Health Research Programme Research Articles

Systematic review of integrated mental and physical health services for children and young people with eating and functional symptoms.

Evidence suggests that by recognising the psychosocial component of illness as equally important to the biological components, care becomes more holistic, and patients can benefit. Providing this type of care requires collaboration among health professionals, rather than working in isolation, to achieve better outcomes. However, there is a lack of evidence about the implementation of integrated health care. This review focuses on children and young people experiencing eating disorders (i.e. disorders related to feeding and eating) or functional symptom disorders (i.e. medically unexplained symptoms). The present review is part of a larger study that will inform the development of a new children's hospital in England. Both eating disorders and functional symptom disorders are conditions that may be particularly likely to benefit from an integrated approach to health care, and this review aims to investigate what service models have been used to integrate care, what factors influence their implementation, and what effects these integrated models have on access to and outcomes from care. We conducted a systematic review of studies based on children and young people with eating disorders or functional symptom disorders, investigating the effectiveness of integrated mental and physical health services versus any other type of services provided in these populations. We searched MEDLINE, EMBASE and PsycInfo® (American Psychological Association, Washington, DC, USA) electronic bibliographic databases in July 2024 without restriction on the date of publication or country of interest. We reviewed only studies written in English. We identified 2668 citations which resulted in 1939 papers eligible for title screening. Only one single-site Australian evaluation of an integrated care model from over 20 years ago was included in our review. The study reported significantly higher number of total admissions and total bed-days utilised in the integrated approach. However, the burden of care shifted from psychiatric wards to medical wards and as a result, the cost per admission and the cost per inpatient decreased. The lack of conceptual consistency about the definition of integrated care may have driven false screening and loss of some evidence. The same limitation applies in terms of the definition of functional symptom disorders. The review identified a gap in the evidence base relating to integrated secondary service provision for children and adolescents with eating disorders or functional symptom disorders in comparison with generic services. No similar studies were identified for children and young people with functional symptom disorders. Our findings align with previous evidence and show that despite the existence of studies describing aspects of integrated care, integration of physical and mental health services for children and young people with eating disorders or functional symptom disorders is underexplored and the limited available evidence is of weak quality. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR133613.

Innovation and diversity in public health team engagement in local alcohol premises licensing: qualitative interview findings from the ExILEnS study.

Evidence suggests that controls on the physical and temporal availability of alcohol can reduce alcohol-related harms. Public health teams in England and Scotland have in recent years been given a statutory role in licensing systems through which premises are granted permits to sell alcohol. The Exploring the Impact of alcohol premises Licensing in England and Scotland study examined public health team efforts to engage in alcohol licensing from 2012 to 2019. We aimed to describe the range of public health team practice in engaging with alcohol licensing across England and Scotland, with a particular focus on unusual or innovative practices. Two sets of interviews were conducted with 20 public health teams in England and Scotland who were actively engaged in alcohol premises licensing. Firstly, representatives of each public health team with experience of licensing activity took part in structured face-to-face or telephone interviews (n = 41) and provided documentation to identify how and when their team engaged with alcohol premises licensing. Secondly, members of public health teams took part in in-depth one-to-one interviews (n = 28) which focused on individual roles and responsibilities. Relevant public health team activity was analysed quantitatively within 19 activities in 6 categories using the 'Public Health engagement In Alcohol Licensing' measure, as well as qualitatively using NVivo (QSR International, Melbourne, Australia). Innovative practices were identified using the highest Public Health engagement In Alcohol Licensing scores for specific activity types across single or multiple 6-month periods. Within each of the six activity categories, a range of practices were observed. More unusual practices included having a dedicated post to work full-time on alcohol licensing; developing a standardised reviewer tool allowing the team to respond to applications and provide the most relevant evidence in a consistent and systematic way; committing to additional scrutiny of occasional licences or temporary event notices; maintaining a detailed database recording applications made, whether the public health team decided to object and the outcome of the licensing board's decision; engaging with applicants prior to them submitting an application; visiting proposed/current licensed premises to gather bespoke data; leading the writing of local licensing policy; and working closely with licensing standards officers. Across six categories of public health team activity relating to the local alcohol premises licensing system, public health team practices varied, and some public health teams stood out as engaging in more innovative or intensive activities. The identified examples will be of value in informing public health team practice in what remains a relatively new area of work for many, despite limitations in the system. The inclusion of examples from both England and Scotland and from many public health teams will facilitate cross-fertilisation of ideas and practice across public health teams. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/129/11.

How to undertake research with refugees: lessons learned from a qualitative health research programme in Southern New Zealand.

Background Refugee health is an issue of global importance. Refugees have high and complex mental, physical and social needs and poor health outcomes. There is a clear need for more research prioritising refugees' perspectives of health care in their settlement countries; however, a number of methodological and ethical challenges can make this process difficult. Methods This methodological paper is an analysis of our recent experience conducting qualitative research with former refugees in Southern New Zealand. We utilized our research team's discussions, reflections and fieldnotes and the relevant literature to identify the key processes of our successful engagement with former refugees. Results Successful engagement with former refugees in qualitative health research entails: establishing relationships, recognising interpreters as cultural brokers, having a responsive suite of methods and finding meaningful ways to communicate. Conclusions This paper offers suggestions and guidance on conducting qualitative health research with former refugees.

