR) School for Primary Care Research as part of the Three NIHR Research Schools Mental Health Programme.

Interventions to improve oral health and related health behaviours of substance use, smoking, and diet in people with severe and multiple disadvantage: a systematic review of effectiveness and cost-effectiveness.

BACKGROUND: Homelessness overlapping with substance use and offending is described as severe and multiple disadvantage (SMD). People experiencing SMD have poor oral health along with high levels of related behaviours such as substance use, smoking, and poor diet. Existing evidence largely describes the prevalence of oral health problems, substance use, and smoking in SMD groups. Little is known about interventions that can address these conditions in SMD groups. We aimed to review the effectiveness and cost-effectiveness of interventions on oral health and related health behaviours in adults experiencing SMD. METHODS: For this systematic review, we searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature for papers published from inception to February 2023. Two researchers independently reviewed the searches. Randomised controlled trials (RCTs), comparative studies and economic evaluations were included. Risk of bias was assessed. Population included adults experiencing SMD (including homelessness and substance use or repeat offending). Outcomes included oral health, and related behaviours (substance use, smoking, poor diet). Results were narratively synthesised. This review was registered with PROSPERO, CRD42020202416. FINDINGS: The review included 38 studies (published between 1991 and 2023), with 34 reporting effectiveness. These studies comprised of 23 RCTs and 11 quasi-experimental studies conducted in the USA (25 studies), Canada (seven studies), France (one study), and Spain (one study). The interventions involving multiple components, such as housing services with substance use and mental health support, effectively reduced substance use in SMD groups; these were mostly individual-level interventions. However, these studies had short follow-up periods and high attrition rates. Only one study addressed oral health outcomes, none focused on diet, and three RCTs covered smoking, with one intervention showing smoking abstinence at 4 weeks. Some limited evidence suggested cost-effectiveness of substance use interventions. INTERPRETATION: This review found that integrating services such as housing with other health-care services together could be effective in improving health behaviours, especially substance use among SMD groups. More evidence is needed specifically on oral health, smoking, and diet-related interventions. The generalisability of findings of this review is limited to high-income countries and shorter-term outcomes. FUNDING: National Institute for Health and Care Research (NIHR) Policy Research Programme.

Investigating social deprivation and comorbid mental health diagnosis as predictors of treatment access among patients with an opioid use disorder using substance use services: a prospective cohort study.

BACKGROUND: Opioid use is a major public health concern across the globe. Opioid use and subsequent access to care is often shaped by co-occurring issues faced by people using opioids, such as deprivation, mental ill-health, and other forms of substance use. We investigated the role of social deprivation and comorbid mental health diagnoses in predicting re-engagement with substance use services or contact with crisis and inpatient services for individuals with opioid use disorder in secondary mental health care in inner-city London. METHODS: We conducted a prospective cohort study which followed individuals diagnosed with a first episode of opioid use disorder who accessed substance use services between September 2015 and May 2020 for up to 12 months, using anonymised electronic health records. We employed negative binominal regression and Cox proportional survival analyses to assess associations between exposures and outcomes. RESULTS: Comorbid mental health diagnoses were associated with higher contact rates with crisis/inpatient services among people with opioid use disorder: incidence rate ratios (IRR) and 95% confidence intervals (CI) were 3.91 (1.74-9.14) for non-opioid substance use comorbidity, 8.92 (1.81-64.4) for a single comorbid mental health diagnosis, and 15.9 (5.89-47.5) for multiple comorbid mental health diagnoses. Social deprivation was not associated with contact rates with crisis/inpatient services within this sample. Similar patterns were found with time to first crisis/inpatient contact. Social deprivation and comorbid mental health diagnoses were not associated with re-engagement with substance use services. CONCLUSION: Comorbid substance and mental health difficulties amongst people with an opioid use disorder led to earlier and more frequent contact with crisis/inpatient mental health services during the first 12 months of follow up. Given the common co-occurrence of mental health and substance use disorders among those who use opioids, a better understanding of their wider needs (such as social, financial and other non-medical concerns) will ensure they are supported in their treatment journeys.

