Differences Between Online Trial Participants Who Have Used Statutory Mental Health Services and Those Who Have Not: Analysis of Baseline Data From 2 Pragmatic Trials of a Digital Health Intervention.

BACKGROUND: Digital health interventions (DHIs) are an established element of mental health service provision internationally. Regulators have positioned the best practice standard of evidence as an interventional study with a comparator reflective of standard care, often operationalized as a pragmatic trial. DHIs can extend health provision to those not currently using mental health services. Hence, for external validity, trials might openly recruit a mixture of people who have used mental health services and people who have not. Prior research has demonstrated phenomenological differences in mental health experience between these groups. Some differences between service users and nonservice users might influence the change created by DHIs; hence, research should systematically examine these differences to inform intervention development and evaluation work. This paper analyzes baseline data collected in the NEON (Narrative Experiences Online; ie, for people with experience of psychosis) and NEON-O (NEON for other [eg, nonpsychosis] mental health problems) trials. These were pragmatic trials of a DHI that openly recruited people who had used specialist mental health services and those who had not. All participants were experiencing mental health distress. NEON Trial participants had experienced psychosis in the previous 5 years. OBJECTIVE: This study aims to identify differences in baseline sociodemographic and clinical characteristics associated with specialist mental health service use for NEON Trial and NEON-O Trial participants. METHODS: For both trials, hypothesis testing was used to compare baseline sociodemographic and clinical characteristics of participants in the intention-to-treat sample who had used specialist mental health services and those who had not. Bonferroni correction was applied to significance thresholds to account for multiple testing. RESULTS: Significant differences in characteristics were identified in both trials. Compared with nonservice users (124/739, 16.8%), NEON Trial specialist service users (609/739, 82.4%) were more likely to be female (P<.001), older (P<.001), and White British (P<.001), with lower quality of life (P<.001) and lower health status (P=.002). There were differences in geographical distribution (P<.001), employment (P<.001; more unemployment), current mental health problems (P<.001; more psychosis and personality disorders), and recovery status (P<.001; more recovered). Current service users were more likely to be experiencing psychosis than prior service users. Compared with nonservice users (399/1023, 39%), NEON-O Trial specialist service users (614/1023, 60.02%) had differences in employment (P<.001; more unemployment) and current mental health problems (P<.001; more personality disorders), with lower quality of life (P<.001), more distress (P<.001), less hope (P<.001), less empowerment (P<.001), less meaning in life (P<.001), and lower health status (P<.001). CONCLUSIONS: Mental health service use history was associated with numerous differences in baseline characteristics. Investigators should account for service use in work to develop and evaluate interventions for populations with mixed service use histories. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-020-04428-6.

Using isotopic tracers to enhance routine watershed monitoring - Insights from an intensively managed agricultural catchment.

Experimental (research-based) and non-research-based watershed monitoring programs often differ with respect to sampling frequency, monitored variables, and monitoring objectives. Isotopic variables, which are more commonly incorporated in research-based programs, can provide an indication of water sources and the transit time of water in a catchment. These variables may be a valuable complement to traditional water quality monitoring variables and have the potential to support improved hydrologic process-related insights from long term monitoring programs that typically have low resolution sampling. The purpose of this investigation is to explore the utility of incorporating isotopic variables (specifically δ18O, δ2H, and 222Rn) into routine monthly sampling regimes by comparing insights gained from these variables to monitoring only specific conductivity and chloride. A complete annual cycle of monthly groundwater and surface water monitoring data collected from the Upper Parkhill watershed in southwestern Ontario, Canada was used to characterize baseline watershed conditions, evaluate watershed resilience to climate change, and examine contamination vulnerability. Study results provide an improved understanding of appropriate tracer use in agricultural regions with isotopic variables able to provide important insights into the seasonality of hydrologic phenomena, such as the timing of groundwater recharge. A comparison of monitoring variables to present-day hydro-meteorological conditions suggests the importance of a winter dominated hydrologic regime and the potential influence of changes in precipitation on groundwater-surface water interactions. Estimated transit time dynamics indicate the likelihood for rapid contaminant transport through surface and shallow subsurface flow and highlight the possible effects of agricultural tile drainage. The sampling approach and data analysis methods adopted in this study provide the basis for improving routine watershed monitoring programs in agricultural regions.

Geochemistry and microbiology of tropical serpentine soils in the Santa Elena Ophiolite, a landscape-biogeographical approach.

