Identifying best modelling practices for tobacco control policy simulations: a systematic review and a novel quality assessment framework.

BACKGROUND: Policy simulation models (PSMs) have been used extensively to shape health policies before real-world implementation and evaluate post-implementation impact. This systematic review aimed to examine best practices, identify common pitfalls in tobacco control PSMs and propose a modelling quality assessment framework. METHODS: We searched five databases to identify eligible publications from July 2013 to August 2019. We additionally included papers from Feirman et al for studies before July 2013. Tobacco control PSMs that project tobacco use and tobacco-related outcomes from smoking policies were included. We extracted model inputs, structure and outputs data for models used in two or more included papers. Using our proposed quality assessment framework, we scored these models on population representativeness, policy effectiveness evidence, simulated smoking histories, included smoking-related diseases, exposure-outcome lag time, transparency, sensitivity analysis, validation and equity. FINDINGS: We found 146 eligible papers and 25 distinct models. Most models used population data from public or administrative registries, and all performed sensitivity analysis. However, smoking behaviour was commonly modelled into crude categories of smoking status. Eight models only presented overall changes in mortality rather than explicitly considering smoking-related diseases. Only four models reported impacts on health inequalities, and none offered the source code. Overall, the higher scored models achieved higher citation rates. CONCLUSIONS: While fragments of good practices were widespread across the reviewed PSMs, only a few included a 'critical mass' of the good practices specified in our quality assessment framework. This framework might, therefore, potentially serve as a benchmark and support sharing of good modelling practices.

Engaging with stakeholders to inform the development of a decision-support tool for the NHS health check programme: qualitative study.

BACKGROUND: The NHS Health Check Programme is a risk-reduction programme offered to all adults in England aged 40-74 years. Previous studies mainly focused on patient perspectives and programme delivery; however, delivery varies, and costs are substantial. We were therefore working with key stakeholders to develop and co-produce an NHS Health Check Programme modelling tool (workHORSE) for commissioners to quantify local effectiveness, cost-effectiveness, and equity. Here we report on Workshop 1, which specifically aimed to facilitate engagement with stakeholders; develop a shared understanding of current Health Check implementation; identify what is working well, less well, and future hopes; and explore features to include in the tool. METHODS: This qualitative study identified key stakeholders across the UK via networking and snowball techniques. The stakeholders spanned local organisations (NHS commissioners, GPs, and academics), third sector and national organisations (Public Health England and The National Institute for Health and Care Excellence). We used the validated Hovmand "group model building" approach to engage stakeholders in a series of pre-piloted, structured, small group exercises. We then used Framework Analysis to analyse responses. RESULTS: Fifteen stakeholders participated in workshop 1. Stakeholders identified continued financial and political support for the NHS Health Check Programme. However, many stakeholders highlighted issues concerning lack of data on processes and outcomes, variability in quality of delivery, and suboptimal public engagement. Stakeholders' hopes included maximising coverage, uptake, and referrals, and producing additional evidence on population health, equity, and economic impacts. Key model suggestions focused on developing good-practice template scenarios, analysis of broader prevention activities at local level, accessible local data, broader economic perspectives, and fit-for-purpose outputs. CONCLUSIONS: A shared understanding of current implementations of the NHS Health Check Programme was developed. Stakeholders demonstrated their commitment to the NHS Health Check Programme whilst highlighting the perceived requirements for enhancing the service and discussed how the modelling tool could be instrumental in this process. These suggestions for improvement informed subsequent workshops and model development.

Evaluating stakeholder involvement in building a decision support tool for NHS health checks: co-producing the WorkHORSE study.

BACKGROUND: Stakeholder engagement is being increasingly recognised as an important way to achieving impact in public health. The WorkHORSE (Working Health Outcomes Research Simulation Environment) project was designed to continuously engage with stakeholders to inform the development of an open access modelling tool to enable commissioners to quantify the potential cost-effectiveness and equity of the NHS Health Check Programme. An objective of the project was to evaluate the involvement of stakeholders in co-producing the WorkHORSE computer modelling tool and examine how they perceived their involvement in the model building process and ultimately contributed to the strengthening and relevance of the modelling tool. METHODS: We identified stakeholders using our extensive networks and snowballing techniques. Iterative development of the decision support modelling tool was informed through engaging with stakeholders during four workshops. We used detailed scripts facilitating open discussion and opportunities for stakeholders to provide additional feedback subsequently. At the end of each workshop, stakeholders and the research team completed questionnaires to explore their views and experiences throughout the process. RESULTS: 30 stakeholders participated, of which 15 attended two or more workshops. They spanned local (NHS commissioners, GPs, local authorities and academics), third sector and national organisations including Public Health England. Stakeholders felt valued, and commended the involvement of practitioners in the iterative process. Major reasons for attending included: being able to influence development, and having insight and understanding of what the tool could include, and how it would work in practice. Researchers saw the process as an opportunity for developing a common language and trust in the end product, and ensuring the support tool was transparent. The workshops acted as a reality check ensuring model scenarios and outputs were relevant and fit for purpose. CONCLUSIONS: Computational modellers rarely consult with end users when developing tools to inform decision-making. The added value of co-production (continuing collaboration and iteration with stakeholders) enabled modellers to produce a "real-world" operational tool. Likewise, stakeholders had increased confidence in the decision support tool's development and applicability in practice.

