School-based physical activity interventions among children and adolescents in the Middle East and Arabic speaking countries: A systematic review.

BACKGROUND: It is widely recognised that noncommunicable diseases are on the rise worldwide, partly due to insufficient levels of physical activity (PA). It is a particularly concerning health issue among children and adolescents in Arabic countries where cultural and environmental factors may limit their opportunity for engaging in physical activities. AIM: This review sought to assess the effectiveness of school-based PA interventions for increasing PA among schoolchildren aged six to 18 years in Middle Eastern and Arabic-speaking countries. METHODS: A systematic literature search was developed to identify studies reporting the evaluation of school-based PA interventions in Arabic-speaking countries. Four different databases were searched from January 2000 to January 2023: PubMed/MEDLINE, Web of Science, Scopus and CINAHL. Article titles and abstracts were screened for relevance. Full article scrutiny of retrieved shortlisted articles was undertaken. After citation searches and reference checking of included papers, full data extraction, quality assessment and narrative synthesis was undertaken for all articles that met the inclusion criteria. This review adhered to PRISMA guidelines for conducting systematic reviews. RESULTS: Seventeen articles met the inclusion criteria. Eleven articles reported statistically significant improvements in the levels of PA among their participants. Based largely on self-reported outcomes, increases in PA between 58% and 72% were reported. The studies with a follow-up period greater than three months reported sustained PA levels. There are a limited range of types of programmes evaluated and evaluations were only identified from 30% of the countries in the region. Relatively few studies focused solely on PA interventions and most of the interventions were multi-component (lifestyle, diet, education). CONCLUSIONS: This review adds to the existing body of research about the efficacy of school-based interventions to increase physical activity levels. To date, few evaluations assess PA specific interventions and most of the interventions were multi-component including education components on lifestyle and diet. Long-term school-based interventions combined with rigorous theoretical and methodological frameworks are necessary to develop, implement and evaluate PA interventions for children and adolescents in Arabic-speaking countries. Also, future work in this area must also consider the complex systems and agents by which physical activity is influenced.

Factors which facilitate or impede patient engagement with pulmonary and cardiac rehabilitation: a rapid evaluation mapping review.

Background: There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes. However, much less is known about effectively engaging and sustaining patients in rehabilitation. There is a need to understand the full range of potential intervention strategies. Methods: We conducted a mapping review of UK review-level evidence published 2017-21. We searched MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health (CINAHL) and conducted a narrative synthesis. Included reviews reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention to facilitate these factors. Study selection was undertaken independently by two reviewers. Results: In total, we identified 20 review papers that met our inclusion criteria. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 16. An additional 11 unpublished interventions were also identified through internet searching of key websites. The reviews included 60 identifiable UK primary studies that considered factors which affected attendance at rehabilitation; 42 considered cardiac rehabilitation and 18 considering pulmonary rehabilitation. They reported on factors from the patients' point of view, as well as the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it. We grouped the factors into patient perspective (support, culture, demographics, practical, health, emotions, knowledge/beliefs and service factors) and professional perspective (knowledge: staff and patient, staffing, adequacy of service provision and referral from other services, including support and wait times). We found considerably fewer reviews (n = 3) looking at interventions to facilitate participation in rehabilitation. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. The majority of access challenges identified by patients would not therefore be addressed by the identified interventions. The more recent unevaluated interventions implemented during the COVID-19 pandemic may have the potential to act on some of the patient barriers in access to services, including travel and inconvenient timing of services. Conclusions: The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. The small number of published interventions we identified that aim to improve access are unlikely to address the majority of these factors, especially those identified by patients as limiting their access. Better understanding of these factors will allow future interventions to be more evidence based with clear objectives as to how to address the known barriers to improve access. Limitations: Time limitations constrained the consideration of study quality and precluded the inclusion of additional searching methods such as citation searching and contacting key authors. This may have implications for the completeness of the evidence base identified. Future work: High-quality effectiveness studies of promising interventions to improve attendance at rehabilitation, both overall and for key patient groups, should be the focus moving forward. Funding: This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HSDR programme or the Department of Health. Study registration: The study protocol is registered with PROSPERO [CRD42022309214].