Genome-wide association study of thyroid-stimulating hormone highlights new genes, pathways and associations with thyroid disease.

Thyroid hormones play a critical role in regulation of multiple physiological functions and thyroid dysfunction is associated with substantial morbidity. Here, we use electronic health records to undertake a genome-wide association study of thyroid-stimulating hormone (TSH) levels, with a total sample size of 247,107. We identify 158 novel genetic associations, more than doubling the number of known associations with TSH, and implicate 112 putative causal genes, of which 76 are not previously implicated. A polygenic score for TSH is associated with TSH levels in African, South Asian, East Asian, Middle Eastern and admixed American ancestries, and associated with hypothyroidism and other thyroid disease in South Asians. In Europeans, the TSH polygenic score is associated with thyroid disease, including thyroid cancer and age-of-onset of hypothyroidism and hyperthyroidism. We develop pathway-specific genetic risk scores for TSH levels and use these in phenome-wide association studies to identify potential consequences of pathway perturbation. Together, these findings demonstrate the potential utility of genetic associations to inform future therapeutics and risk prediction for thyroid diseases.

The facilitators and barriers to improving functional activity and wellbeing in people with dementia: a qualitative study from the process evaluation of Promoting Activity, Independence and Stability in Early Dementia (PrAISED).

BACKGROUND: The PRomoting Activity, Independence and Stability in Early Dementia (PrAISED) study delivered an exercise and functional activity programme to participants living with dementia. A Randomised Controlled Trial showed no measurable benefits in activities of daily living, physical activity or quality of life. OBJECTIVE: To explore participants' responses to PrAISED and explain why an intervention that might be expected to have produced measurable health gains did not do so. METHODS: A process evaluation using qualitative methods, comprising interviews and researcher notes. SETTING: Data were collected in participants' homes or remotely by telephone or videoconferencing. SAMPLE: A total of 88 interviews were conducted with 44 participants living with dementia (n = 32 intervention group; n = 12 control group) and 39 caregivers. A total of 69 interviews were conducted with 26 therapists. RESULTS: Participants valued the intervention as proactively addressing health issues that were of concern to them, and as a source of social contact, interaction, information and advice. Facilitators to achieving positive outcomes included perceiving progress towards desired goals, positive expectations, therapists' skills and rapport with participants, and caregiver support. Barriers included: cognitive impairment, which prevented independent engagement and carry-over between sessions; chronic physical health problems and intercurrent acute illness and injury; 'tapering' (progressively infrequent supervision intended to help develop habits and independent activity); and the COVID-19 pandemic. CONCLUSIONS: Self-directed interventions may not be appropriate in the context of dementia, even in the mild stages of the condition. Dementia-specific factors affected outcomes including caregiver support, rapport with therapists, availability of supervision, motivational factors and the limitations of remote delivery. The effects of cognitive impairment, multimorbidity and frailty overwhelmed any positive impact of the intervention. Maintenance of functional ability is valued, but in the face of inevitable progression of disease, other less tangible outcomes become important, challenging how we frame 'health gain' and trial outcomes.

Promoting Activity, Independence, and Stability in Early Dementia and mild cognitive impairment (PrAISED): randomised controlled trial.

