Developing a framework to guide the evaluation of training in research skills for health and care professionals.

Background: Delivering research skills training to health professionals through short, applied sessions outside a formal higher education program, can help fill gaps in training and build research capacity in clinical settings. This has been the endeavor of some of the Applied Research Collaborations funded by the National Institute for Health and Care Research in England since 2014. How to evaluate this type of training in terms of the wider impact it may have, has not featured heavily in the literature and methods have largely borrowed from more generic approaches to training evaluation which can over-simplify outcomes and ignore longer-term impacts. Methods: We developed the framework in four stages: mapping potential impacts of our research skills training courses to identify key concepts; shaping into three domains in which impact could be expected, informed by established definitions of research capacity building; testing the initial framework and adapting wording of impacts; refining the framework into a practical tool. Results: The final framework specifies types of impact in three domains of influence - individual, group/organization and health system, and maps these against key questions to guide inquiry, as well as suggested methods for capturing the impact and expected timeframe for each type of impact. Discussion: The framework provides a structure for guiding the evaluation of research training as well as a focus on medium-longer term impacts, encouraging a broader and continuous approach to evaluation. It is hoped this will support educators in other contexts and fields, in the planning of a wider range of training evaluation activities, to capture impact more fully.

Exploring the role of exposure to green and blue spaces in preventing anxiety and depression among young people aged 14-24 years living in urban settings: A systematic review and conceptual framework.

Despite the growing problem of anxiety and depression amongst young people aged 14-24 years living in urban settings, reviews about the role of exposure to green and blue spaces or nature in preventing anxiety and depression tend to focus on children, adults or sometimes adolescents. This review aims to explore whether exposure to green and blue spaces reduces the risk of anxiety and depression among young people aged 14-24 years living in urban settings and provide a conceptual framework. The academic databases CINAHL plus, Global Health, MEDLINE, ProQuest: Dissertations and Theses, PsycINFO, Scopus and OpenGrey were searched for research published in English between January 2000 and June 2020. All study designs were eligible. All included studies were assessed for quality. Searches identified 9208 sources with 48 meeting the inclusion criteria for the review. Experimental studies provided evidence that walking or being in a green space improves mood and state anxiety immediately following the intervention. Non-randomised evaluations and observational studies suggest that social interaction, physical activity, and mindfulness mediate the relationship between exposure to green space and mental health. We propose that the absence of noise and restorative qualities of green spaces promotes mindfulness and interrupt rumination, which in turn reduce the risk of anxiety disorders and depression. This review and the resulting conceptual framework provide evidence to healthcare professionals about the value of contact with nature and green social prescribing. For policymakers, it provides evidence about the value of bringing the benefits of forests, vegetation and nature into cities, and ensuring that these spaces are accessible and safe for young people to use.

Effects of city-wide 20 mph (30km/hour) speed limits on road injuries in Bristol, UK.

Twenty miles per hour (32 km/hour) or 30 km/hour speed limits represent a potential strategy to reduce urban road injuries and are becoming increasingly widespread. However, no study has conducted a robust evaluation of the effects of city-wide 20 mph speed limits on road injuries. This study reports the effects of such an intervention, based on a natural experiment that took place in Bristol, UK. Based on a stepped-wedge design using count data, negative binomial regressions showed that between 2008 and 2016, the 20 mph speed limit intervention was associated with a city-level reduction of fatal injuries of around 63% (95% CI 2% to 86%), controlling for trends over time and areas. There was also a general trend of reduction of the total number of injuries at city level and in 20 mph roads. These findings highlight the potential benefits of city-wide 20 mph speed limits. We hypothesise that this city-wide approach may encourage a general behaviour change in drivers that, in turn, may contribute to reducing injuries across the city.

Prospective Pathways to Depressive Symptoms and Disordered Eating in Adolescence: A 7-Year Longitudinal Cohort Study.