While we know quite a lot about what makes rehabilitation for heart (cardiac) or lung (pulmonary) conditions effective, less is known about how to engage people with these services and how to encourage them to continue to attend. We have looked at what studies have already been done to summarise the factors that affect whether someone chooses to attend rehabilitation and what is being tried to improve rates of attendance. We were particularly interested in people who are less likely to attend for rehabilitation. We searched in research databases for studies published since 2017 that included UK patients and services. We found 17 relevant summary papers which included a total of 52 UK studies. Most of these papers looked at the factors that affect attendance at rehabilitation, with far fewer studies considering ways to improve attendance. There were more studies looking at rehabilitation for cardiac than pulmonary conditions. Whether someone attended rehabilitation was affected by factors such as whether they felt supported, cultural and personal factors, practical factors such as travel and access, plus patient health, emotions, knowledge and beliefs about rehabilitation services. From a staff perspective, knowledge (staff and patient), staffing levels, level of service provision, and referral from other services were believed to affect attendance. We found a few studies where changes had been made to try to improve access including a number of studies of online delivery of rehabilitation services during COVID-19. Our summary of the factors that affect attendance at rehabilitation may be helpful to inform services about what changes they should make in the future to improve levels of attendance.

Exploring the relationship between working from home, mental and physical health and wellbeing: a systematic review.

Background: Understanding the impact of working from home on health and wellbeing is of great interest to employers and employees alike, with a strong need for up-to-date guidance. The aim of this systematic review was to identify, appraise and synthesise existing research evidence that explores the impact of home working on health and wellbeing outcomes for working people and health inequalities in the population. Methods: We conducted a systematic review of qualitative, quantitative and observational studies. We searched databases, reference lists and UK grey literature and completed citation searching of included papers. We extracted and tabulated key data from the included papers and synthesised narratively. Factors associated with the health and wellbeing of people working at home reported in the literature were displayed by constructing mind maps of each individual factor which had been identified. The findings were combined with an a priori model to develop a final model, which was validated in consultation with stakeholders. Results: Of 96 studies which were found to meet the inclusion criteria for the review, 30 studies were published before the COVID-19 pandemic and a further 66 were published during the pandemic. The quality of evidence was limited by the study designs employed by the authors, with the majority of studies being cross-sectional surveys (n = 59). For the most part, for studies which collected quantitative data, measures were self-reported. The largest volume of evidence identified consisted of studies conducted during the COVID-19 pandemic which looked at factors which influence the relationship between working from home and measures relating to mental health and wellbeing. Fifteen studies which considered the potential for working at home to have different effects for different subgroups suggested that working at home may have more negative consequences during the COVID-19 pandemic for women and in particular, mothers. There was very little evidence on age (two studies), ethnicity (one study), education or income (two studies) in terms of moderating home working effects, and very limited evidence from before the COVID-19 pandemic. The concept of enforced working from home and having 'no choice' was reported in only one paper prior to the pandemic and two papers reporting on working from home as a result of COVID-19. However, the concept of lack of choice around working from home was implicit in much of the literature - even though it was not directly measured. There were no clear patterns of wellbeing measures which changed from positive to negative association (or vice versa) during the pandemic. Limitations: The quality of the evidence base was very much limited by study designs, particularly for studies published during the COVID-19 pandemic, with the majority of studies consisting of data collected by cross-sectional surveys (often online). Due to the rapidly expanding nature of the evidence on this topic, it is possible that new studies were published after the final citation searches were conducted. Discussion: The evidence base for the factors which influence the relationship between home working and health-related outcomes has expanded significantly as a result of the need for those whose work could be done from home to work at home during the COVID-19 pandemic. Our findings suggest that there are factors relating to the external context, the role of employers and the circumstances of the employee which contribute to determining whether someone works at home and what the associated impacts on health and wellbeing may be. Learning from the COVID-19 lockdown experience will be important to inform future policy on home and hybrid working. Future work: There is a need for better-quality studies of the health impact of home working, in particularly studies which recruit a range of participants who are representative of the working population and which are designed to minimise sampling/recruitment biases and response biases. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (project reference 18/93 PHR Public Health Review Team) and will be published in full in Public Health Research; Vol. 11, No. 4. See the NIHR Journals Library website for further project information. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Study registration: This study is registered as PROSPERO 2021 CRD42021253474.