OBJECTIVE: To determine the effectiveness of an exercise and functional activity therapy intervention in adults with early dementia or mild cognitive impairment compared with usual care. DESIGN: Randomised controlled trial. SETTING: Participants' homes and communities at five sites in the United Kingdom. PARTICIPANTS: 365 adults with early dementia or mild cognitive impairment who were living at home, and family members or carers. INTERVENTION: The intervention, Promoting activity, Independence, and Stability in Early Dementia and mild cognitive impairment (PrAISED), was a specially designed, dementia specific, rehabilitation programme focusing on strength, balance, physical activity, and performance of activities of daily living, which was tailored and progressive and addressed risk and the psychological needs of people with dementia. Up to 50 therapy sessions were provided over 12 months. The control group received usual care plus a falls risk assessment. Procedures were adapted during the covid-19 pandemic. MAIN OUTCOME MEASURES: The primary outcome was score on the carer (informant) reported disability assessment for dementia scale 12 months after randomisation. Secondary outcomes were self-reported activities of daily living, physical activity, quality of life, balance, functional mobility, fear of falling, frailty, cognition, mood, carer strain, service use at 12 months, and falls between months 4 and 15. RESULTS: 365 patient participants were randomised, 183 to intervention and 182 to control. The median age of participants was 80 years (range 65-95), median Montreal cognitive assessment score was 20 out of 30 (range 13-26), and 58% (n=210) were men. Intervention participants received a median of 31 therapy sessions (interquartile range 22-40) and reported completing a mean 121 minutes of PrAISED exercise each week. Primary outcome data were available for 149 intervention and 141 control participants. Scores on the disability assessment for dementia scale did not differ between groups: adjusted mean difference -1.3, 95% confidence interval -5.2 to 2.6; Cohen's d effect size -0.06, 95% confidence interval -0.26 to 0.15; P=0.51). Upper 95% confidence intervals excluded small to moderate effects on any of the range of outcome measures. Between months 4 and 15 the intervention group experienced 79 falls and the control group 200 falls (adjusted incidence rate ratio 0.78, 95% confidence interval 0.5 to 1.3; P=0.3). CONCLUSION: The intensive PrAISED programme of exercise and functional activity training did not improve activities of daily living, physical activity, or quality of life; reduce falls; or improve any other secondary health status outcomes, despite good uptake. Future research should consider alternative approaches to maintaining ability and wellbeing in people with dementia. TRIAL REGISTRATION: ISRCTN Registry ISRCTN15320670.

Play Active physical activity policy intervention and implementation support in early childhood education and care: results from a pragmatic cluster randomised trial.

BACKGROUND: Policy interventions to increase physical activity in early childhood education and care (ECEC) services are effective in increasing physical activity among young children. However, a large proportion of ECEC services do not have nor implement a physical activity policy. Play Active is an evidence-informed physical activity policy intervention with implementation support strategies to enable ECEC services to successfully implement their policy. This study examined the effectiveness, implementation, and process outcomes of Play Active. METHODS: A pragmatic cluster randomised trial in 81 ECEC services in Perth, Western Australia was conducted in 2021. Services implemented their physical activity policy over a minimum of three months. The effectiveness outcomes were changes in educator practices related to daily time provided for total physical activity and energetic play. Implementation outcomes included changes in director- and educator-reported uptake of policy practices and director-reported uptake of high impact and low effort policy practices. Process evaluation outcomes included awareness, fidelity, reach, and acceptability of the intervention and implementation strategies. Analysis involved descriptive statistics and generalised linear mixed effects models. RESULTS: There was a significant increase in the uptake of director-reported policy practices (p = 0.034), but no change in the uptake of the subset of high impact and low effort policy practices. Intervention group educators reported high awareness of the Play Active policy recommendations (90%). Play Active acceptability was high among educators (83%) and directors (78%). Fidelity and reach were high for most implementation support strategies (> 75%). There were no significant changes in the amount of physical activity or energetic play educators provided to children or in the proportion of educators providing the policy recommended ≥ 180 min of physical activity/day or ≥ 30 min of energetic play/day for intervention compared to wait-listed comparison services. CONCLUSIONS: Play Active resulted in significantly higher uptake of physical activity practices. However, there was no change in the amount of physical activity provided to children, which may be explained by the relatively short policy implementation period. Importantly, Play Active had high awareness, fidelity, reach, and acceptability. Future research should investigate the effectiveness of Play Active over longer implementation periods and its scalability potential. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (reference number 12620001206910, registered 13/11/2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378304&isReview=true ).