Eating pathology and depressive symptoms increase during adolescence, yet predictive pathways remain predominantly unexplored, despite their implications for prevention. The present study aimed to identify shared risk factors for eating pathology and depressive symptoms by evaluating an adapted Dual-Pathway Model of disordered eating, which postulated that higher BMI would predict disordered eating and depressive symptoms via pathways between body dissatisfaction, later BMI, depressive symptoms, and visible indicators of puberty (breast development for girls, height for boys). The participants were 8915 children (49% girls) from the Avon Longitudinal Study of Parents and Children, a population-based cohort study of British children, who were assessed at different intervals between the age of 7 to 14 years. Path analyses revealed that, for girls, childhood BMI exerted indirect effects on disordered eating via body dissatisfaction, depressive symptoms, and more advanced breast development, with indirect pathways identified to depressive symptoms via earlier depressive symptoms and more advanced breast development. For boys, childhood BMI had indirect effects on disordered eating via later BMI and body dissatisfaction, while only earlier depressive symptoms were found to have an independent and direct effect on adolescent depressive symptoms. This study reveals shared and independent risk factors for eating pathology and depressive symptoms in adolescence and suggests targets for preventative interventions, including higher BMI, body dissatisfaction, and depressive symptoms, in addition to advanced breast development, for girls.

Building capacity to use and undertake applied health research: establishing a training programme for the health workforce in the West of England.

OBJECTIVES: Increasing research capacity is important for health services as part of improving the conduct of high-quality research, which addresses the needs of patients and the public. It is a core function of the 13 Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) established in England between 2008 and 2013. This article reports on the development of an innovative capacity building programme in CLAHRC West over an 18-month period (May 2015 to December 2016). It aims to disseminate the learning from the initiative and share our experience with other CLAHRCs. STUDY DESIGN: The study design was an evaluation of a training programme to build research capacity. METHODS: We carried out a training needs assessment among local stakeholders and scoped existing provision of research-related training. This informed the development of a programme of free short courses, which were targeted at health and social care professionals including those working in local authorities and the voluntary sector. We aimed to engage professionals working at all levels in these organisations and to promote interprofessional education, to build a research culture. We engaged a variety of educators to provide a range of 1-day courses at an introductory level, which were accessible to practitioners. RESULTS: During the first 18 months of the training programme, we delivered 31 courses and trained 350 participants. Attendees came from secondary care (20%), voluntary sector (18%) and local authorities (18%). Professionals working in the mental health sector comprised 11% and commissioning 6%. Less well represented were primary care (3%) and community care (4%). The largest professional group was public health, followed by medical, nursing and allied health professionals in approximately equal proportions. Courses were evaluated on a scale of 1 (poor) to 4 (excellent) with the mean being 3.6 (range 3.3-4.0). CONCLUSIONS: The training programme has been highly successful with many courses oversubscribed, and all courses being well evaluated by participants. It has met the needs of local professionals for brief, applied training in research, as well as attracting those from other parts of the United Kingdom, suggesting the courses are both appropriate and helping to fill a gap in provision. We are building on this work to further engage audiences working in areas such as the wider determinants of health and commissioning, as well as primary and community sectors. CLAHRCs are uniquely placed to drive a culture change in the use, understanding and application of research across the healthcare community.

Proximity to overhead power lines and childhood leukaemia: an international pooled analysis.

BACKGROUND: Although studies have consistently found an association between childhood leukaemia risk and magnetic fields, the associations between childhood leukaemia and distance to overhead power lines have been inconsistent. We pooled data from multiple studies to assess the association with distance and evaluate whether it is due to magnetic fields or other factors associated with distance from lines. METHODS: We present a pooled analysis combining individual-level data (29,049 cases and 68,231 controls) from 11 record-based studies. RESULTS: There was no material association between childhood leukaemia and distance to nearest overhead power line of any voltage. Among children living < 50 m from 200 + kV power lines, the adjusted odds ratio for childhood leukaemia was 1.33 (95% CI: 0.92-1.93). The odds ratio was higher among children diagnosed before age 5 years. There was no association with calculated magnetic fields. Odds ratios remained unchanged with adjustment for potential confounders. CONCLUSIONS: In this first comprehensive pooled analysis of childhood leukaemia and distance to power lines, we found a small and imprecise risk for residences < 50 m of 200 + kV lines that was not explained by high magnetic fields. Reasons for the increased risk, found in this and many other studies, remains to be elucidated.

Promoting positive body image and tackling overweight/obesity in children and adolescents: A combined health psychology and public health approach.

This article draws attention to the dual global problems of disordered eating and overweight/obesity among children and adolescents. It is well recognised that the main risk factor for disordered eating is body dissatisfaction, yet public health messages to tackle overweight/obesity are likely to increase body dissatisfaction. This tension between key public health messages and a health psychology approach is examined, with the goal of seeking a common way forward. We focus on the UK as a case study, where there is currently no statutory education in schools on body image. Since more prescriptive guidance on the curriculum covering personal/social/health issues is soon to be introduced, it is timely to consider the content, and in particular its impact on body image as well as overweight/obesity. Having reviewed current interventions and policy, we argue for a more holistic approach to the obesity problem, using a whole school approach to create a body confident culture.