INTRODUCTION: Working from home is becoming more common and has increased due to the COVID-19 pandemic. However, the impact of working at home on the health of home workers and the general population remains unclear. METHODS: We looked for research which had been undertaken to help to understand the impact of home working on people's health. One researcher summarised the findings of each paper in tables, and these were checked by a second researcher. These were then drawn together into a final diagram to summarise the findings of all the relevant studies. RESULTS: We found 96 papers and reports: 30 published before the COVID-19 pandemic and 66 published during the pandemic. This shows that the number of studies in this area has increased significantly as a result of home working due to COVID-19 lockdowns. The largest volume of studies we found were conducted during the pandemic and looked at measures of wellbeing and mental health. Lack of choice over whether to work from home was also considered in respect to wellbeing. Further measures linked to the home-work environment included feeling in control of time, lack of commuting to work, more time with the family, lower work/family conflict, and spaces shared with others. Openness to new ways of living was also included. Fifteen studies suggested overall that working at home may have more negative consequences during the COVID-19 pandemic for women and, in particular, mothers. There was very little evidence to tell us how a person's age, ethnicity, education or income might affect their health when working from home. CONCLUSIONS: Many factors determine whether someone works at home, and the effects on their health and wellbeing. These are related to what is happening in the world, the employer and type of job, and the circumstances of the employee.

Factors that influence mental health of university and college students in the UK: a systematic review.

BACKGROUND: Worsening mental health of students in higher education is a public policy concern and the impact of measures to reduce transmission of COVID-19 has heightened awareness of this issue. Preventing poor mental health and supporting positive mental wellbeing needs to be based on an evidence informed understanding what factors influence the mental health of students. OBJECTIVES: To identify factors associated with mental health of students in higher education. METHODS: We undertook a systematic review of observational studies that measured factors associated with student mental wellbeing and poor mental health. Extensive searches were undertaken across five databases. We included studies undertaken in the UK and published within the last decade (2010-2020). Due to heterogeneity of factors, and diversity of outcomes used to measure wellbeing and poor mental health the findings were analysed and described narratively. FINDINGS: We included 31 studies, most of which were cross sectional in design. Those factors most strongly and consistently associated with increased risk of developing poor mental health included students with experiences of trauma in childhood, those that identify as LGBTQ and students with autism. Factors that promote wellbeing include developing strong and supportive social networks. Students who are prepared and able to adjust to the changes that moving into higher education presents also experience better mental health. Some behaviours that are associated with poor mental health include lack of engagement both with learning and leisure activities and poor mental health literacy. CONCLUSION: Improved knowledge of factors associated with poor mental health and also those that increase mental wellbeing can provide a foundation for designing strategies and specific interventions that can prevent poor mental health and ensuring targeted support is available for students at increased risk.

Is working in later life good for your health? A systematic review of health outcomes resulting from extended working lives.

BACKGROUND: Work, rather than unemployment, is recognised as being good for health, but there may be an age when the benefits are outweighed by adverse impacts. As countries around the world increase their typical retirement age, the potential effect on population health and health inequalities requires scrutiny. METHODS: We carried out a systematic review of literature published since 2011 from developed countries on the health effects of employment in those over 64 years of age. We completed a narrative synthesis and used harvest plots to map the direction and volume of evidence for the outcomes reported. We followed the Preferred Reporting Items for Systematic Reviews (PRISMA) checklist in our methods and reporting. RESULTS: We identified seventeen relevant studies, which were of cohort or cross-sectional design. The results indicate evidence of beneficial or neutral effects from extended working on overall health status and physical health for many employees, and mixed effects on mental health. The benefits reported however, are most likely to be for males, those working part-time or reducing to part-time, and employees in jobs which are not low quality or low reward. CONCLUSIONS: Extending working life (particularly part time) may have benefits or a neutral effect for some, but adverse effects for others in high demand or low reward jobs. There is the potential for widening health inequalities between those who can choose to reduce their working hours, and those who need to continue working full time for financial reasons. There is a lack of evidence for effects on quality of life, and a dearth of interventions enabling older workers to extend their healthy working life.

