Patient and public involvement in abortion research: reflections from the Shaping Abortion for Change (SACHA) Study.

Patient and public involvement (PPI) is limited within abortion-related research. Possible reasons for this include concerns about engaging with a stigmatised patient group who value confidentiality and may be reluctant to re-engage with services. Structural barriers, including limited funding for abortion-related research, also prevent researchers from creating meaningful PPI opportunities. Here, we describe lessons learnt on undertaking PPI as part of the Shaping Abortion for Change (SACHA) Study, which sought to create an evidence base to guide new directions in abortion care in Britain.Two approaches to PPI were used: involving patients and the public in the oversight of the research and its dissemination as lay advisors, and group meetings to obtain patients' views on interpretation of findings and recommendations. All participants observed the SACHA findings aligned with their own experiences of having an abortion in Britain. These priorities aligned closely with those identified in a separate expert stakeholder consultation undertaken as part of the SACHA Study. One additional priority which had not been identified during the research was identified by the PPI participants.We found abortion patients to be highly motivated to engage in the group meetings, and participation in them actively contributed to the destigmatisation of abortion by giving them a space to share their experiences. This may alleviate any ethical concerns about conducting research and PPI on abortion, including the assumption that revisiting an abortion experience will cause distress. We hope that our reflections are useful to others considering PPI in abortion-related research and service improvement.

What Drives Counter-Extremism? The Extent of P/CVE Policies in the West and Their Structural Correlates.

Counter-extremism (P/CVE) policies have shot to global prominence rapidly, yet there are large discrepancies in their implementation both between, and inside, countries. In this paper, we construct and present a robust index of P/CVE policies in Western countries (N = 38), based on data submitted by national experts, which we then use to test three hypothesized structural correlates of the extent of P/CVE implementation: threat of terrorism (measured as the number of past attacks/victims), size of Muslim minorities (Muslim communities have been "securitised" as potential threats in the post 9/11 period), and neoliberal governance (drawing on criminological literature that connects neoliberalism to anticipatory crime control). We find the first two structural factors to be positively and significantly correlated to the intensity of P/CVE deployment, while neoliberal governance negatively and significantly. In the discussion, we highlight the usefulness of a complementary in-depth qualitative research inspired by these findings.

Geriatric assessment prior to cancer treatment: A health economic evaluation.

INTRODUCTION: To address uncertainty regarding the cost-effectiveness of implementing geriatric assessment (GA) in oncology practice, we undertook a synthetic, model-based economic evaluation. MATERIALS AND METHODS: A decision-analytic model with embedded Markov chains was developed to simulate a cost-effectiveness analysis of implementing GA within standard oncological care compared to current practice. This was for patients aged 77 years (the mean age in included trials) receiving chemotherapy or surgery as first-line treatment. Assumptions were made about model parameters, based on available literature, to calculate the incremental net health benefit (INHB) of GA, using a data synthesis. RESULTS: GA has additional costs over standard care alone of between £390 and £576, depending upon implementation configuration. When major assumptions about the effectiveness of GA were modelled, INHB was marginally positive (0.09-0.12) at all cost-effectiveness thresholds (CETs). If no reduction in postoperative complications was assumed, the intervention was shown not to be cost-effective (INHB negative at all CETs). When used before chemotherapy, with minimal healthcare staffing inputs and technological assistance, GA is cost-effective (INHB positive between 0.06 and 0.07 at all CETs). DISCUSSION: Considering emerging evidence that GA improves outcomes in oncology, GA may not be a cost-effective intervention when used for all older adults with cancer. However, with judicious selection of implementation models, GA has the potential to be cost-effective. Due to significant heterogeneity and centre dependent success in implementation and effectiveness, GA is difficult to study in oncology settings. Stakeholders could take a pragmatic approach towards GA introduction with local evaluation favoured over generalisable research. Because GA tends towards utilitarianism and has no safety issues, it is a suitable intervention for more widespread implementation.

Geographical distance and reduced access to palliative radiotherapy: systematic review and meta-analysis.