Following in the footsteps of tobacco and alcohol? Stakeholder discourse in UK newspaper coverage of the Soft Drinks Industry Levy.

OBJECTIVE: In politically contested health debates, stakeholders on both sides present arguments and evidence to influence public opinion and the political agenda. The present study aimed to examine whether stakeholders in the Soft Drinks Industry Levy (SDIL) debate sought to establish or undermine the acceptability of this policy through the news media and how this compared with similar policy debates in relation to tobacco and alcohol industries. DESIGN: Quantitative and qualitative content analysis of newspaper articles discussing sugar-sweetened beverage (SSB) taxation published in eleven UK newspapers between 1 April 2015 and 30 November 2016, identified through the Nexis database. Direct stakeholder citations were entered in NVivo to allow inductive thematic analysis and comparison with an established typology of industry stakeholder arguments used by the alcohol and tobacco industries. SETTING: UK newspapers. PARTICIPANTS: Proponents and opponents of SSB tax/SDIL cited in UK newspapers. RESULTS: Four hundred and ninety-one newspaper articles cited stakeholders' (n 287) arguments in relation to SSB taxation (n 1761: 65 % supportive and 35 % opposing). Stakeholders' positions broadly reflected their vested interests. Inconsistencies arose from: changes in ideological position; insufficient clarity on the nature of the problem to be solved; policy priorities; and consistency with academic rigour. Both opposing and supportive themes were comparable with the alcohol and tobacco industry typology. CONCLUSIONS: Public health advocates were particularly prominent in the UK newspaper debate surrounding the SDIL. Advocates in future policy debates might benefit from seeking a similar level of prominence and avoiding inconsistencies by being clearer about the policy objective and mechanisms.

Effects of reducing processed culinary ingredients and ultra-processed foods in the Brazilian diet: a cardiovascular modelling study.

OBJECTIVE: To estimate the impact of reducing saturated fat, trans-fat, salt and added sugar from processed culinary ingredients and ultra-processed foods in the Brazilian diet on preventing cardiovascular deaths by 2030. DESIGN: A modelling study. SETTING: Data were obtained from the Brazilian Household Budget Survey 2008/2009. All food items purchased were categorized into food groups according to the NOVA classification. We estimated the energy and nutrient profile of foods then used the IMPACT Food Policy model to estimate the reduction in deaths from CVD up to 2030 in three scenarios. In Scenario A, we assumed that the intakes of saturated fat, trans-fat, salt and added sugar from ultra-processed foods and processed culinary ingredients were reduced by a quarter. In Scenario B, we assumed a reduction of 50 % of the same nutrients in ultra-processed foods and processed culinary ingredients. In Scenario C, we reduced the same nutrients in ultra-processed foods by 75 % and in processed culinary ingredients by 50 %. RESULTS: Approximately 390 400 CVD deaths might be expected in 2030 if current mortality patterns persist. Under Scenarios A, B and C, CVD mortality can be reduced by 5·5, 11·0 and 29·0 %, respectively. The main impact is on stroke with a reduction of approximately 6·0, 12·6 and 32·0 %, respectively. CONCLUSIONS: Substantial potential exists for reducing the CVD burden through overall improvements of the Brazilian diet. This might require reducing the penetration of ultra-processed foods by means of regulatory policies, as well as improving the access to and promotion of fresh and minimally processed foods.

Systematic review of dietary trans-fat reduction interventions.