Should screening for risk of gambling-related harm be undertaken in health, care and support settings? A systematic review of the international evidence.

BACKGROUND: Gambling-related harm is an increasing recognised problem internationally. Recent years have seen an explosion in opportunities to gamble, both in person and online. Health and other care settings have the potential to act as screening sites to identify and support gamblers who may be at high risk of experiencing gambling-related harm. This study aimed to identify interventions to screen for risk of gambling-related harm in the general population which may be delivered in health, care and support settings. METHODS: Systematic review. Searches of key databases and grey sources since 2012 were undertaken in October 2019. Electronic database searches generated a total of 5826 unique hits. Nine studies published 2013-2019, along with thirteen grey literature documents met our eligibility criteria. The criteria were setting (health, care and support settings), participants (any attendee in help, care and support settings), interventions (screening to identify risk of harm from gambling behaviours) and outcome measures (gambling behaviours, service use). RESULTS: Three papers evaluating screening interventions delivered in general practice (repeat visits and written advice), mental health service (the use of screening tools to identify risk of harm), and substance abuse treatment (intensive outpatient treatment for substance use disorders or methadone maintenance) indicated evidence of potential effectiveness. Six papers supported the feasibility and acceptability of delivering interventions in various settings. Grey literature reports described the implementation of interventions such as training materials, and transfer of interventions developed for substance abuse populations by practitioners. CONCLUSIONS: Health, care and support services offer potentially important contexts in which to identify and offer support to people who are at risk of gambling related harm. Screening interventions appear feasible and acceptable in a range of community and healthcare settings for those at risk of gambling harm. Evaluation of effectiveness and cost-effectiveness of screening in these populations should therefore be prioritised.

What makes a 'successful' collaborative research project between public health practitioners and academics? A mixed-methods review of funding applications submitted to a local intervention evaluation scheme.

BACKGROUND: The national Public Health Practice Evaluation Scheme (PHPES) is a response-mode funded evaluation programme operated by the National Institute for Health Research School for Public Health Research (NIHR SPHR). The scheme enables public health professionals to work in partnership with SPHR researchers to conduct rigorous evaluations of their interventions. Our evaluation reviewed the learning from the first five years of PHPES (2013-2017) and how this was used to implement a revised scheme within the School. METHODS: We conducted a rapid review of applications and reports from 81 PHPES projects and sampled eight projects (including unfunded) to interview one researcher and one practitioner involved in each sampled project (n = 16) in order to identify factors that influence success of applications and effective delivery and dissemination of evaluations. Findings from the review and interviews were tested in an online survey with practitioners (applicants), researchers (principal investigators [PIs]) and PHPES panel members (n = 19) to explore the relative importance of these factors. Findings from the survey were synthesised and discussed for implications at a national workshop with wider stakeholders, including public members (n = 20). RESULTS: Strengths: PHPES provides much needed resources for evaluation which often are not available locally, and produces useful evidence to understand where a programme is not delivering, which can be used to formatively develop interventions. Weaknesses: Objectives of PHPES were too narrowly focused on (cost-)effectiveness of interventions, while practitioners also valued implementation studies and process evaluations. Opportunities: PHPES provided opportunities for novel/promising but less developed ideas. More funded time to develop a protocol and ensure feasibility of the intervention prior to application could increase intervention delivery success rates. Threats: There can be tensions between researchers and practitioners, for example, on the need to show the 'success' of the intervention, on the use of existing research evidence, and the importance of generalisability of findings and of generating peer-reviewed publications. CONCLUSIONS: The success of collaborative research projects between public health practitioners (PHP) and researchers can be improved by funders being mindful of tensions related to (1) the scope of collaborations, (2) local versus national impact, and (3) increasing inequalities in access to funding. Our study and comparisons with related funding schemes demonstrate how these tensions can be successfully resolved.

Interventions to reduce the public health burden of gambling-related harms: a mapping review.