BACKGROUND: Palliative radiotherapy (PRT) is an effective way of reducing symptoms caused by advanced incurable cancer. Several studies have investigated factors that contribute to inequalities in access to PRT; distance to a radiotherapy centre has been identified as one potential barrier. AIM: To assess whether there is an association between distance to a radiotherapy centre and utilisation rates of PRT in adults with cancer. METHODS: A systematic review and meta-analysis protocol was registered in the PROSPERO database (CRD42020190772). MEDLINE, EMBASE, CINAHL and APA-PsycINFO were searched for relevant papers up to 28 February 2021. RESULTS: Twenty-one studies were included. Twelve studies focused on whether patients with incurable cancer received PRT, as part of their treatment package. Pooled results reported that living ≥50 km vs <50 km from the radiotherapy centre was associated with a reduced likelihood of receiving PRT (OR 0.84 (95%CI 0.80, 0.88)). Nine focused on distance from the radiotherapy centre and compared single-fraction (SF) versus multiple-fraction PRT, indicating that patients living further away were more likely to receive SF. Pooled results comparing ≥50 km versus <50 km showed increased odds of receiving SF for those living ≥50 km (OR 1.48 (95%CI 1.26,1.75)). CONCLUSION: Patients living further away from radiotherapy centres were less likely to receive PRT and those who received PRT were more likely to receive SF PRT, providing some evidence of inequalities in access to PRT treatment based on proximity to centres providing radiotherapy. Further research is needed to understand whether these inequalities are influenced by clinical referral patterns or by patients unwilling or unable to travel longer distances. PROSPERO REGISTRATION NUMBER: CRD42020190772.

Use of weight-based vs age-based groupings in the study of typical values of air kerma area product (PKA) for paediatric radiographs of chest and abdomen.

OBJECTIVE: To compare age groupings versus weight groupings in the calculation of typical air kerma area product (PKA) values in paediatric X-ray exams of chest and abdomen in our hospital. METHODS: Data were analysed from 687 abdominal and 1374 chest X-ray examinations. The PKA of exams was extracted with Radimetrics, and patient weights were collected from electronic records. Data were organised in different age groups and typical PKA values were estimated. The process was repeated by organising data in different weight groups. RESULTS: Typical PKA values for the four younger age groups (<1m, 1m - < 4y, 4y - < 10y and 10y - < 14y) were comparable to typical values for their equivalent weight groups (<5 kg, 5-15 kg, 15-30 kg and 30-50 kg, respectively). However, typical PKA values at the late adolescent age group (14y - < 18y) were much lower than its equivalent weight group (>50 kg). CONCLUSIONS: Age and weight groupings were found at our site to be interchangeable for the calculation of typical paediatric PKA values. The only exception was the late adolescent group, whose weight distribution can account for the difference in typical PKA results within its equivalent weight group. ADVANCES IN KNOWLEDGE: In calculating typical PKA values for radiological paediatric body examinations, departments must ascertain if using age groups, which is typical practice, is equivalent to using weight groups. Otherwise, results may misrepresent local practice.

Technical evaluation of a clinical, bi-planar, digital and upright X-ray imaging unit.

We describe the technical evaluation of the commercially available, clinical, bi-planar, low dose, digital X-ray system (EOS System, EOS imaging, France). The unit is used for upright, weight-bearing musculoskeletal pathologies, in particular, in the spine and lower limbs. The evaluation incorporated tests on the X-ray generator performance, radiation/imaging field alignment, dose area product accuracy and image quality. The assessment methodology was based on objective parameters and required equipment readily available for technical evaluation of other radiological equipment. Results demonstrated that the system performs well within acceptable performance criteria with regard to X-ray generator performance, radiation/imaging field alignment and dose area product accuracy. In addition, results from the image-quality assessment were aligned with previously published work. The work presented in this article can be used for the technical evaluation of the EOS System at other clinical sites.

Inter-rater reliability of care home staff's proxy judgements with residents' assessments of their own health-related quality of life: an analysis of the PATCH trial EQ-5D data.