The Santa Elena Ophiolite is a well-studied ultramafic system in Costa Rica mainly comprised of peridotites. Here, tropical climatic conditions promote active laterite formation processes, but the biogeochemistry of the resulting serpentine soils is still poorly understood. The aim of this study was to characterize the soil geochemical composition and microbial community of contrasting landscapes in the area, as the foundation to start exploring the biogeochemistry of metals occurring there. The soils were confirmed as Ni-rich serpentine soils but differed depending on their geographical location within the ophiolite area, showing three serpentine soil types. Weathering processes resulted in mountain soils rich in trace metals such as cobalt, manganese and nickel. The lowlands showed geochemical variations despite sharing similar landscapes: the inner ophiolite lowland soils were more like the surrounding mountain soils rather than the north lowland soils at the border of the ophiolite area, and within the same riparian basin, concentrations of trace metals were higher downstream towards the mangrove area. Microbial community composition reflected the differences in geochemical composition of soils and revealed potential geomicrobiological inputs to local metal biogeochemistry: iron redox cycling bacteria were more abundant in the mountain soils, while more manganese-oxidizing bacteria were found in the lowlands, with the highest relative abundance in the mangrove areas. The fundamental ecological associations recorded in the serpentine soils of the Santa Elena Peninsula, and its potential as a serpentinization endemism hotspot, demonstrate that is a model site to study the biogeochemistry, geomicrobiology and ecology of tropical serpentine areas.

How do recorded mental health recovery narratives create connection and improve hopefulness?

BACKGROUND: Mental health recovery narratives are an active ingredient of recovery-oriented interventions such as peer support. Recovery narratives can create connection and hope, but there is limited evidence on the predictors of impact. AIMS: The aim of this study was to identify characteristics of the narrator, narrative content and participant which predict the short-term impact of recovery narratives on participants. METHOD: Independent studies were conducted in an experimental (n = 40) and a clinical setting (n = 13). In both studies, participants with mental health problems received recorded recovery narratives and rated impact on hopefulness and connection. Predictive characteristics were identified using multi-level modelling. RESULTS: The experimental study found that narratives portraying a narrator as living well with mental health problems that is intermediate between no and full recovery, generated higher self-rated levels of hopefulness. Participants from ethnic minority backgrounds had lower levels of connection with narrators compared to participants from a white background, potentially due to reduced visibility of a narrator's diversity characteristics. CONCLUSIONS: Narratives describing partial but not complete recovery and matching on ethnicity may lead to a higher impact. Having access to narratives portraying a range of narrator characteristics to maximise the possibility of a beneficial impact on connection and hopefulness.

Occurrence of Arsenic in Nearshore Aquifers Adjacent to Large Inland Lakes.

Metal oxides that form near sediment-water interfaces in marine and riverine settings are known to act as a sediment trap for pollutants of environmental concern (e.g., arsenic and mercury). The occurrence of these pollutant traps near sediment-water interfaces in nearshore lake environments is unclear yet important to understand because they may accumulate pollutants that may be later released as environmental conditions change. This study evaluates the prevalence of pollutant sediment traps in nearshore aquifers adjacent to large lakes and the factors that affect the accumulation and release of pollutants, specifically arsenic. Field data from six sites along the Laurentian Great Lakes indicate widespread enrichment of arsenic in nearshore aquifers with arsenic sequestered to iron oxide phases. Arsenic enrichment at all sites (solid-phase arsenic >2 µg/g) suggests that this is a naturally occurring phenomenon. Arsenic was more mobile in reducing aquifers with elevated dissolved arsenic (up to 60 µg/L) observed, where reducing groundwater mixes with infiltrating oxic lake water. Dissolved arsenic was low (<3 µg/L) in all oxic nearshore aquifers studied despite high solid-phase arsenic concentrations. The findings have broad implications for understanding the widespread accumulation of reactive pollutants in nearshore aquifers and factors that affect their release to large lakes.

Clinical and cost-effectiveness of two ways of delivering guided self-help for people with an eating disorder: A multi-arm randomized controlled trial.