Effectiveness and implementation of interventions for health promotion in urgent and emergency care settings: an umbrella review.

BACKGROUND: Urgent and emergency care (UEC) settings provide an opportunity to prevent ill-health and promote healthy lifestyles with potential to screen and deliver interventions to under-served, at-risk populations. The aim of this study was to synthesise and summarise the evidence on the effectiveness and implementation of interventions for health promotion in UEC settings. METHODS: PubMed and Embase (OVID) databases were used to search for studies published in English between January 2010 and January 2023. Systematic reviews and meta-analyses of studies that examined the effectiveness or implementation of face-to-face health promotion interventions for lifestyle behaviours delivered in UEC settings were eligible. Extracted data were synthesised and qualitatively summarised by lifestyle behaviour. Reviews were quality assessed using AMSTAR 2. RESULTS: Eighteen reviews met the inclusion criteria; all included studies were conducted in emergency departments or trauma units. We identified 15 reviews on alcohol interventions (13 on effectiveness; 2 on implementation) and 3 on smoking interventions (effectiveness). There were no reviews of intervention studies targeting physical activity or diet and nutrition. There was heterogeneity across studies for study design, target populations, intervention design and content, comparator/control groups and outcomes assessed. The effectiveness of alcohol and smoking interventions in UEC settings varied but some reviews provided evidence of a significant decrease in alcohol consumption, alcohol-related outcomes and smoking in intervention groups, particularly in the short-term and in specific population groups. Research has focused on 'brief' interventions as part of screening, brief intervention and referral to treatment (SBIRT) approaches. Interventions are delivered by a wide range of staff with substantial variation in design. Alcohol brief interventions appear to be acceptable to UEC patients but clinicians face barriers in delivering them. CONCLUSIONS: UEC settings have been under-researched and appear to be under-utilised for delivering health promotion activities, except for alcohol prevention. Review level evidence suggests alcohol and smoking interventions are warranted in some population groups. However, further research is needed to determine the optimal intervention design, content and delivery mode for lifestyle behaviours which are suitable for implementation in UEC settings and promote long-term intervention effectiveness. Changes in clinical practice may be needed, including increased training, integration into service delivery and supportive policy, to facilitate the implementation of SBIRT for lifestyle behaviours. Interventions may need to be delivered in the wider UEC system such as urgent care centres, minor injury units and walk-in centres, in addition to emergency departments and trauma units, to support and increase health promotion activities in UEC settings.

Cytokine receptor IL27RA is an NF-κB-responsive gene involved in CD38 upregulation in multiple myeloma.

Multiple myeloma (MM) shows constitutive activation of canonical and noncanonical nuclear factor κB (NF-κB) signaling via genetic mutations or tumor microenvironment (TME) stimulations. A subset of MM cell lines showed dependency for cell growth and survival on the canonical NF-κB transcription factor RELA alone, suggesting a critical role for a RELA-mediated biological program in MM pathogenesis. Here, we determined the RELA-dependent transcriptional program in MM cell lines and found the expression of the cell surface molecules interleukin-27 receptor-α (IL-27Rα) and the adhesion molecule JAM2 to be responsive to RELA at the messenger RNA and protein levels. IL-27Rα and JAM2 were expressed on primary MM cells at higher levels than on healthy long-lived plasma cells (PCs) in the bone marrow. IL-27 activated STAT1, and to a lesser extent STAT3, in MM cell lines and in PCs generated from memory B cells in an IL-21-dependent in vitro PC differentiation assay. Concomitant activity of IL-21 and IL-27 enhanced differentiation into PCs and increased the cell-surface expression of the known STAT target gene CD38. In accordance, a subset of MM cell lines and primary MM cells cultured with IL-27 upregulated CD38 cell-surface expression, a finding with potential implications for enhancing the efficacy of CD38-directed monoclonal antibody therapies by increasing CD38 expression on tumor cells. The elevated expression of IL-27Rα and JAM2 on MM cells compared with that on healthy PCs may be exploited for the development of targeted therapeutic strategies that modulate the interaction of MM cells with the TME.