Weight gain in mid-childhood and its relationship with the fast food environment.

Background: Childhood obesity is a serious public health issue. Understanding environmental factors and their contribution to weight gain is important if interventions are to be effective. Aims: The purpose of this research was to assess the relationship between weight gain in children and accessibility of fast-food outlets. Methods: A longitudinal sample of 1577 children was created using two time points from the National Child Measurement Programme in South Gloucestershire (2006/7 and 2012/13). A spatial analysis was conducted using a weighted accessibility score on the number of fast-food outlets within a 1-km network radius of each child's residence to quantify access to fast food. Results: The mean accessibility score for all children was 0.73 (standard deviation: 1.14). Fast-food outlets were more prevalent in areas of deprivation. A moderate association was found between deprivation score and accessibilty score (r = 0.4, P < 0.01). Children who had greater access to fast-food outlets were more likely (odds ratio = 1.89, P = 0.04) to gain significant weight (>50 percentile points) compared to children who had no access to fast-food outlets. Conclusions: This paper supports previous research that fast-food outlets are more prevalent in areas of deprivation and presents new evidence on fast-food outlets as a potential contributor towards weight gain in mid-childhood.

Changes in objectively measured BMI in children aged 4-11 years: data from the National Child Measurement Programme.

BACKGROUND: This study looked at the degree of weight gain between the first (Reception) and last year (Year 6) of primary school and how weight status in Reception predicts becoming overweight/obese by Year 6. METHODS: A longitudinal sample of 1863 children was created using two time points (2006/7, 2012/13) from the National Child Measurement Programme (NCMP) in South Gloucestershire. T-test and logistic regression were used to test the difference between the BMI z-scores and BMI percentiles, and predict the probability of being overweight (BMI ≥ 85th) or obese (≥95th) at Year 6 based on BMI percentile in Reception. RESULTS: Of those children who were obese at Reception age, 68% were obese at Year 6. Compared with children with a BMI in the 2nd to 49th percentile range, children between the 75th and 84th percentiles of BMI at Reception age were 10 times more likely (odds ratio (OR) = 10.18, P < 0.01), and those with a BMI between the 85th and 94th percentiles were 13 times more likely (OR = 13.38, P < 0.01), to become obese by Year 6. Boys were more likely than girls to revert to a healthy weight. CONCLUSIONS: This is the first study to link data from the NCMP. It provides estimates of prevalence and offers new evidence on obesity emergence and gender differences.

A randomised controlled trial comparing opt-in and opt-out home visits for tracing lost participants in a prospective birth cohort study.

BACKGROUND: Attrition is an important problem in cohort studies. Tracing cohort members who have moved or otherwise lost contact with the study is vital. There is some debate about the acceptability and relative effectiveness of opt-in versus opt-out methods of contacting cohort members to re-engage them in this context. We conducted a randomised controlled trial to compare the two approaches in terms of effectiveness (tracing to confirm address and consenting to continue in the study), cost-effectiveness and acceptability. METHODS: Participants in this trial were individuals (young people and mothers) recruited to the Avon Longitudinal Study of Parents and Children (ALSPAC), who had not engaged with the study in the previous 5 years and for whom mail had been returned from their last known address. The sampling frame was restricted to those for whom database searching led to a potential new address being found in the Bristol area. 300 participants were randomly selected and assigned using stratified randomisation to the opt-in or opt-out arm. A tailored letter was sent to the potential new address, either asking participants to opt in to a home visit, or giving them the option to opt out of a home visit. Fieldworkers from Ipsos MORI conducted home visits to confirm address details. RESULTS: The proportion who were traced was higher in the opt-out arm (77/150 = 51 %) than the opt-in arm (6/150 = 4 %), as was the proportion who consented to continue in ALSPAC (46/150 = 31 % v 4/150 = 3 %). The mean cost per participant was £8.14 in the opt-in arm and £71.93 in the opt-out arm. There was no evidence of a difference in acceptability between the opt-in and opt-out approaches. CONCLUSION: Since the opt-in approach yielded very low response rates, and there were no differences in terms of acceptability, we conclude that the opt-out approach is the most effective method of tracing disengaged study members. The gains made in contacting participants must be weighed against the increase in cost using this methodology.