Public engagement to refine a whole-school intervention to promote adolescent mental health.

Despite high rates of adolescent mental health problems, there are few effective school-based interventions to address this. Whole-school interventions offer a feasible and sustainable means of promoting mental health, but few have to date been evaluated. Previously we trialled the Learning Together intervention comprising local needs assessment, student and staff participation in decision-making, restorative practice, and a social and emotional skills curriculum. This was effective not only in preventing bullying (primary outcome), but also in promoting mental well-being and psychological functioning (secondary outcomes). We aimed to adapt Learning Together to develop Learning Together for Mental Health, focused on promoting mental health. This paper reports on how we refined and elaborated intervention materials to produce the Learning Together for Mental Health intervention including through patient and public involvement and engagement. We reviewed evidence to inform choice of the curriculum component and the contents of our needs assessment survey. We conducted patient and public involvement and engagement with school staff and students, and children and young people from the National Children's Bureau to adapt the intervention. We also conducted a systematic review of reviews to inform a menu of evidence-based actions, but this is reported separately. Southern England. Patient and public involvement and engagement was conducted with four staff and five students from one secondary school, and a group of two school senior leadership team members from different schools, and about eight children and young people who were members of the Young National Children's Bureau. None. We refined and elaborated our initial plans for Learning Together for Mental Health to generate an intervention supported by full materials, training and external facilitation. We focused needs assessment on mental health, added a menu of evidence-based whole-school mental health actions, and switched to a different social and emotional skills curriculum. We retained restorative practice and staff/student involvement in decisions. No further refinements were made to the intervention theory of change or overall approach. Patient and public involvement and engagement was useful, but not all suggestions were acted on either because some participants suggested dropping pre-determined elements (e.g. needs survey) or because suggestions (e.g. to include aromatherapy) lacked evidence of effectiveness. Not all of our engagements with patient and public involvement and engagement stakeholders were sustained over time. Our patient and public involvement and engagement work was affected by its having occurred within the recovery period from COVID-19 when schools were more stressed than normal. We had planned for the school involved in patient and public involvement and engagement to be above average in student free-school-meals eligibility, but the school initially recruited dropped out at the last minute. Its replacement had a lower-than-average rate of free-school-meal entitlement. This paper reports on the process of adaptation and reflects on the various ways in which engagement and evidence review were useful in this process. We found that it is possible to refine interventions and elaborate them to provide full materials and support via processes drawing on evidence review and patient and public involvement and engagement. The latter proved valuable in informing refinement of Learning Together for Mental Health in terms of ensuring its feasibility, acceptability, and inclusiveness. However, in our opinion, not all suggestions from patient and public involvement and engagement can or should be acted on, especially when they do not align with the evidence base. A feasibility study to optimise the intervention and assess whether progression to a full trial is justified. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131594.

Clinical and cost-effectiveness of first contact physiotherapy for musculoskeletal disorders in primary care: the FRONTIER, mixed method realist evaluation.

First-contact physiotherapists assess and diagnose patients with musculoskeletal disorders, determining the best course of management without prior general practitioner consultation. The primary aim was to determine the clinical and cost-effectiveness of first-contact physiotherapists compared with general practitioner-led models of care. Mixed-method realist evaluation of effectiveness and costs, comprising three main phases: A United Kingdom-wide survey of first contact physiotherapists. Rapid realist review of first contact physiotherapists to determine programme theories. A mixed-method case study evaluation of 46 general practices across the United Kingdom, grouped as three service delivery models: General practitioner: general practitioner-led models of care (no first contact physiotherapists). First-contact physiotherapists standard provision: standard first-contact physiotherapist-led model of care. First-contact physiotherapists with additional qualifications: first-contact physiotherapists with additional qualifications to enable them to inject and/or prescribe. United Kingdom general practice. A total of 46 sites participated in the case study evaluation and 426 patients were recruited; 80 staff and patients were interviewed. Short Form 36 physical outcome component score and costs of treatment. No statistically significant difference in the primary outcome Short Form 36 physical component score measure at 6-month primary end point between general practitioner-led, first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models of care. A greater number of patients who had first-contact physiotherapist standard provision (72.4%) and first-contact physiotherapist with additional qualifications (66.4%) showed an improvement at 3 months compared with general practitioner-led care (54.7%). No statistically significant differences were found between the study arms in other secondary outcome measures, including the EuroQol-5 Dimensions, five-level version. Some 6.3% of participants were lost to follow-up at 3 months; a further 1.9% were lost to follow-up after 3 months and before 6 months. Service-use analysis data were available for 348 participants (81.7%) at 6 months. Inspecting the entire 6 months of the study, a statistically significant difference in total cost was seen between the three service models, irrespective of whether inpatient costs were included or excluded from the calculation. In both instances, the general practitioner service model was found to be significantly costlier, with a median total cost of £105.50 versus £41.00 for first-contact physiotherapist standard provision and £44.00 for first-contact physiotherapists with additional qualifications. Base-case analysis used band 7 for first-contact physiotherapist groups. A sensitivity analysis was undertaken at band 8a for first-contact physiotherapists with additional qualifications; the general practitioner-led model of care remained significantly costlier. Qualitative investigation highlighted key issues to support implementation: understanding role remit, integrating and supporting staff including full information technology access and extended appointment times. Services were significantly impacted by COVID-19 treatment restrictions, and recruitment was hampered by additional pressures in primary care. A further limitation was the lack of diversity within the sample. First-contact physiotherapists and general practitioner models of care are equally clinically effective for people with musculoskeletal disorders. Analysis showed the general practitioner-led model of care is costlier than both the first-contact physiotherapist standard provision and first-contact physiotherapist with additional qualifications models. Implementation is supported by raising awareness of the first-contact physiotherapist role, retention of extended appointment times, and employment models that provide first-contact physiotherapists with professional support. Determining whether shifting workforce impacts physiotherapy provision and outcomes across the musculoskeletal pathway. The study is registered as Research Registry UIN researchregistry5033. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/03) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 49. See the NIHR Funding and Awards website for further award information.