OBJECTIVES: to compare care staff proxies with care home residents' self-assessment of their health-related quality of life (HRQoL). METHODS: we assessed the degree of inter-rater reliability between residents and care staff proxies for the EQ-5D-5L index, domains and EQ Visual Analogue Scale at baseline, 3 months and 6 months, collected as part of the PATCH trial. We calculated kappa scores. Interpreted as <0 no agreement, 0-0.2 slight, 0.21-0.60 fair to moderate and >0.6 substantial to almost perfect agreement. Qualitative interviews with care staff and researchers explored the challenges of completing these questions. RESULTS: over 50% of the HRQoL data from residents was missing at baseline compared with a 100% completion rate by care staff proxies. A fair-to-moderate level of agreement was found for the EQ-5D-5L index. A higher level of agreement was achieved for the EQ-5D-5L domains of mobility and pain. Resident 'non-completers' were more likely to: be older, have stayed a longer duration in the care home, have lower Barthel Index and Physical Activity and Mobility in Residential Care (PAM-RC) scores, a greater number of co-morbidities and have joined the trial through consultee agreement. Interviews with staff and researchers indicated that it was easier to rate residents' mobility levels than other domains, but in general it was difficult to obtain data from residents or to make an accurate proxy judgement for those with dementia. CONCLUSIONS: whilst assessing HRQoL by care staff proxy completion provides a more complete dataset, uncertainty remains as to how representative these values are for different groups of residents within care homes.

Analysis of an Ambulatory Care Pathway for Patients With COVID-19 Utilising Remote Pulse Oximetry at a London District General Hospital.

The identification of coronavirus disease 2019 (COVID-19) patients with oxygen saturations between 90-94% who can be safely discharged from the emergency department (ED) is challenging due to the difficulty of community monitoring. A pathway consisting of home pulse oximetry with telephone follow-up was devised and implemented at a London District General Hospital to facilitate the safe discharge of these patients from the ED. Twenty patients with confirmed or suspected COVID-19 with oxygen saturations between 90%-94% were discharged on this novel ambulatory care pathway. Eighty-five percent of patients successfully avoided hospitalisation, whilst 15% were re-assessed and subsequently admitted to hospital. Home pulse oximetry monitoring was utilised to aid discharge from the ED and therefore prevent hospital admission. Telephone follow-up identified patients requiring further assessment. This study demonstrates the potential for safe ambulation of a subgroup of patients with COVID-19.

Digital onboarding in finance: a novel model and related cybersecurity risks.

Over the last few years, the financial sector has undergone a digital revolution that has had a severe impact on different related areas such as, the entities, the cybersecurity of systems, regulations and, of course, customers. SOTER project takes the challenge providing a complete set of tools to enhance the cybersecurity levels by implementing, in addition to non-technological tools, an innovative onboarding process has been implemented with the goals of increasing security, improving the user experience and integrity in the sector, and facilitating the customer entry into the digital marketplace by combining a set of breakthrough technologies. The cybersecurity research plays a crucial role in the conception and implementation of the onboarding process and for this kind of processes it has to be studied as an individual area by itself, as it is necessary to analyze the possible threats that can affect them, their origin and the solution(s) that can be taken to address them. Therefore, the SOTER project presents a fully digital onboarding process, innovative, adaptable to both current and future market needs and to possible changes in regulation, based on the most advanced technologies available today, and above all guaranteeing the cybersecurity of both entities and end users.

A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial).

BACKGROUND: provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence and skills of staff who provide care. This trial assessed the feasibility of undertaking a definitive evaluation of a posture and mobility training programme for care staff. DESIGN AND SETTING: a cluster randomised controlled feasibility trial with embedded process evaluation. Ten care homes in Yorkshire, United Kingdom, were randomised (1:1) to the skilful care training package (SCTP) or usual care (UC). PARTICIPANTS: residents who were not independently mobile. INTERVENTION: SCTP-delivered by physiotherapists to care staff. OBJECTIVES AND MEASUREMENTS: key objectives informed progression to a definitive trial. Recruitment, retention and intervention uptake were monitored. Data, collected by a blinded researcher, included pain, posture, mobility, hospitalisations and falls. This informed data collection feasibility and participant safety. RESULTS: a total of 348 residents were screened; 146 were registered (71 UC, 75 SCTP). Forty two were lost by 6 months, largely due to deaths. While data collection from proxy informants was good (>95% expected data), attrition meant that data completion rates did not meet target. Data collection from residents was poor due to high levels of dementia. Intervention uptake was variable-staff attendance at all sessions ranged from 12.5 to 65.8%. There were no safety concerns. CONCLUSION: care home and resident recruitment are feasible, but refinement of data collection approaches and intervention delivery are needed for this trial and care home research more widely.