OBJECTIVE: Increasing the availability and accessibility of evidence-based treatments for eating disorders is an important goal. This study investigated the effectiveness and cost-effectiveness of guided self-help via face-to-face meetings (fGSH) and a more scalable method, providing support via email (eGSH). METHOD: A pragmatic, randomized controlled trial was conducted at three sites. Adults with binge-eating disorders were randomized to fGSH, eGSH, or a waiting list condition, each lasting 12 weeks. The primary outcome variable for clinical effectiveness was overall severity of eating psychopathology and, for cost-effectiveness, binge-free days, with explorative analyses using symptom abstinence. Costs were estimated from both a partial societal and healthcare provider perspective. RESULTS: Sixty participants were included in each condition. Both forms of GSH were superior to the control condition in reducing eating psychopathology (IRR = -1.32 [95% CI -1.77, -0.87], p < .0001; IRR = -1.62 [95% CI -2.25, -1.00], p < .0001) and binge eating. Attrition was higher in eGSH. Probabilities that fGSH and eGSH were cost-effective compared with WL were 93% (99%) and 51% (79%), respectively, for a willingness to pay of £100 (£150) per additional binge-free day. DISCUSSION: Both forms of GSH were associated with clinical improvement and were likely to be cost-effective compared with a waiting list condition. Provision of support via email is likely to be more convenient for many patients although the risk of non-completion is greater.

Improving the healthcare response to domestic violence and abuse in UK primary care: interrupted time series evaluation of a system-level training and support programme.

BACKGROUND: It is unknown whether interventions known to improve the healthcare response to domestic violence and abuse (DVA)-a global health concern-are effective outside of a trial. METHODS: An observational interrupted time series study in general practice. All registered women aged 16 and above were eligible for inclusion. In four implementation boroughs' general practices, there was face-to-face, practice-based, clinically relevant DVA training, a prompt in the electronic medical record, reminding clinicians to consider DVA, a simple referral pathway to a named advocate, ensuring direct access for women to specialist services, overseen by a national, health-focused DVA organisation, fostering best practice. The fifth comparator borough had only a session delivered by a local DVA specialist agency at community venues conveying information to clinicians. The primary outcome was the daily number of referrals received by DVA workers per 1000 women registered in a general practice, from 205 general practices, in all five northeast London boroughs. The secondary outcome was recorded new DVA cases in the electronic medical record in two boroughs. Data was analysed using an interrupted time series with a mixed effects Poisson regression model. RESULTS: In the 144 general practices in the four implementation boroughs, there was a significant increase in referrals received by DVA workers-global incidence rate ratio of 30.24 (95% CI 20.55 to 44.77, p < 0.001). There was no increase in the 61 general practices in the other comparator borough (incidence rate ratio of 0.95, 95% CI 0.13 to 6.84, p = 0.959). New DVA cases recorded significantly increased with an incident rate ratio of 1.27 (95% CI 1.09 to 1.48, p < 0.002) in the implementation borough but not in the comparator borough (incidence rate ratio of 1.05, 95% CI 0.82 to 1.34, p = 0.699). CONCLUSIONS: Implementing integrated referral routes, training and system-level support, guided by a national health-focused DVA organisation, outside of a trial setting, was effective and sustainable at scale, over four years (2012 to 2017) increasing referrals to DVA workers and new DVA cases recorded in electronic medical records.

Endemic and cosmopolitan fungal taxa exhibit differential abundances in total and active communities of Antarctic soils.

Our understanding of the diversity and community dynamics of soil fungi has increased greatly through the use of DNA-based identification. Community characterization of metabolically active communities via RNA sequencing has previously revealed differences between 'active' and 'total' fungal communities, which may be influenced by the persistence of DNA from nonactive components. However, it is not known how fungal traits influence their prevalence in these contrasting community profiles. In this study, we coextracted DNA and RNA from soil collected from three Antarctic islands to test for differences between total and active soil fungal communities. By matching these geographically isolated fungi against a global dataset of soil fungi, we show that widely dispersed taxa are often more abundant in the total community, whilst taxa restricted to Antarctica are more likely to have higher abundance in the active community. In addition, we find that active communities have lower richness, and show a reduction in the abundance of the most dominant fungi, whilst there are consistent differences in the abundances of certain taxonomic groups between the total and active communities. These results suggest that the views of soil fungal communities offered by DNA- and RNA-based characterization differ in predictable ways.

Effect of Transient Wave Forcing on the Behavior of Arsenic in a Nearshore Aquifer.