OBJECTIVE: To systematically review published studies of interventions to reduce people's intake of dietary trans-fatty acids (TFAs). METHODS: We searched online databases (CINAHL, the CRD Wider Public Health database, Cochrane Database of Systematic Reviews, Ovid®, MEDLINE®, Science Citation Index and Scopus) for studies evaluating TFA interventions between 1986 and 2017. Absolute decrease in TFA consumption (g/day) was the main outcome measure. We excluded studies reporting only on the TFA content in food products without a link to intake. We included trials, observational studies, meta-analyses and modelling studies. We conducted a narrative synthesis to interpret the data, grouping studies on a continuum ranging from interventions targeting individuals to population-wide, structural changes. RESULTS: After screening 1084 candidate papers, we included 23 papers: 12 empirical and 11 modelling studies. Multiple interventions in Denmark achieved a reduction in TFA consumption from 4.5 g/day in 1976 to 1.5 g/day in 1995 and then virtual elimination after legislation banning TFAs in manufactured food in 2004. Elsewhere, regulations mandating reformulation of food reduced TFA content by about 2.4 g/day. Worksite interventions achieved reductions averaging 1.2 g/day. Food labelling and individual dietary counselling both showed reductions of around 0.8 g/day. CONCLUSION: Multicomponent interventions including legislation to eliminate TFAs from food products were the most effective strategy. Reformulation of food products and other multicomponent interventions also achieved useful reductions in TFA intake. By contrast, interventions targeted at individuals consistently achieved smaller reductions. Future prevention strategies should consider this effectiveness hierarchy to achieve the largest reductions in TFA consumption.

The effects of maximising the UK's tobacco control score on inequalities in smoking prevalence and premature coronary heart disease mortality: a modelling study.

BACKGROUND: Smoking is more than twice as common among the most disadvantaged socioeconomic groups in England compared to the most affluent and is a major contributor to health-related inequalities. The United Kingdom (UK) has comprehensive smoking policies in place: regular tax increases; public information campaigns; on-pack pictorial health warnings; advertising bans; cessation; and smoke-free areas. This is confirmed from its high Tobacco Control Scale (TCS) score, an expert-developed instrument for assessing the strength of tobacco control policies. However, room remains for improvement in tobacco control policies. Our aim was to evaluate the cumulative effect on smoking prevalence of improving all TCS components in England, stratified by socioeconomic circumstance. METHODS: Effect sizes and socioeconomic gradients for all six types of smoking policy in the UK setting were adapted from systematic reviews, or if not available, from primary studies. We used the IMPACT Policy Model to link predicted changes in smoking prevalence to changes in premature coronary heart disease (CHD) mortality for ages 35-74. Health outcomes with a time horizon of 2025 were stratified by quintiles of socioeconomic circumstance. RESULTS: The model estimated that improving all smoking policies to achieve a maximum score on the TCS might reduce smoking prevalence in England by 3% (95% Confidence Interval (CI): 1-4%), from 20 to 17% in absolute terms, or by 15% in relative terms (95% CI: 7-21%). The most deprived quintile would benefit more, with absolute reductions from 31 to 25%, or a 6% reduction (95% CI: 2-7%). There would be some 3300 (95% CI: 2200-4700) fewer premature CHD deaths between 2015-2025, a 2% (95% CI: 1.4-2.9%) reduction. The most disadvantaged quintile would benefit more, reducing absolute inequality of CHD mortality by about 4 % (95% CI: 3-9%). CONCLUSIONS: Further, feasible improvements in tobacco control policy could substantially improve population health, and reduce health-related inequalities in England.

Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact.

BACKGROUND: Interventions to promote healthy eating make a potentially powerful contribution to the primary prevention of non communicable diseases. It is not known whether healthy eating interventions are equally effective among all sections of the population, nor whether they narrow or widen the health gap between rich and poor. We undertook a systematic review of interventions to promote healthy eating to identify whether impacts differ by socioeconomic position (SEP). METHODS: We searched five bibliographic databases using a pre-piloted search strategy. Retrieved articles were screened independently by two reviewers. Healthier diets were defined as the reduced intake of salt, sugar, trans-fats, saturated fat, total fat, or total calories, or increased consumption of fruit, vegetables and wholegrain. Studies were only included if quantitative results were presented by a measure of SEP. Extracted data were categorised with a modified version of the "4Ps" marketing mix, expanded to 6 "Ps": "Price, Place, Product, Prescriptive, Promotion, and Person". RESULTS: Our search identified 31,887 articles. Following screening, 36 studies were included: 18 "Price" interventions, 6 "Place" interventions, 1 "Product" intervention, zero "Prescriptive" interventions, 4 "Promotion" interventions, and 18 "Person" interventions. "Price" interventions were most effective in groups with lower SEP, and may therefore appear likely to reduce inequalities. All interventions that combined taxes and subsidies consistently decreased inequalities. Conversely, interventions categorised as "Person" had a greater impact with increasing SEP, and may therefore appear likely to reduce inequalities. All four dietary counselling interventions appear likely to widen inequalities. We did not find any "Prescriptive" interventions and only one "Product" intervention that presented differential results and had no impact by SEP. More "Place" interventions were identified and none of these interventions were judged as likely to widen inequalities. CONCLUSIONS: Interventions categorised by a "6 Ps" framework show differential effects on healthy eating outcomes by SEP. "Upstream" interventions categorised as "Price" appeared to decrease inequalities, and "downstream" "Person" interventions, especially dietary counselling seemed to increase inequalities. However the vast majority of studies identified did not explore differential effects by SEP. Interventions aimed at improving population health should be routinely evaluated for differential socioeconomic impact.