The banality of counterterrorism "after, after 9/11"? Perspectives on the Prevent duty from the UK health care sector.

Since 2015, the UK healthcare sector sector has (along with education and social care) been responsibilised for noticing signs of radicalisation and reporting patients to the Prevent programme. The Prevent Duty frames the integration of healthcare professionals into the UK's counterterrorism effort as the banal extension of safeguarding. But safeguarding has previously been framed as the protection of children, and adults with care and support needs, from abuse. This article explores the legitimacy of situating Prevent within safeguarding through interviews with safeguarding experts in six National Health Service (NHS) Trusts and Clinical Commissioning Groups. It also describes the factors which NHS staff identified as indicators of radicalisation - data which was obtained from an online questionnaire completed by 329 health care professionals. The article argues that the "after, after 9/11" era is not radically distinct from earlier periods of counterterrorism but does contain novel features, such as the performance of anticipatory counterterrorism under the rubric of welfare and care.

Estimating progression-free survival in patients with glioblastoma using routinely collected data.

Glioblastoma (GBM) represents 80% of all primary malignant brain tumours in adults. Prognosis is poor, and there is a clear correlation between disease progression and deterioration in functional status. In this pilot study we assess whether we can estimate disease progression and progression free survival (PFS) from routinely collected electronic healthcare data. We identified fifty patients with glioblastoma who had chemo-radiotherapy. For each patient we manually collected a reference data set recording demographics, surgery, radiotherapy, chemotherapy, follow-up and death. We also obtained an electronic routine data set for each patient by combining local data on chemotherapy/radiotherapy and hospital admissions. We calculated overall survival (OS) and PFS using the reference data set, and estimated them using the routine data sets using two different methods, and compared the estimated measures with the reference measures. Overall survival was 68% at 1 year and median OS was 12.8 months. The routine data correctly identified progressive disease in 37 of 40 patients and stable disease in 7 of 10 patients. PFS was 7.4 months and the estimated PFS using routine data was 9.1 and 7.8 months with methods 1 and 2 respectively. There was acceptable agreement between reference and routine data in 49 of 50 patients for OS and 35 of 50 patients for PFS. The event of progression, subsequent treatment and OS are well estimated using our approach, but PFS estimation is less accurate. Our approach could refine our understanding of the disease course and allow us to report PFS, OS and treatment nationally.

The Geography of Pre-Criminal Space: Epidemiological Imaginations of Radicalisation Risk in the UK Prevent Strategy, 2007-2017.

This paper explores geographical and epistemological shifts in the deployment of the UK Prevent strategy, 2007 - 2017. Counter-radicalisation policies of the Labour governments (2006 - 2010) focused heavily upon resilience-building activities in residential communities. They borrowed from historical models of crime prevention and public health to imagine radicalisation risk as an epidemiological concern in areas showing a 2% or higher demography of Muslims. However, this racialized and localised imagination of pre-criminal space was replaced, after the election of the Conservative-Liberal Democrat coalition in 2010. Residential communities were then de-emphasised as sites of risk, transmission and pre-criminal intervention. The Prevent Duty now deploys counter-radicalisation through national networks of education and healthcare provision. Localised models of crime prevention (and their statistical, crime prevention epistemologies) have been de-emphasised in favour of big data inflected epistemologies of inductive, population-wide 'safeguarding'. Through the biopolitical discourse of 'safeguarding vulnerable adults' the Prevent Duty has radically reconstituted the epidemiological imagination of pre-criminal space, imagining that all bodies are potentially vulnerable to infection by radicalisers and thus warrant surveillance.