Smoking prevalence amongst UK Armed Forces recruits: changes in behaviour after 3 years follow-up and factors affecting smoking behaviour.

OBJECTIVES: The purpose of this study was to investigate smoking prevalence of Tri-Service recruits, and changes in smoking behaviour at 3-year follow-up, by trade group and gender. Associations with educational attainment and deprivation were also assessed. METHODS: Analysis of a survey into the health behaviours of 10 531 recruits in 1998/1999. A follow-up 3 years later measured changes in behaviour. Correlation and multiple regression was used to investigate the relationship between smoking prevalence in each trade group and both educational attainment and deprivation, using Index of Multiple Deprivation 2004 (IMD 2004) scores. RESULTS: Army recruits exhibited a significantly higher smoking prevalence (45%) than Royal Navy recruits (34%) and Royal Air Force (RAF) recruits (31%). There were marked differences between smoking levels amongst officer cadets (12%, 20% and 10% in the Navy, Army and RAF, respectively) and other rank trade groups (24-56%), with the exception of the Marines (13%). At follow up, smoking had generally increased, and in some parts of the infantry had risen to 66%. There was a clear correlation between smoking at enlistment and both educational attainment (correlation coefficient=0.7, p<0.005) and deprivation score (correlation coefficient=0.8, p<0.005). CONCLUSIONS: There were clear differences between Services, rank and trade groups in smoking prevalence at recruitment. Smoking levels increased in the 3 years after recruitment to the Armed Forces. Deprivation was more important than educational attainment in determining the smoking status of recruits.

The diversity and evolution of electric organs in Neotropical knifefishes.

The Gymnotiformes, also known as the South American or Neotropical knifefishes, include the strongly electric Electrophorus electricus and many other weakly electric species. These fish possess specialised electric organs that are able to release electric discharges into the water, for electrolocation and communication, and sometimes for predation and defence. All Gymnotiform species possess a myogenic electric organ (mEO) derived from the muscle tissue, and members of the Apteronotidae family uniquely possess a neurogenic electric organ (nEOs) derived from the nervous tissue. A mEO may consist of 'Type A' electrocytes that develop within the tail muscle (for example, in Apteronotus leptorhynchus), or 'Type B' electrocytes that develop below the tail muscle (for example, in Brachyhypopomus gauderio). In this review, we discuss the diversity in the anatomy, electric discharge and development of electric organs found in different Gymnotiform species, as well as the ecological and environmental factors that have likely contributed to this diversity. We then describe various hypotheses regarding the evolution of electric organs, and discuss the potential evolutionary origin of the nEO: a pair of nerve cords that are located on either side of the aorta in B. gauderio, and which may have expanded and developed into a nEO in the Apteronotidae family during its evolution from a common ancestral species. Finally, we compare potential Gymnotiform phylogenies and their supporting evidence.

Exposure to Green and Historic Urban Environments and Mental Well-Being: Results from EEG and Psychometric Outcome Measures.

Previous studies have identified the benefits of exposure to green or historic environments using qualitative methods and psychometric measures, but studies using a combination of measures are lacking. This study builds on current literature by focusing specifically on green and historic urban environments and using both psychological and physiological measures to investigate the impact of virtual exposure on well-being. Results from the psychological measures showed that the presence of historic elements was associated with a significantly stronger recuperation of hedonic tone (p = 0.01) and reduction in stress (p = 0.04). However, the presence of greenness had no significant effect on hedonic tone or stress. In contrast, physiological measures (EEG) showed significantly lower levels of alpha activity (p < 0.001) in occipital regions of the brain when participants viewed green environments, reflecting increased engagement and visual attention. In conclusion, this study has added to the literature by showing the impact that historic environments can have on well-being, as well as highlighting a lack of concordance between psychological and physiological measures. This supports the use of a combination of subjective and direct objective measures in future research in this field.

Systematic Review of the Health and Equity Impacts of Remediation and Redevelopment of Contaminated Sites.