The role of mixed methods in improved cookstove research.

The challenge of promoting access to clean and efficient household energy for cooking and heating is a critical issue facing low- and middle-income countries today. Along with clean fuels, improved cookstoves (ICSs) continue to play an important part in efforts to reduce the 4 million annual premature deaths attributed to household air pollution. Although a range of ICSs are available, there is little empirical evidence on appropriate behavior change approaches to inform adoption and sustained used at scale. Specifically, evaluations using either quantitative or qualitative methods provide an incomplete picture of the challenges in facilitating ICS adoption. This article examines how studies that use the strengths of both these approaches can offer important insights into behavior change in relation to ICS uptake and scale-up. Epistemological approaches, study design frameworks, methods of data collection, analytical approaches, and issues of validity and reliability in the context of mixed methods ICS research are examined, and the article presents an example study design from an evaluation study in Kenya incorporating a nested approach and a convergent case oriented design. The authors discuss the benefits and methodological challenges of mixed-methods approaches in the context of researching behavior change and ICS use recognizing that such methods represent relatively uncharted territory. The authors propose that more published examples are needed to provide frameworks for other researchers seeking to apply mixed methods in this context and suggest a comprehensive research agenda is required that incorporates integrated mixed-methods approaches, to provide best evidence for future scale-up.

Smorgasbord or symphony? Assessing public health nutrition policies across 30 European countries using a novel framework.

BACKGROUND: Countries across Europe have introduced a wide variety of policies to improve nutrition. However, the sheer diversity of interventions represents a potentially bewildering smorgasbord. We aimed to map existing public health nutrition policies, and examine their perceived effectiveness, in order to inform future evidence-based diet strategies. METHODS: We created a public health nutrition policy database for 30 European countries. National nutrition policies were classified and assigned using the marketing "4 Ps" approach Product (reformulation, elimination, new healthier products); Price (taxes, subsidies); Promotion (advertising, food labelling, health education) and Place (schools, workplaces, etc.). We interviewed 71 senior policy-makers, public health nutrition policy experts and academics from 14 of the 30 countries, eliciting their views on diverse current and possible nutrition strategies. RESULTS: Product Voluntary reformulation of foods is widespread but has variable and often modest impact. Twelve countries regulate maximum salt content in specific foods. Denmark, Austria, Iceland and Switzerland have effective trans fats bans. Price EU School Fruit Scheme subsidies are almost universal, but with variable implementation.Taxes are uncommon. However, Finland, France, Hungary and Latvia have implemented 'sugar taxes' on sugary foods and sugar-sweetened beverages. Finland, Hungary and Portugal also tax salty products. Promotion Dialogue, recommendations, nutrition guidelines, labelling, information and education campaigns are widespread. Restrictions on marketing to children are widespread but mostly voluntary. Place Interventions reducing the availability of unhealthy foods were most commonly found in schools and workplace canteens. Interviewees generally considered mandatory reformulation more effective than voluntary, and regulation and fiscal interventions much more effective than information strategies, but also politically more challenging. CONCLUSIONS: Public health nutrition policies in Europe appear diverse, dynamic, complex and bewildering. The "4 Ps" framework potentially offers a structured and comprehensive categorisation. Encouragingly, the majority of European countries are engaged in activities intended to increase consumption of healthy food and decrease the intake of "junk" food and sugary drinks. Leading countries include Finland, Norway, Iceland, Denmark, Hungary, Portugal and perhaps the UK. However, all countries fall short of optimal activities. More needs to be done across Europe to implement the most potentially powerful fiscal and regulatory nutrition policies.

Tobacco Control Policy Simulation Models: Protocol for a Systematic Methodological Review.