The cost-effectiveness of a mechanical compression device in out-of-hospital cardiac arrest.

AIM: To assess the cost-effectiveness of LUCAS-2, a mechanical device for cardiopulmonary resuscitation (CPR) as compared to manual chest compressions in adults with non-traumatic, out-of-hospital cardiac arrest. METHODS: We analysed patient-level data from a large, pragmatic, multi-centre trial linked to administrative secondary care data from the Hospital Episode Statistics (HES) to measure healthcare resource use, costs and outcomes in both arms. A within-trial analysis using quality adjusted life years derived from the EQ-5D-3L was conducted at 12-month follow-up and results were extrapolated to the lifetime horizon using a decision-analytic model. RESULTS: 4471 patients were enrolled in the trial (1652 assigned to the LUCAS-2 group, 2819 assigned to the control group). At 12 months, 89 (5%) patients survived in the LUCAS-2 group and 175 (6%) survived in the manual CPR group. In the vast majority of analyses conducted, both within-trial and by extrapolation of the results over a lifetime horizon, manual CPR dominates LUCAS-2. In other words, patients in the LUCAS-2 group had poorer health outcomes (i.e. lower QALYs) and incurred higher health and social care costs. CONCLUSION: Our study demonstrates that the use of the mechanical chest compression device LUCAS-2 represents poor value for money when compared to standard manual chest compression in out-of-hospital cardiac arrest.

Exposure to traffic-related air pollution and risk of development of childhood asthma: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: The question of whether children's exposure to traffic-related air pollution (TRAP) contributes to their development of asthma is unresolved. We conducted a systematic review and performed meta-analyses to analyze the association between TRAP and asthma development in childhood. DATA SOURCES: We systematically reviewed epidemiological studies published until 8 September 2016 and available in the Embase, Ovid MEDLINE (R), and Transport databases. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: We included studies that examined the association between children's exposure to TRAP metrics and their risk of 'asthma' incidence or lifetime prevalence, from birth to age 18years old. STUDY APPRAISAL AND SYNTHESIS METHODS: We extracted key characteristics of each included study using a predefined data items template and these were tabulated. We used the Critical Appraisal Skills Programme checklists to assess the validity of each included study. Where four or more independent risk estimates were available for a continuous pollutant exposure, we conducted overall and age-specific meta-analyses, and four sensitivity analyses for each summary meta-analytic exposure-outcome association. RESULTS: Forty-one studies met our eligibility criteria. There was notable variability in asthma definitions, TRAP exposure assessment methods and confounder adjustment. The overall random-effects risk estimates (95% CI) were 1.08 (1.03, 1.14) per 0.5×10-5m-1 black carbon (BC), 1.05 (1.02, 1.07) per 4µg/m3 nitrogen dioxide (NO2), 1.48 (0.89, 2.45) per 30µg/m3 nitrogen oxides (NOx), 1.03 (1.01, 1.05) per 1µg/m3 Particulate Matter <2.5µm in diameter (PM2.5), and 1.05 (1.02, 1.08) per 2µg/m3 Particulate Matter <10µm in diameter (PM10). Sensitivity analyses supported these findings. Across the main analysis and age-specific analysis, the least heterogeneity was seen for the BC estimates, some heterogeneity for the PM2.5 and PM10 estimates and the most heterogeneity for the NO2 and NOx estimates. LIMITATIONS, CONCLUSIONS AND IMPLICATION OF KEY FINDINGS: The overall risk estimates from the meta-analyses showed statistically significant associations for BC, NO2, PM2.5, PM10 exposures and risk of asthma development. Our findings support the hypothesis that childhood exposure to TRAP contributes to their development of asthma. Future meta-analyses would benefit from greater standardization of study methods including exposure assessment harmonization, outcome harmonization, confounders' harmonization and the inclusion of all important confounders in individual studies. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO 2014: CRD42014015448.

Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review.