Recognition is growing that gambling, although highly profitable for corporations and governments, is a source of serious and unevenly distributed harm. This recognition has led to demands for public health strategies at the local, national, and international levels. We aimed to identify review-level evidence for interventions to address or prevent gambling-related harms and explore policy implications, using stakeholder consultation to assess the evidence base, identify gaps, and suggest key research questions. We opted for a systematic mapping review and narrative synthesis for all forms of gambling in any setting. We included participants from the whole population, identified gamblers including self-defined, and specific populations at risk (eg, children and young people). We included all outcome measures relating to prevention or treatment of gambling-related harms that were reported by review authors. After duplication, the searches generated 1080 records. Of 43 potential papers, 13 were excluded at the full paper stage and 30 papers were included in the Review. We identified whole-population preventive interventions, such as demand reduction (n=3) and supply reduction (n=4) interventions, and targeted treatment interventions for individuals addicted to gambling, such as therapeutic (n=12), pharmacological (n=5), and self-help or mutual support (n=4) interventions. We also reviewed studies (n=2) comparing these approaches. Interventions to screen, identify, and support individuals at risk of gambling-related harms and interventions to support ongoing recovery and prevent relapse for individuals with a gambling addiction were not represented in the review-level evidence. A public health approach suggests that there are opportunities to reduce gambling-related harms by intervening across the whole gambling pathway, from regulation of access to gambling to screening for individuals at risk and services for individuals with an identified gambling problem. The dearth of evidence for some interventions means that implementation must be accompanied by robust evaluation.

Exploring the relationship between housing concerns, mental health and wellbeing: a qualitative study of social housing tenants.

BACKGROUND: The rising prevalence of mental health problems is a growing public health issue. Poor mental health is not equally distributed across social groups and is associated with poverty and insecure housing. An evaluation of a social housing intervention provided an opportunity to explore the connections between housing and wider determinants of health and wellbeing. METHODS: We undertook 44 interviews with social housing tenants over a two-year period to explore their views on housing, health and wellbeing. RESULTS: Poor mental health was common. The results suggest that perceptions of housing quality, service responsiveness, community safety, benefit changes and low income all have a detrimental effect on tenants' mental health. CONCLUSIONS: Social housing providers who wish to have a positive impact on the mental health of their tenants need to consider how to best support or mitigate the impact of these stresses. Addressing traditional housing officer functions such as reporting or monitoring home repairs alongside holistic support remains an important area where social housing departments can have substantial health impact. Tackling the complex nature of mental health requires a joined up approach between housing and a number of services.

Bridging the gap between the home and the hospital: a qualitative study of partnership working across housing, health and social care.

Rising demand and financial challenges facing public services have increased the impetus for greater integration across housing, health and social care. To provide insight into the benefits and challenges of partnership, we interviewed 37 housing professionals and held a validation workshop with eight external agencies working within a new, integrated housing service in the United Kingdom. The strength of the initiative rests on the capacity of neighborhood officers to conduct home visits and refer tenants to support agencies. Yet this strength poses problems in partnership building because increased referrals threaten to overwhelm already stretched health services. Despite broadly supporting the initiative, officers expressed concern over losing specialist housing knowledge whilst filling in gaps for services. Tensions over professional role boundaries between officers and social workers, poor communication, lack of capacity in external agencies and difficulties in sharing information were identified as barriers to partnership. Whilst capacity issues were acknowledged, partner agencies welcomed the initiative and called for joint meetings and colocation of services. Lack of capacity of external agencies to respond to referrals threatens integrated housing and health initiatives. Greater interprofessional collaboration and further investment across the system is required to increase capacity and ensure referrals are translated into healthcare outcomes.

Taking preventative health messages into the wider caring professions: the views of housing staff and tenants.