BACKGROUND: Tobacco control models are mathematical models predicting tobacco-related outcomes in defined populations. The policy simulation model is considered as a subcategory of tobacco control models simulating the potential outcomes of tobacco control policy options. However, we could not identify any existing tool specifically designed to assess the quality of tobacco control models. OBJECTIVE: The aims of this systematic methodology review are to: (1) identify best modeling practices, (2) highlight common pitfalls, and (3) develop recommendations to assess the quality of tobacco control policy simulation models. Crucially, these recommendations can empower model users to assess the quality of current and future modeling studies, potentially leading to better tobacco policy decision-making for the public. This protocol describes the planned systematic review stages, paper inclusion and exclusion criteria, data extraction, and analysis. METHODS: Two reviewers searched five databases (Embase, EconLit, PsycINFO, PubMed, and CINAHL Plus) to identify eligible studies published between July 2013 and August 2019. We included papers projecting tobacco-related outcomes with a focus on tobacco control policies in any population and setting. Eligible papers were independently screened by two reviewers. The data extraction form was designed and piloted to extract model structure, data sources, transparency, validation, and other qualities. We will use a narrative synthesis to present the results by summarizing model trends, analyzing model approaches, and reporting data input and result quality. We will propose recommendations to assess the quality of tobacco control policy simulation models using the findings from this review and related literature. RESULTS: Data collection is in progress. Results are expected to be completed and submitted for publication by April 2021. CONCLUSIONS: This systematic methodological review will summarize the best practices and pitfalls existing among tobacco control policy simulation models and present a recommendation list of a high-quality tobacco control simulation model. A more standardized and quality-assured tobacco control policy simulation model will benefit modelers, policymakers, and the public on both model building and decision making. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020178146; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178146. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26854.

Exploring the use and challenges of implementing virtual visits during COVID-19 in primary care and lessons for sustained use.

BACKGROUND: The COVID-19 pandemic has rapidly transformed how healthcare is delivered to limit the transmission of the virus. This descriptive cross-sectional study explored the current use of virtual visits in providing care among primary care providers in southwestern Ontario during the first wave of the COVID-19 pandemic and the anticipated level of utilization post-pandemic. It also explored clinicians' perceptions of the available support tools and resources and challenges to incorporating virtual visits within primary care practices. METHODS: Primary care physicians and nurse practitioners currently practicing in the southwestern part of Ontario were invited to participate in an online survey. The survey invite was distributed via email, different social media platforms, and newsletters. The survey questions gathered clinicians' demographic information and assessed their experience with virtual visits, including the proportion of visits conducted virtually (before, during the pandemic, and expected volume post-pandemic), overall satisfaction and comfort level with offering virtual visits using modalities, challenges experienced, as well as useful resources and tools to support them in using virtual visits in their practice. RESULTS: We received 207 responses, with 96.6% of respondents offering virtual visits in their practice. Participants used different modalities to conduct virtual visits, with the vast majority offering visits via phone calls (99.5%). Since the COVID-19 pandemic, clinicians who offered virtual visits have conducted an average of 66.4% of their visits virtually, compared to an average of 6.5% pre-pandemic. Participants anticipated continuing use of virtual visits with an average of 43.9% post-pandemic. Overall, 74.5% of participants were satisfied with their experience using virtual visits, and 88% believed they could incorporate virtual visits well within the usual workflow. Participants highlighted some challenges in offering virtual care. For example, 58% were concerned about patients' limited access to technology, 55% about patients' knowledge of technology, and 41% about the lack of integration with their current EMR, the increase in demand over time, and the connectivity issues such as inconsistent Wi-Fi/Internet connection. There were significant differences in perception of some challenges between clinicians in urban vs, rural areas. Clinicians in rural areas were more likely to consider the inconsistent Wi-Fi and limited connectivity as barriers to incorporating virtual visits within the practice setting (58.8% vs. 40.2%, P = 0.030). In comparison, clinicians in urban areas were significantly more concerned about patients overusing virtual care services (39.4% vs. 21.6%, P = 0.024). As for support tools, 47% of clinicians advocated for virtual care standards outlined by their profession's college. About 32% identified change management support and technical training as supportive tools. Moreover, 39% and 28% thought local colleagues and in-house organizational support are helpful resources, respectively. CONCLUSION: Our study shows that the adoption of virtual visits has exponentially increased during the pandemic, with a significant interest in continuing to use virtual care options in the delivery of primary care post-pandemic. The study sheds light on tools and resources that could enhance operational efficiencies in adopting virtual visits in primary care settings and highlights challenges that, when addressed, can expand the health system capacity and sustained use of virtual care.

The QUEST for Effective and Equitable Policies to Prevent Non-communicable Diseases: Co-Production Lessons From Stakeholder Workshops.