OBJECTIVES: To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this. DESIGN: Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south. SETTINGS: A wide range of settings within primary and secondary care (these were not restricted in the search). RESULTS: 108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies. CONCLUSIONS: The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.

The 18-kDa mitochondrial translocator protein in gliomas: from the bench to bedside.

The 18-kDa mitochondrial translocator protein (TSPO) is known to be highly expressed in several types of cancer, including gliomas, whereas expression in normal brain is low. TSPO functions in glioma are still incompletely understood. The TSPO can be quantified pre-operatively with molecular imaging making it an ideal candidate for personalized treatment of patient with glioma. Studies have proposed to exploit the TSPO as a transporter of chemotherapics to selectively target tumour cells in the brain. Our studies proved that positron emission tomography (PET)-imaging can contribute to predict progression of patients with glioma and that molecular imaging with TSPO-specific ligands is suitable to stratify patients in view of TSPO-targeted treatment. Finally, we proved that TSPO in gliomas is predominantly expressed by tumour cells.

Carbon footprint of patient journeys through primary care: a mixed methods approach.

BACKGROUND: The NHS has a target of cutting its carbon dioxide (CO2) emissions by 80% below 1990 levels by 2050. Travel comprises 17% of the NHS carbon footprint. This carbon footprint represents the total CO2 emissions caused directly or indirectly by the NHS. Patient journeys have previously been planned largely without regard to the environmental impact. The potential contribution of 'avoidable' journeys in primary care is significant. AIM: To investigate the carbon footprint of patients travelling to and from a general practice surgery, the issues involved, and potential solutions for reducing patient travel. DESIGN AND SETTING: A mixed methods study in a medium-sized practice in Yorkshire. METHOD: During March 2012, 306 patients completed a travel survey. GIS maps of patients' travel (modes and distances) were produced. Two focus groups (12 clinical and 13 non-clinical staff) were recorded, transcribed, and analysed using a thematic framework approach. RESULTS: The majority (61%) of patient journeys to and from the surgery were made by car or taxi; main reasons cited were 'convenience', 'time saving', and 'no alternative' for accessing the surgery. Using distances calculated via ArcGIS, the annual estimated CO2 equivalent carbon emissions for the practice totalled approximately 63 tonnes. Predominant themes from interviews related to issues with systems for booking appointments and repeat prescriptions; alternative travel modes; delivering health care; and solutions to reducing travel. CONCLUSION: The modes and distances of patient travel can be accurately determined and allow appropriate carbon emission calculations for GP practices. Although challenging, there is scope for identifying potential solutions (for example, modifying administration systems and promoting walking) to reduce 'avoidable' journeys and cut carbon emissions while maintaining access to health care.

Health impacts of free bus travel for young people: evaluation of a natural experiment in London.

BACKGROUND: We used the introduction of free bus travel for young people in London in 2005 as a natural experiment with which to assess its effects on active travel, car use, road traffic injuries, assaults, and on one measure of social inclusion, total number of trips made. METHODS: A controlled before-after analysis was conducted. We estimated trips by mode and distances travelled in the preintroduction and postintroduction periods using data from London Travel Demand Surveys. We estimated rates of road traffic injury and assault in each period using STATS19 data and Hospital Episode Statistics, respectively. We estimated the ratio of change in the target age group (12-17 years) to the change in adults (ages 25-59 years), with 95% CIs. RESULTS: The proportion of short trips travelled by bus by young people increased postintroduction. There was no evidence for an increase in the total number of bus trips or distance travelled by bus by young people attributable to the intervention. The proportion of short trips by walking decreased, but there was no evidence for any change to total distance walked. Car trips declined in both age groups, although distance travelled by car decreased more in young people. Road casualty rates declined, but the pre-post ratio of change was greater in young people than adults (ratio of ratios 0.84; 95% CI 0.82 to 0.87). Assaults increased and the ratio of change was greater in young people (1.20; 1.13 to 1.27). The frequency of all trips by young people was unchanged, both in absolute terms and relative to adults. CONCLUSIONS: The introduction of free bus travel for young people had little impact on active travel overall and shifted some travel from car to buses that could help broader environmental objectives.