Groundwater-coastal water interactions influence the fate of inorganic chemicals in nearshore aquifers and their flux to receiving coastal waters. This study evaluates the impact of variable wave conditions on the geochemical changes and distribution of mobile arsenic (As) in a nearshore aquifer. Field measurements in a sandy nearshore aquifer on Lake Erie, Canada, are presented with geochemical changes analyzed over a period of high waves. A numerical model of wave-induced groundwater flow dynamics, validated against field data, is used to provide insight into the physical flow processes underlying the observed geochemical changes. Rapid changes in dissolved As, Fe, Mn, and S demonstrate the importance of reactions as well as dynamic transport in controlling the behavior of reactive species, especially those that are redox sensitive. Field data suggest the presence of sediment traps, which under certain hydrological and geochemical conditions may result in a "hot moment" with episodic release of As. The study provides new insight into factors controlling the fate of reactive species in dynamic coastal environments as required to better predict chemical fluxes to coastal waters. Additionally, it highlights the need to pay particular attention to "hot moments" for reaction and transport caused by storms and waves.

Asynchrony among local communities stabilises ecosystem function of metacommunities.

Temporal stability of ecosystem functioning increases the predictability and reliability of ecosystem services, and understanding the drivers of stability across spatial scales is important for land management and policy decisions. We used species-level abundance data from 62 plant communities across five continents to assess mechanisms of temporal stability across spatial scales. We assessed how asynchrony (i.e. different units responding dissimilarly through time) of species and local communities stabilised metacommunity ecosystem function. Asynchrony of species increased stability of local communities, and asynchrony among local communities enhanced metacommunity stability by a wide range of magnitudes (1-315%); this range was positively correlated with the size of the metacommunity. Additionally, asynchronous responses among local communities were linked with species' populations fluctuating asynchronously across space, perhaps stemming from physical and/or competitive differences among local communities. Accordingly, we suggest spatial heterogeneity should be a major focus for maintaining the stability of ecosystem services at larger spatial scales.

Effect of Low Energy Waves on the Accumulation and Transport of Fecal Indicator Bacteria in Sand and Pore Water at Freshwater Beaches.

Elevated fecal indicator bacteria (FIB) in beach sand and pore water represent an important nonpoint source of contamination to surface waters. This study examines the physical processes governing the accumulation and distribution of FIB in a beach aquifer. Field data indicate E. coli and enterococci can be transported 1 and 2 m, respectively, below the water table. Data were used to calibrate a numerical model whereby FIB are delivered to a beach aquifer by wave-induced infiltration across the beach face. Simulations indicate FIB rapidly accumulate in a beach aquifer with FIB primarily associated with sand rather than freely residing in the pore water. Simulated transport of E. coli in a beach aquifer is complex and does not correlate with conservative tracer transport. Beaches with higher wave-induced infiltration rate and vertical infiltration velocity (i.e., beaches with higher beach slope and wave height, and lower terrestrial groundwater discharge) had greater E. coli accumulation and E. coli was transported deeper below the beach face. For certain beach conditions, the amount of FIB accumulated in sand over 5-6 days was found to be sufficient to trigger a beach advisory if eroded to surface water.

Not poles apart: Antarctic soil fungal communities show similarities to those of the distant Arctic.

Antarctica's extreme environment and geographical isolation offers a useful platform for testing the relative roles of environmental selection and dispersal barriers influencing fungal communities. The former process should lead to convergence in community composition with other cold environments, such as those in the Arctic. Alternatively, dispersal limitations should minimise similarity between Antarctica and distant northern landmasses. Using high-throughput sequencing, we show that Antarctica shares significantly more fungi with the Arctic, and more fungi display a bipolar distribution, than would be expected in the absence of environmental filtering. In contrast to temperate and tropical regions, there is relatively little endemism, and a strongly bimodal distribution of range sizes. Increasing southerly latitude is associated with lower endemism and communities increasingly dominated by fungi with widespread ranges. These results suggest that micro-organisms with well-developed dispersal capabilities can inhabit opposite poles of the Earth, and dominate extreme environments over specialised local species.

Release of Escherichia coli from Foreshore Sand and Pore Water during Intensified Wave Conditions at a Recreational Beach.