BACKGROUND: Non-communicable diseases (NCDs) account for some 90% of premature UK deaths, most being preventable. However, the systems driving NCDs are complex. This complexity can make NCD prevention strategies difficult to develop and implement. We therefore aimed to explore with key stakeholders the upstream policies needed to prevent NCDs and related inequalities. METHODS: We developed a theory-based co-production process and used a mixed methods approach to engage with policy- and decision-makers from across the United Kingdom in a series of 4 workshops, to better understand and respond to the complex systems in which they act. The first and fourth workshops (London) aimed to better understand the public health policy agenda and effective methods for co-production, communication and dissemination. In workshops 2 and 3 (Liverpool and Glasgow), we used nominal group techniques to identify policy issues and equitable prevention strategies, we prioritised emerging policy options for NCD prevention, using the MoSCoW approach. RESULTS: We engaged with 43 diverse stakeholders. They identified 'healthy environment' as an important emerging area. Reducing NCDs and inequalities was identified as important, underpinned by a frustration relating to the evidence/ policy gap. Evidence for NCD risk factor epidemiology was perceived as strong, the evidence underpinning the best NCD prevention policy interventions was considered patchier and more contested around the social, commercial and technological determinants of health. A comprehensive communications strategy was considered essential. The contribution of 'elite actors' (ministers, public sector leaders) was seen as key to the success of NCD prevention policies. CONCLUSION: NCDs are generated by complex adaptive systems. Early engagement of diverse stakeholders in a theory-based co-production process can provide valuable context and relevance. Subsequent partnership-working will then be essential to develop, disseminate and implement the most effective NCD prevention strategies.

Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users.

BACKGROUND: Local authorities in England commission the NHS Health Check programme to invite everyone aged 40-74 years without pre-existing conditions for risk assessment and eventual intervention, if needed. However, the programme's effectiveness, cost-effectiveness and equity impact remain uncertain. AIM: To develop a validated open-access flexible web-based model that enables local commissioners to quantify the cost-effectiveness and potential for equitable population health gain of the NHS Health Check programme. OBJECTIVES: The objectives were as follows: (1) co-produce with stakeholders the desirable features of the user-friendly model; (2) update the evidence base to support model and scenario development; (3) further develop our computational model to allow for developments and changes to the NHS Health Check programme and the diseases it addresses; (4) assess the effectiveness, cost-effectiveness and equity of alternative strategies for implementation to illustrate the use of the tool; and (5) propose a sustainability and implementation plan to deploy our user-friendly computational model at the local level. DESIGN: Co-production workshops surveying the best-performing local authorities and a systematic literature review of strategies to increase uptake of screening programmes informed model use and development. We then co-produced the workHORSE (working Health Outcomes Research Simulation Environment) model to estimate the health, economic and equity impact of different NHS Health Check programme implementations, using illustrative-use cases. SETTING: Local authorities in England. PARTICIPANTS: Stakeholders from local authorities, Public Health England, the NHS, the British Heart Foundation, academia and other organisations participated in the workshops. For the local authorities survey, we invited 16 of the best-performing local authorities in England. INTERVENTIONS: The user interface allows users to vary key parameters that represent programme activities (i.e. invitation, uptake, prescriptions and referrals). Scenarios can be compared with each other. MAIN OUTCOME MEASURES: Disease cases and case-years prevented or postponed, incremental cost-effectiveness ratios, net monetary benefit and change in slope index of inequality. RESULTS: The survey of best-performing local authorities revealed a diversity of effective approaches to maximise the coverage and uptake of NHS Health Check programme, with no distinct 'best buy'. The umbrella literature review identified a range of effective single interventions. However, these generally need to be combined to maximally improve uptake and health gains. A validated dynamic, stochastic microsimulation model, built on robust epidemiology, enabled service options analysis. Analyses of three contrasting illustrative cases estimated the health, economic and equity impact of optimising the Health Checks, and the added value of obtaining detailed local data. Optimising the programme in Liverpool can become cost-effective and equitable, but simply changing the invitation method will require other programme changes to improve its performance. Detailed data inputs can benefit local analysis. LIMITATIONS: Although the approach is extremely flexible, it is complex and requires substantial amounts of data, alongside expertise to both maintain and run. CONCLUSIONS: Our project showed that the workHORSE model could be used to estimate the health, economic and equity impact comprehensively at local authority level. It has the potential for further development as a commissioning tool and to stimulate broader discussions on the role of these tools in real-world decision-making. FUTURE WORK: Future work should focus on improving user interactions with the model, modelling simulation standards, and adapting workHORSE for evaluation, design and implementation support. STUDY REGISTRATION: This study is registered as PROSPERO CRD42019132087. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 35. See the NIHR Journals Library website for further project information.