(1) Background: Globally there is a vast legacy of contaminated sites from past industrial, commercial and military activity, waste disposal, and mineral extraction. This review examined the extent to which the remediation of contaminated sites reduces health risks to new and existing populations. (2) Methods: Standard academic databases were searched for papers that reported on health-related outcomes in humans following remediation and redevelopment of contaminated sites. Title/abstract screening, followed by full-text screening identified sixteen papers that met the eligibility criteria. (3) Results: Most studies were set in the United States of America and reported changes in blood lead concentrations in children, following soil remediation and, in some cases, public health campaigns to reduce exposure. Two further studies examined the impacts of remediation on soil contaminated with chromium and sediments contaminated with polychlorinated biphenyls (PCBs). (4) Conclusions: Overall, the evidence suggests that remediation via removal, capping, and replacing soil, and planting vegetation is effective at reducing concentrations of lead and chromium in blood and urine in children. There is also evidence that sediment dredging can reduce PCB concentrations in umbilical cords in infants. Study designs are relatively weak and some recommendations are provided for those wishing to examine the health impacts of remediation.

Exposure to Green, Blue and Historic Environments and Mental Well-Being: A Comparison between Virtual Reality Head-Mounted Display and Flat Screen Exposure.

Improving the mental health of urban residents is a global public health priority. This study builds on existing work that demonstrates the ability of virtual exposure to restorative environments to improve population mental health. It compares the restorative effects of green, blue and historic environments delivered by both flat screen and immersive virtual reality technology, and triangulates data from psychological, physiological and qualitative sources. Results from the subjective measure analyses showed that exposures to all the experimental videos were associated with self-reported reduced anxiety and improved mood, although the historic environment was associated with a smaller reduction of anxiety (p < 0.01). These results were supported by the qualitative accounts. For two of the electroencephalography (EEG) frequency bands, higher levels of activity were observed for historic environments. In relation to the mode of delivery, the subjective measures did not suggest any effect, while for the EEG analyses there was evidence of a significant effect of technology across three out of four frequency bands. In conclusion, this study adds to the evidence that the benefits of restorative environments can be delivered through virtual exposure and suggests that virtual reality may provide greater levels of immersion than flat screen viewing.

Body dissatisfaction predicts the onset of depression among adolescent females and males: a prospective study.

RATIONALE: Body dissatisfaction is prevalent in mid-adolescence and may be associated with the onset of depression. OBJECTIVE: The study assessed the influence of body dissatisfaction on the occurrence of later depressive episodes in a population-based sample of British adolescents. METHOD: Participants were 2078 females and 1675 males from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Logistic regression was used to test if body dissatisfaction at 14 years old predicted the onset of depressive episodes at 18 years old, controlling for baseline depression. RESULTS: Among females, body dissatisfaction predicted mild (OR=1.63, 95% CI=1.31, 2.04), moderate (OR=1.67, 95% CI=1.28, 2.18) and severe depressive episodes (OR=1.84, 95% CI=1.09, 3.12). Among males, body dissatisfaction predicted mild (OR=1.50, 95% CI=1.00, 2.25) and severe depressive episodes (OR=2.85, 95% CI=1.18, 6.87) at 18 years of age. CONCLUSIONS: This is the first prospective study to demonstrate that body dissatisfaction in adolescence predicts the occurrence of later depressive episodes in a cohort born in the early 1990s. The findings highlight that body dissatisfaction is a public health concern.

Suicide after leaving the UK armed forces--a cohort study.

BACKGROUND: Few studies have examined suicide risk in individuals once they have left the military. We aimed to investigate the rate, timing, and risk factors for suicide in all those who had left the UK Armed Forces (1996-2005). METHODS AND FINDINGS: We carried out a cohort study of ex-Armed Forces personnel by linking national databases of discharged personnel and suicide deaths (which included deaths receiving either a suicide or undetermined verdict). Comparisons were made with both general and serving populations. During the study period 233,803 individuals left the Armed Forces and 224 died by suicide. Although the overall rate of suicide was not greater than that in the general population, the risk of suicide in men aged 24 y and younger who had left the Armed Forces was approximately two to three times higher than the risk for the same age groups in the general and serving populations (age-specific rate ratios ranging from 170 to 290). The risk of suicide for men aged 30-49 y was lower than that in the general population. The risk was persistent but may have been at its highest in the first 2 y following discharge. The risk of suicide was greatest in males, those who had served in the Army, those with a short length of service, and those of lower rank. The rate of contact with specialist mental health was lowest in the age groups at greatest risk of suicide (14% for those aged under 20 y, 20% for those aged 20-24 y). CONCLUSIONS: Young men who leave the UK Armed Forces were at increased risk of suicide. This may reflect preservice vulnerabilities rather than factors related to service experiences or discharge. Preventive strategies might include practical and psychological preparation for discharge and encouraging appropriate help-seeking behaviour once individuals have left the services.