BACKGROUND: In order to harness the potential impact of the wider public health workforce, innovative services are providing opportunities for social housing staff to extend their public health role. This study explored the views of housing professionals and social housing residents on the delivery of preventative health messages by housing staff in the context of the evaluation of the roll-out of a new service. METHODS: We conducted semi structured interviews with 21 neighbourhood housing officers, 4 managers and 30 social housing tenants to understand their views on the widening role and the potential impact on the preventative healthcare messages being delivered. RESULTS: Neighbourhood officers were willing to discuss existing health conditions with tenants; but they often did not feel comfortable discussing their lifestyle choices. Most tenants also reported that they would feel discussions around lifestyle behaviours to be intrusive and outside the remit of housing staff. CONCLUSIONS: Resistance to discussions of lifestyle topics during home visits was found among both housing staff and tenants. Appropriate staff training and the development of strong and trusting relationships between officers and tenants is needed, if similar programmes to extend the role of housing staff are to succeed in terms of health impact.

Severe acute malnutrition in children aged under 5 years can be successfully managed in a non-emergency routine community healthcare setting in Ghana.

This study investigated the performance of community-based management of severe acute malnutrition (CMAM) within routine healthcare services in Ghana. This was a retrospective cohort study of n = 488 children (6-59 months) who had received CMAM. Data for recovery, default, and mortality rates were obtained from enrolment cards in 56 outpatient centres in Upper East region, Ghana. Satisfactory rates of recovery of 71.8% were reported. Children who were enrolled with higher mid-upper arm circumference (MUAC) ≥11.5 cm had seven times greater chance of recovery compared with children who were enrolled with lower MUAC <11.5 cm, OR = 7.35, 95% CI [2.56, 21.15], p < .001. Children who were diagnosed without malaria at baseline were 30 times, OR = 30.39, 95% CI [10.02, 92.13], p < .001, more likely to recover compared with those with malaria (p < .001). The average weight gain was 4.7 g-1 ·kg-1 ·day-1 , which was influenced by MUAC status at baseline, ß = .78, 95% CI [0.46, 1.00], p < .001, presence of malaria, ß = -1.25, 95% CI [-1.58, 0.92], p < .001, and length of stay, ß = 0.13, 95% CI [0.08, 0.18], p < .001. The default rate (28.5%) was higher than international standards recommendations by Sphere. Mortality rate (1.6%) was lower than international standards. Our findings suggest that community-based management of SAM can achieve similar success when delivered in routine non-emergency settings. However, this success can be diluted by a high default rate, and the factors contributing to this need to be explored to improve programme effectiveness within communities.

Non-pharmacological treatments for stuttering in children and adults: a systematic review and evaluation of clinical effectiveness, and exploration of barriers to successful outcomes.

BACKGROUND: Despite many years of research, there is no certainty regarding the cause of stuttering. Although numerous interventions have been developed, a broad-based systematic review across all forms of intervention for adults and children was needed including views and perceptions of people who stutter. OBJECTIVE: The aims of the study were to report the clinical effectiveness of interventions for people who stutter (or clutter), to examine evidence regarding the views of people who stutter and the views of professionals regarding interventions. DATA SOURCES: A systematic review of quantitative and qualitative literature was carried out between August 2013 and April 2014. The following electronic databases were searched: (1) MEDLINE, (2) EMBASE, (3) The Cochrane Library (including The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database and NHS Economic Evaluations Database), (4) PsycINFO, (5) Science Citation Index, (6) Social Science Citation Index, (7) Cumulative Index to Nursing and Allied Health Literature, (8) ASSIA, (9) Linguistics and Language Behavior Abstracts, (10) Sociological Abstracts and (11) the EPPI Centre. Reference lists of included papers and other reviews were screened and also key journals in the subject area were hand-searched. REVIEW METHODS: The searches aimed to identify (1) evidence of clinical effectiveness in populations of pre-school children, school-aged children, adolescents and adults, and (2) data relating to perceptions of barriers and facilitators to intervention clinical effectiveness among staff and people who stutter. A metasynthesis of the two linked elements via development of a conceptual model was also carried out to provide further interpretation of the review findings. RESULTS: A systematic search of the literature identified a large number of potentially relevant studies. Of these, 111 studies examining the clinical effectiveness of interventions, 25 qualitative papers and one mixed-methods paper met the criteria for inclusion in this review. Review of the effectiveness literature indicated evidence of positive outcomes across all types of interventions. Virtually all evidence we identified reported at least some positive effect for some participants. However, there was evidence of considerable individual variation in outcome for study participants. The qualitative literature highlighted the need for programmes to be tailored to individual need with variation at the levels of the intervention, the individual and interpersonal/social elements. Metasynthesis of the data highlighted the complexity of elements that need to be considered in evaluation of long-term impacts following stuttering interventions. LIMITATIONS: Around two-thirds of the studies were considered to be at higher risk of bias. The heterogeneous nature and variability in outcomes meant that we were unable to complete a meta-analysis. CONCLUSIONS: Although much of the evidence we identified was from studies at risk of bias, it is suggested that most available interventions for stuttering may be of benefit to at least some people who stutter. There is a requirement for greater clarity regarding what the core outcomes following stuttering intervention should be and also enhanced understanding of the process whereby interventions effect change. Further analysis of those for whom interventions have not produced a significant benefit may provide additional insights into the complex intervention-outcomes pathway. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013004861.