The NHS Health Check programme is available for adults aged 40­74 years in England to find the early risk of heart disease, cancers, lung disease and dementia, and lower that risk. However, some studies have suggested that the current scheme could perhaps be improved. We systematically looked at previous studies to understand what makes a screening programme successful. We also contacted local authorities with the best NHS Health Check programmes to find out how they were being delivered so well. The most successful local authorities highlighted a wide variety of methods for achieving success. All had concrete plans in place for delivery, including different approaches for encouraging more adults to participate. We further developed our existing computer model into a web-based tool [workHORSE (working Health Outcomes Research Simulation Environment)]. This tool can help those responsible for commissioning NHS Health Checks to further improve the delivery of their local programme. We held four workshops with relevant professionals to develop the workHORSE model. These workshops resulted in a useful 'real-world' tool for local commissioners: a tool that can calculate the current and potential future benefits of different programmes. We used the model to show how commissioners can explore and compare a variety of different programmes. We found that combining several improvements can be useful. However, this provides modest benefits in improving health and value for money. At the same time, the impact on reducing inequalities is less clear and depends on the interventions used. Our results suggest that: a variety of successful approaches can be used to help increase the uptake of screening programmes such as NHS Health Checksjointly developing a computer model with end-users leads to a more user-friendly and relevant model to improve the programmethe stage is now set for further work to identify the best approach in each local area.

Health and Climate Impacts of Scaling Adoption of Liquefied Petroleum Gas (LPG) for Clean Household Cooking in Cameroon: A Modeling Study.

BACKGROUND: The Cameroon government has set a target that, by 2030, 58% of the population will be using Liquefied Petroleum Gas (LPG) as a cooking fuel, in comparison with less than 20% in 2014. The National LPG Master Plan (Master Plan) was developed for scaling up the LPG sector to achieve this target. OBJECTIVES: This study aimed to estimate the potential impacts of this planned LPG expansion (the Master Plan) on population health and climate change mitigation, assuming primary, sustained use of LPG for daily cooking. METHODS: We applied existing and developed new mathematical models to calculate the health and climate impacts of expanding LPG primary adoption for household cooking in Cameroon over two periods: a) short-term (2017-2030): Comparing the Master Plan 58% target with a counterfactual LPG adoption of 32% in 2030, in line with current trends; and b) long-term (2031-2100, climate modeling only), assuming Cameroon will become a mature and saturated LPG market by 2100 (73% adoption, based on Latin American countries). We compared this with a counterfactual adoption of 41% by 2100, in line with current trends. RESULTS: By 2030, successful implementation of the Master Plan was estimated to avert about 28,000 (minimum=22,000, maximum=35,000) deaths and 770,000 (minimum=580,000 maximum=1 million) disability-adjusted life years. For the same period, we estimated reductions in pollutant emissions of more than a third in comparison with the counterfactual, leading to a global cooling of -0.1 milli °C in 2030. For 2100, a cooling impact from the Master Plan leading to market saturation (73%) was estimated to be -0.70 milli °C in comparison with to the counterfactual, with a range of -0.64 to -0.93 milli °C based on different fractions of nonrenewable biomass. DISCUSSION: Successful implementation of the Master Plan could have significant positive impacts on population health in Cameroon with no adverse impacts on climate. https://doi.org/10.1289/EHP4899.

Using photovoice methods as a community-based participatory research tool to advance uptake of clean cooking and improve health: The LPG adoption in Cameroon evaluation studies.

Each year up to 2.6 million people die prematurely from household air pollution (HAP) due to cooking with polluting fuels such as wood and charcoal, particularly in low and middle-income countries (LMICs). The World Health Organisation recommends scaling the adoption of clean fuels to improve maternal and child health. Liquefied Petroleum Gas (LPG) represents a scalable clean fuel that provides health and environmental benefits when used for household energy in LMICs. In Cameroon, over 70% of people rely on biomass for cooking, and the Government aims to increase LPG use from <20% to 58% by 2030. Supporting households make this transition requires involvement of multiple stakeholders and an understanding of perspectives from the community's perspective. We used visual participatory methods 'Photovoice' to explore households' perceptions of factors influencing the uptake of LPG for cooking in South-West Cameroon. Two groups of participants from rural (n = 7) and peri-urban (n = 8) areas photographed subjects they identified as preventing and facilitating LPG uptake in their communities. Subsequently, individual interviews (n = 15) and group discussions (n = 5) explored participants' reflections on the photographs. Thematic analysis was conducted using NVivo 10 software. The main barriers identified included difficulty in affording the initial LPG equipment and ongoing refills, scarcity of LPG retail shops and refills, and safety concerns. Facilitators included (i) increasing awareness of the benefits of LPG (e.g. health), (ii) increasing retail outlet density in rural areas, (iii) addressing safety concerns (e.g. replacing damaged cylinders), and (iv) reducing the price of LPG refills. Participants presented their photos at a public exhibition, which generated discussions with key stakeholders (e.g. government ministries) about how best to assist communities in this transition. Photovoice was found to be an innovative and effective approach for exploring how to advance equitable access to LPG from a community perspective and successfully engage with key stakeholders.