A Systematic Review of Qualitative Studies Exploring Lived Experiences, Perceived Impact, and Coping Strategies of Children and Young People Whose Parents Use Substances.

Parental substance use is highly prevalent worldwide, presenting major child safeguarding and public health concerns. Qualitative research enables in-depth understanding of how young people experience parental substance use and helps inform practice and policy through illustrative cases of experiences. This review aimed to synthesize published qualitative evidence exploring the lived experiences, perceived impact, and coping strategies of children and young people whose parents use substances. International literature databases including Medline, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, International Bibliography of the Social Sciences, Social Science Database, Sociology Collection, and Scopus were searched from inception to 2022, alongside grey literature searching and relevant websites. Qualitative accounts were included, provided by participants aged below 25 years. No language, date, or geographical limits were applied. A thematic synthesis of 35 studies, across 49 papers, covering over 700 children and young people's voices, identified five overarching themes. These themes included, (a) living with the unpredictable: insecurity within the family; (b) social and emotional impact of parental substance use; (c) controlling the uncontrollable: creating safety within the family; (d) coping with and resisting the emotional and social impacts; and (e) formal and informal support. The findings emphasize that children and young people who experience parental substance use are trying to manage and mitigate vulnerabilities and be resilient to unpredictable, adverse, and often stigmatizing experiences, usually without formal support in place. Further research is needed to coproduce child-centered interventions that promote children and young people's social and emotional resilience.

Substance Use, Health, and Adverse Life Events amongst Amphetamine-Type Stimulant Users in North East England: A Cross-Sectional Study.

Amphetamine-type stimulants (ATS) are the second most commonly used class of illicit drugs globally, yet there is limited understanding of which factors contribute to different pathways of ATS use. We sought to compare current, former, and exposed non-ATS users' substance use, mental/physical health, and adverse life experiences. A cross-sectional survey, using computer-assisted personal interview software, was conducted between June 2018 and March 2019 in North East England. Quota-based sampling was used to recruit 389 individuals (aged 18 to 68; 52.6% male): 137 current ATS users; 174 former users; and 78 exposed non-users. Standardized screening questionnaires captured current/prior substance use. Participants self-reported diagnoses of selected physical and mental health disorders and specific adverse life experiences. Analysis used descriptive statistics and comparative tests (including chi-square, Kruskal-Wallis and Mann-Whitney U). Early exposure to illicit substances, challenging mental health, and certain adverse life experiences (such as growing up in statutory care) were more common in individuals currently using ATS compared to those who had never used or stopped using stimulants. Multi-level interventions are needed that address the mental health, social, and economic needs of people with dependent drug use. These could include targeted efforts to support children growing up under care, integrated mental health and substance use support, and joined-up substance use interventions reflective of wider structural factors.

Adolescent Experiences of the COVID-19 Pandemic and School Closures and Implications for Mental Health, Peer Relationships and Learning: A Qualitative Study in South-West England.

The COVID-19 'lockdown' and multiple school closures disrupted the daily lives and routines of the entire UK population. However, adolescents were likely particularly impacted by such measures due to this time being key for social and educational development. This qualitative study explored young people's experiences of lockdowns and school closures. Fifteen secondary schools within south-west England were initially contacted and three schools participated in recruitment efforts. From December 2020 to March 2021, 25 students aged 14-15 participated in a combination of individual interviews (n = 5) and focus groups (n = 3). Findings revealed diverse experiences of the pandemic and highlighted the complexity of experiences according to individual student contexts. Three main themes were identified: (1) Learning environments; (2) Connection to peers; (3) Transition, adaptation and coping. These findings highlight the value young people place on face-to-face social contact with close friends, and the sense of structure provided by school, with implications for future home-based learning. Further in-depth qualitative research is needed to continue to understand the varied experiences during the course of the pandemic, particularly longer-term impacts on mental health and learning.