The state of the art in non-pharmacological interventions for developmental stuttering. Part 2: qualitative evidence synthesis of views and experiences.

BACKGROUND: A range of interventions have been developed to treat stuttering in recent years. The effectiveness of these interventions has largely been assessed in studies focusing on the impact of specific types of therapy on patient outcomes. Relatively little is known about the factors that influence how the delivery and impact of different types of intervention may be experienced from the perspective of both people who deliver as well as those who receive interventions. AIMS: To synthesize the available evidence in relation to factors that might enhance or mitigate against successful outcomes following interventions for stuttering by identifying and synthesizing relevant qualitative research that explored the experiences of people delivering and receiving interventions that aim to improve fluency. METHODS & PROCEDURES: We carried out a systematic review including research that had used in-depth interviews and focus groups and conducted a substantive qualitative analysis of the data collected. Included study populations were either adults or children affected by a diagnosed stutter and/or providers of therapy for stuttering. An iterative approach was used to search for published qualitative evidence in relevant databases from 1990 to 2014. Retrieved citations were sifted for relevance and the data from articles that met the inclusion criteria were extracted. Each included paper was assessed for quality and a thematic analysis and synthesis of findings was carried out. MAIN CONTRIBUTION: Synthesized qualitative evidence highlights the changing experiences for people who stutter both historically and, for individuals, over the life course. Barriers and facilitators to the implementation of interventions for stuttering are encountered at the individual, intervention, interpersonal and social levels. Interventions may be particularly pertinent at certain transition points in the life course. Attention to emotional as well as practical aspects of stuttering is valued by people receiving therapy. The client-therapist relationship and support from others are also key factors in achieving successful outcomes. CONCLUSIONS & IMPLICATIONS: A synthesis of qualitative findings from published papers has added to the effectiveness data reported in an accompanying paper in understanding how stuttering impacts on people across the life course. Evidence suggests that a client-centred and individually tailored approach enhances the likelihood of successful intervention outcomes through attention to emotional, situational and practical needs.

The state of the art in non-pharmacological interventions for developmental stuttering. Part 1: a systematic review of effectiveness.

BACKGROUND: The growing range of available treatment options for people who stutter presents a challenge for clinicians, service managers and commissioners, who need to have access to the best available treatment evidence to guide them in providing the most appropriate interventions. While a number of reviews of interventions for specific populations or a specific type of intervention have been carried out, a broad-based systematic review across all forms of intervention for adults and children was needed to provide evidence to underpin future guidelines, inform the implementation of effective treatments and identify future research priorities. AIMS: To identify and synthesize the published research evidence on the clinical effectiveness of the broad range of non-pharmacological interventions for the management of developmental stuttering. METHODS & PROCEDURES: A systematic review of the literature reporting interventions for developmental stuttering was carried out between August 2013 and April 2014. Searches were not limited by language or location, but were restricted by date to studies published from 1990 onwards. Methods for the identification of relevant studies included electronic database searching, reference list checking, citation searching and hand searching of key journals. Appraisal of study quality was performed using a tool based on established criteria for considering risk of bias. Due to heterogeneity in intervention content and outcomes, a narrative synthesis was completed. MAIN CONTRIBUTION: The review included all available types of intervention and found that most may be of benefit to at least some people who stutter. There was evidence, however, of considerable individual variation in response to these interventions. The review indicated that effects could be maintained following all types of interventions (although this was weakest with regard to feedback and technology interventions). CONCLUSIONS: This review highlights a need for greater consensus with regard to the key outcomes used to evaluate stuttering interventions, and also a need for enhanced understanding of the process whereby interventions effect change. Further analysis of the variation in effectiveness for different individuals or groups is needed in order to identify who may benefit most from which intervention.