Foreshore beach sands and pore water may act as a reservoir and nonpoint source of fecal indicator bacteria (FIB) to surface waters. This paper presents data collected at a fine sand beach on Lake Huron, Canada over three field events. The data show that foreshore sand erosion as wave height increases results in elevated Escherichia coli concentrations in surface water, as well as depletion of E. coli from the foreshore sand and pore water. E. coli initially attached to foreshore sand rather than initially residing in the pore water was found to be the main contributor to elevated surface water concentrations. Surface water E. coli concentrations were a function of not only wave height (and associated sand erosion) but also the time elapsed since a preceding period of high wave intensity. This finding is important for statistical regression models used to predict beach advisories. While calculations suggest that foreshore sand erosion may be the dominant mechanism for releasing E. coli to surface water during intensified wave conditions at a fine sand beach, comparative characterization of the E. coli distribution at a coarse sand-cobble beach suggests that interstitial pore water flow and discharge may be more important for coarser sand beaches.

Role of Pb(II) defects in the mechanism of dissolution of plattnerite (ß-PbO2) in water under depleting chlorine conditions.

Destabilization of lead corrosion scales present in plumbing materials used in water distribution systems results in elevated lead concentrations in drinking water. Soluble lead release caused by changes in water chemistry has been linked to dissolution of lead carbonate and/or lead oxide solid phases. Although prior studies have examined the effects of varying water chemistry on the dissolution of plattnerite (ß-PbO2), ß-PbO2 dissolution under depleting chlorine conditions is poorly understood. This paper reports results obtained for long-term batch dissolution experiments for solid phase ß-PbO2 under depleting chlorine conditions. Results indicate that the initial availability of free chlorine effectively depresses dissolved lead concentrations released from ß-PbO2. However, the dissolved lead levels remained low (∼4 µg/L) even after free chlorine was depleted. Detailed spectroscopic characterization of solid samples collected during the ß-PbO2 experiments indicates that changes in the electronic structure of PbO2 occurred during the dissolution. This further points out that Pb2+ defects present in crystalline ß-PbO2 play a dominant role in the dissolution of this solid phase.

Effect of groundwater--lake interactions on arsenic enrichment in freshwater beach aquifers.

Field measurements combined with numerical simulations provide insight into the water exchange, groundwater flow, and geochemical processes controlling the mobility of arsenic (As) in freshwater beach aquifers. Elevated dissolved As (up to 56 µg/L) was observed 1-2 m below the shoreline at two sandy beaches on Lake Erie, Ontario, Canada. Water and solid-phase analyses suggest that Fe (hydr)oxides present below the shoreline accumulate As, creating a risk of high As in the beach aquifer. Groundwater flow simulations combined with vertical hydraulic gradient measurements indicate that wave-induced flow recirculations across the groundwater-lake interface are significant. These recirculations, which vary with wave intensity and lake water level fluctuations, set up redox and pH gradients, where Fe precipitates and subsequently sequesters As. The elevated As concentrations observed at both beaches, combined with the distribution of other dissolved species, suggest that the As enrichment may be naturally occurring. Regardless of the As source, the interacting hydrologic and geochemical processes revealed may have important implications for the flux of As and also other oxyanions, such as phosphate, across the groundwater-lake interface in nearshore areas of the Great Lakes.

Spatiotemporal investigation of geochemical and hydrological controls on release of soluble reactive phosphorus from the shallow aquifer of a riparian zone.

Phosphorus (P) that accumulates in agricultural riparian zones can be released under certain hydrological and biogeochemical conditions, thereby limiting the effectiveness of these zones in reducing P loads from field to stream. The study objective was to explore factors that may be contributing to, or limiting, high soluble reactive phosphorus (SRP) concentrations in the shallow aquifer of an alluvial upland riparian zone located in a continental climate. Field investigations including porewater sampling from six vertical nests, soil sampling, and continuous soil moisture, groundwater table, and redox measurements were conducted over 19 months. Porewater SRP concentrations were generally low in the aquifer considering all sampling times (median = 14.7 µg/L; interquartile range [IQR] = 11.1 µg/L, 287 samples). The overall low SRP may be due to low reducible labile soil P (median = 21.1 µgP/g dw, IQR = 10.9 µgP/g dw, 21 samples). However, high SRP concentrations (>52 µg/L, 95% quartile) did occur intermittently in space and time with no clear spatial or temporal patterns. Analyses indicate that most high concentrations were likely not associated with factors previously reported to influence SRP release in riparian aquifers, including redox conditions, pH, and soil drying and wetting. Further, data indicate that internally released or externally supplied SRP may undergo rapid (re-) sequestration within the aquifer, limiting its vertical or horizontal transport. The study findings highlight the complexity of P behavior in riparian zones and the need for caution when assessing the effectiveness of conservation practices and in interpreting potential impacts of subsurface water quality on stream water quality when monitoring locations are distant from the stream.