Self-harm in UK armed forces personnel: descriptive and case-control study of general hospital presentations.

BACKGROUND: Little is known about self-harm in the armed forces. AIMS: To investigate the characteristics of armed forces personnel presenting to a general hospital following self-harm and compare these with matched controls who had self-harmed. METHOD: Investigation of armed forces personnel presenting to hospital between 1989 and 2003 following self-harm and case-control comparison with people in the general population who had self-harmed. RESULTS: One hundred and sixty-six armed forces personnel presented with self-harm during the study period, of whom 72.3% (120) were male. Nearly two-thirds (62.7%) were aged under 25 years. Relationship problems (62.0%), employment problems (43.9%) and alcohol misuse (40.5%) were common. Fewer armed forces personnel than controls had evidence of current or past psychiatric disorders or treatment or a prior history of self-harm, and their suicidal intent was lower (males only). Of 64 people in the armed forces who presented during the first 9 years of the study period, 1 had died (from natural causes) by the end of 2000, compared with 9 (5.1%) of the controls, 6 by probable suicide. CONCLUSIONS: Self-harm by armed forces personnel may often be a response to interpersonal and employment problems complicated by alcohol misuse, with relatively low suicide intent.

Adolescent body dissatisfaction and disordered eating: Predictors of later risky health behaviours.

RATIONALE: Body dissatisfaction is prevalent among teenagers, and may influence the uptake of risky health behaviours. OBJECTIVE: The study assessed the influence of body dissatisfaction on smoking, cannabis use, drug use, self-harm, gambling, and drinking and the mediating role of disordered eating in a population-based sample of British adolescents. METHOD: Participants were 2634 females and 1684 males from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort. Logistic regression was used to test if body dissatisfaction at 14 years old predicted the onset of risky health behaviours at 21 years old. Mediation analysis tested the mediating role of disordered eating at 16 years old on each risky health behaviour. RESULTS: Among females, body dissatisfaction predicted smoking (OR = 1.40, 95% CI = 1.15, 1.72), cannabis use (OR = 1.20, 95% CI = 1.00, 1.43), drug use (OR = 1.51, 95% CI = 1.20, 1.90), self-harm (OR = 1.44, 95% CI = 1.13, 1.84) and high-risk drinking (OR = 1.41, 95% CI = 1.10, 1.80). Disordered eating symptoms had mediating effects on some behaviours. Among males, body dissatisfaction predicted smoking (OR = 1.44, 95% CI = 1.14, 1.81) and no effect of disordered eating was found on any risky health behaviour. CONCLUSIONS: This is the first prospective study to demonstrate that body dissatisfaction in adolescence predicts the occurrence of several risky health behaviours, and elucidates the mediating role of disordered eating. The findings highlight that body dissatisfaction is a public health concern. Early interventions to promote body satisfaction may reduce the prevalence of later risky health behaviours.

Mode of delivery affected questionnaire response rates in a birth cohort study.

OBJECTIVES: Cohort studies must collect data from their participants as economically as possible, while maintaining response rates. This randomized controlled trial investigated whether offering a choice of online or paper questionnaires resulted in improved response rates compared with offering online first. STUDY DESIGN AND SETTING: Eligible participants were young people in the Avon Longitudinal Study of Parents and Children (ALSPAC) study (born April 1, 1991, to December 31, 1992, in the Avon area). After exclusions, 8,795 participants were randomized. The "online first" group were invited to complete the questionnaire online. The "choice" group were also sent a paper questionnaire and offered a choice of completion method. The trial was embedded within routine data collection. The main outcome measure was the number of questionnaires returned. Data on costs were also collected. RESULTS: Those in the "online first" arm of the trial were less likely to return a questionnaire [adjusted odds ratio: 0.90; 95% confidence interval (CI): 0.82, 0.99]. The "choice" arm was more expensive (mean difference per participant £0.71; 95% CI: £0.65, £0.76). It cost an extra £47 to have one extra person to complete the questionnaire in the "choice" arm. CONCLUSION: Offering a choice of completion methods (paper or online) for questionnaires in ALSPAC increased response rates but was more expensive than offering online first.