Referral interventions from primary to specialist care: a systematic review of international evidence.

BACKGROUND: Demand management defines any method used to monitor, direct, or regulate patient referrals. Strategies have been developed to manage the referral of patients to secondary care, with interventions that target primary care, specialist services, or infrastructure. AIM: To review the international evidence on interventions to manage referral from primary to specialist care. DESIGN AND SETTING: Systematic review. METHOD: Iterative, systematic searches of published and unpublished sources public health, health management, management, and grey literature databases from health care and other industries were undertaken to identify recent, relevant studies. A narrative synthesis of the data was completed to structure the evidence into groups of similar interventions. RESULTS: The searches generated 8327 unique results, of which 140 studies were included. Interventions were grouped into four intervention categories: GP education (n = 50); process change (n = 49); system change (n = 38); and patient-focused (n = 3). It is clear that there is no 'magic bullet' to managing demand for secondary care services: although some groups of interventions may have greater potential for development, given the existing evidence that they can be effective in specific contexts. CONCLUSIONS: To tackle demand management of primary care services, the focus cannot be on primary care alone; a whole-systems approach is needed because the introduction of interventions in primary care is often just the starting point of the referral process. In addition, more research is needed to develop and evaluate interventions that acknowledge the role of the patient in the referral decision.

Using logic model methods in systematic review synthesis: describing complex pathways in referral management interventions.

BACKGROUND: There is increasing interest in innovative methods to carry out systematic reviews of complex interventions. Theory-based approaches, such as logic models, have been suggested as a means of providing additional insights beyond that obtained via conventional review methods. METHODS: This paper reports the use of an innovative method which combines systematic review processes with logic model techniques to synthesise a broad range of literature. The potential value of the model produced was explored with stakeholders. RESULTS: The review identified 295 papers that met the inclusion criteria. The papers consisted of 141 intervention studies and 154 non-intervention quantitative and qualitative articles. A logic model was systematically built from these studies. The model outlines interventions, short term outcomes, moderating and mediating factors and long term demand management outcomes and impacts. Interventions were grouped into typologies of practitioner education, process change, system change, and patient intervention. Short-term outcomes identified that may result from these interventions were changed physician or patient knowledge, beliefs or attitudes and also interventions related to changed doctor-patient interaction. A range of factors which may influence whether these outcomes lead to long term change were detailed. Demand management outcomes and intended impacts included content of referral, rate of referral, and doctor or patient satisfaction. CONCLUSIONS: The logic model details evidence and assumptions underpinning the complex pathway from interventions to demand management impact. The method offers a useful addition to systematic review methodologies. TRIAL REGISTRATION NUMBER: PROSPERO registration number: CRD42013004037.

Patient perceptions of the referral of older adults to an epilepsy clinic: do patients and professionals agree who should be referred to a specialist?

The aim of this study was to establish whether older patients concurred with previously reported staff perceptions of why older adults may be underrepresented in epilepsy clinics. Fifteen interviews with older patients provided support for four of seven key factors previously suggested by professionals as leading to underreferral of older adults: unclear referral pathway, complex differential diagnosis, gaps in referrer knowledge, and the length of time since onset. However, the patients interviewed did not report that patient difficulties accessing the hospital, patient reluctance to attend clinics, or the particular characteristics of older patients (knowledge, awareness, and willingness to ask for help) made it less likely that older adults would want to attend a specialist epilepsy clinic. While recognizing the limitations of the study, particularly in relation to the number of participants, we believe that it provides valuable further insights into the age-bias apparent in referral patterns to specialist epilepsy services. Of particular concern are professional assumptions regarding older patients' willingness to attend appointments and about the impact of seizures on the life of an older adult.