Barriers and Facilitators to the Adoption and Sustained Use of Cleaner Fuels in Southwest Cameroon: Situating 'Lay' Knowledge within Evidence-Based Policy and Practice.

Approximately four million people die each year in low- and middle-income countries from household air pollution (HAP) due to inefficient cooking with solid fuels. Liquid Petroleum Gas (LPG) offers a clean energy option in the transition towards renewable energy. This qualitative study explored lay knowledge of barriers and facilitators to scaling up clean fuels in Cameroon, informed by Quinn et al.'s Logic Model. The model has five domains and we focused on the user and community needs domain, reporting the findings of 28 semi-structured interviews (SSIs) and four focus group discussions (FGDs) that explored the reasons behind fuel use choices. The findings suggest that affordability, safety, convenience, and awareness of health issues are all important influences on decision making to the adoption and sustained use of LPG, with affordability being the most critical issue. We also found the ability of clean fuels to meet cooking needs to be central to decision-making, rather than an aspect of convenience, as the logic model suggests. Local communities provide important insights into the barriers and facilitators to using clean fuels. We adapt Quinn et al.'s logic model accordingly, giving more weight to lay knowledge so that it is better positioned to inform policy development.

Household Determinants of Liquified Petroleum Gas (LPG) as a Cooking Fuel in South West Cameroon.

Currently 70% of the population in Cameroon are reliant on solid fuel for cooking (90% in rural communities) and the associated household air pollution contributes to significant mortality and morbidity in the country. To address the problems of energy security, deforestation and pollution the government has developed a strategy (Masterplan) to increase use of liquified petroleum gas (LPG) as a cooking fuel from 12% to 58% by 2030. As a clean fuel scaled adoption of LPG has the potential to make significant positive impacts on population health. The LPG Adoption in Cameroon Evaluation (LACE) studies are assessing in the community (i) barriers and enablers for and (ii) local interventions to support, adoption and sustained use of LPG. A census survey conducted for LACE in rural and peri-urban regions of SW Cameroon provided an opportunity to investigate current fuel use patterns and factors associated with primary and exclusive use of LPG. A cross-sectional survey of 1577 households (1334 peri-urban and 243 rural) was conducted in March 2016 using standardised fuel use and household socio-demographic questions, administered by trained fieldworkers. Wood (40.7%) and LPG (51.1%) were the most frequently reported fuels, although the dominant fuels in rural and peri-urban communities were wood (81%) and LPG (58%) respectively. Fuel stacking was observed for the majority of LPG using households (91% of peri-urban and 99% of rural households). In rural homes, a higher level of education, access to sanitation and piped water and household wealth (income and asset ownership) were all significantly associated with LPG use (p < 0.05). In peri-urban homes, younger age, access to sanitation and piped water and increasing education were significantly associated with both any and exclusive use of LPG (p < 0.05). However, whilst household wealth was related to any LPG use, there was no relationship with exclusive use. Results from this census survey of a relatively well-established LPG market with lower levels of poverty and high levels of education than Cameroon as a whole, find LPG usage well below target levels set by the Cameroon government (58% by 2030). Fuel stacking is an issue for the majority of LPG using households. Whilst, as observed here, education, household wealth and socio-economic status are well recognised predictors of adoption and sustained use of clean modern fuels, it is important to consider factors across the whole LPG eco-system when developing policies to support their scaled expansion. A comprehensive approach is therefore required to ensure implementation of the Cameroon LPG Masterplan achieves its aspirational adoption target within its stated timeframe.

Correction to: Household Determinants of Liquified Petroleum Gas (LPG) as a Cooking Fuel in South West Cameroon.

Household Determinants of Liquified Petroleum Gas (LPG) as a Cooking Fuel in South West Cameroon.