Conceptualizing Controlling Factors for PFAS Salting Out in Groundwater Discharge Zones Along Sandy Beaches.

Understanding fate and transport processes for per- and poly-fluoroalkyl substances (PFAS) is critical for managing impacted sites. "PFAS Salting Out" in groundwater, defined herein, is an understudied process where PFAS in fresh groundwater mixes with saline groundwater near marine shorelines, which increases sorption of PFAS to aquifer solids. While sorption reduces PFAS mass discharge to marine surface water, the fraction that sorbs to beach sediments may be mobilized under future salinity changes. The objective of this study was to conceptually explore the potential for PFAS Salting Out in sandy beach environments and to perform a preliminary broad-scale characterization of sandy shoreline areas in the continental U.S. While no site-specific PFAS data were collected, our conceptual approach involved developing a multivariate regression model that assessed how tidal amplitude and freshwater submarine groundwater discharge affect the mixing of fresh and saline groundwater in sandy coastal aquifers. We then applied this model to 143 U.S. shoreline areas with sandy beaches (21% of total beaches in the USA), indirectly mapping potential salinity increases in shallow freshwater PFAS plumes as low (<10 ppt), medium (10-20 ppt), or high (>20 ppt) along groundwater flow paths before reaching the ocean. Higher potential salinity increases were observed in West Coast bays and the North Atlantic coastline, due to the combination of moderate to large tides and large fresh groundwater discharge rates, while lower increases occurred along the Gulf of Mexico and the southern Florida Atlantic coast. The salinity increases were used to estimate potential perfluorooctane sulfonic acid (PFOS) sorption in groundwater due to salting out processes. Low-category shorelines may see a 1- to 2.5-fold increase in sorption of PFOS, medium-category a 2.0- to 6.4-fold increase, and high-category a 3.8- to 25-fold increase in PFOS sorption. The analysis presented provides a first critical step in developing a large-scale approach to classify the PFAS Salting Out potential along shorelines and the limitations of the approach adopted highlights important areas for further research.

Study protocol for a pragmatic randomised controlled trial of comparing enhanced acceptance and commitment therapy plus (+) added to usual aftercare versus usual aftercare only, in patients living with or beyond cancer: SUrvivors' Rehabilitation Evaluation after CANcer (SURECAN) trial.

BACKGROUND: Two million people in the UK are living with or beyond cancer and a third of them report poor quality of life (QoL) due to problems such as fatigue, fear of cancer recurrence, and concerns about returning to work. We aimed to develop and evaluate an intervention based on acceptance and commitment therapy (ACT), suited to address the concerns of cancer survivors and in improving their QoL. We also recognise the importance of exercise and vocational activity on QoL and therefore will integrate options for physical activity and return to work/vocational support, thus ACT Plus (+). METHODS: We will conduct a multi-centre, pragmatic, theory driven, randomised controlled trial. We will assess whether ACT+ including usual aftercare (intervention) is more effective and cost-effective than usual aftercare alone (control). The primary outcome is QoL of participants living with or beyond cancer measured using the Functional Assessment of Cancer Therapy: General scale (FACT-G) at 52 weeks. We will recruit 344 participants identified from secondary care sites who have completed hospital-based treatment for cancer with curative intent, with low QoL (determined by the FACT-G) and randomise with an allocation ratio of 1:1 to the intervention or control. The intervention (ACT+) will be delivered by NHS Talking Therapies, specialist services, and cancer charities. The intervention consists of up to eight sessions at weekly or fortnightly intervals using different modalities of delivery to suit individual needs, i.e. face-to-face sessions, over the phone or skype. DISCUSSION: To date, there have been no robust trials reporting both clinical and cost-effectiveness of an ACT based intervention for people with low QoL after curative cancer treatment in the UK. We will provide high quality evidence of the effectiveness and cost-effectiveness of adding ACT+ to usual aftercare provided by the NHS. If shown to be effective and cost-effective then commissioners, providers and cancer charities will know how to improve QoL in cancer survivors and their families. TRIAL REGISTRATION: ISRCTN: ISRCTN67900293 . Registered on 09 December 2019. All items from the World Health Organization Trial Registration Data Set for this protocol can be found in Additional file 2 Table S1.