Early mental health intervention and supported self-care for LGBTQ+ young people in the UK: a mixed-methods study.

Lesbian, gay, bisexual, trans, queer/questioning, plus young people have a higher risk of poor mental health in comparison to cisgendered heterosexual young people, and they underutilise mental health services and support. In addition, there is a paucity of research conducted in United Kingdom examining mental health early intervention provision for lesbian, gay, bisexual, trans, queer/questioning, plus young people. To produce a model of what works for early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people and increase understanding of lesbian, gay, bisexual, trans, queer/questioning, plus young people's access to, navigation of, and engagement with mental health support. This was a multi-methods theory-led case study evaluation with three distinct stages: (1) a meta-narrative review of existing literature to develop a theoretical framework to explain effective mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people; (2) an online and offline service mapping exercise to locate current mental health early intervention support for lesbian, gay, bisexual, trans, queer/questioning, plus young people in the United Kingdom in order to produce a service typology; and (3) a theory-led case study evaluation of 12 case study sites selected from the service typology produced in stage 2, to establish the components of appropriate quality, early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people. Stage 1 produced an interdisciplinary theoretical framework indicating that early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus youth must prioritise addressing normative environments that marginalise youth, lesbian, gay, bisexual, trans, queer/questioning, plus identities and mental health problems. Stage 2 mapping found 111 services, the majority in urban settings in England. There was an absence of mainstream National Health Service support that specifically addressed the needs of lesbian, gay, bisexual, trans, queer/questioning, plus young people. The majority of lesbian, gay, bisexual, trans, queer/questioning, plus youth mental health support was provided by voluntary/community organisations. Stage 3 case study evaluation found that an intersectional, youth-rights approach is the most appropriate way to deliver early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people. Youth rights should underpin mental health support to address the multiple marginalisation, isolation and stigmatisation that lesbian, gay, bisexual, trans, queer/questioning, plus young people may experience and to enable them to make informed independent decisions about their own bodies and lives, and for the right to freedom of safe self-expression to be upheld. The model that we have produced contains 13 principles that are necessary to the provision of mental health support, and to improve access to, engagement with, and navigation of mental health services. In the United Kingdom, a rights-based approach to mental health service provision is not prominent. In addition, at the time of writing, lesbian, gay, bisexual, trans, queer/questioning, plus young people are facing active legislative and policy attacks on their human rights. This study provides the first large-scale theory-led evaluation of early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people with common mental health problems. The resulting intersectional, youth-rights approach provides evidence on ways of improving lesbian, gay, bisexual, trans, queer/questioning, plus young people's mental health. Further research on the implementation of an intersectional, youth-rights approach to early intervention mental health support for lesbian, gay, bisexual, trans, queer/questioning, plus young people with mental health problems is required. This study is registered as PROSPERO CRD42019135722. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/09/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 47. See the NIHR Funding and Awards website for further award information.

Impact of short-term aircraft noise on cardiovascular disease risk in the area surrounding London Heathrow airport: the RISTANCO epidemiological study.

Long-term exposure to aircraft noise has been associated with small increases in cardiovascular disease risk, but there are almost no short-term exposure studies. Research questions were: Is there an association between short-term changes in exposure to aircraft noise and cardiovascular morbidity and mortality? What are the key effect modifiers? Is there variability in risk estimates between areas with consistent versus changing patterns of noise exposure? Do risk estimates differ when using different noise metrics? Descriptive analyses of noise levels and variability at different times of day, analyses of inequalities in noise exposure and case-crossover analyses of cardiovascular events in relation to aircraft noise exposure. Area surrounding London Heathrow airport. 2014-18. Whole population in study area. Cardiovascular disease hospitalisations and mortality. Aircraft noise levels modelled using a standard noise model for: (1) daily equivalent continuous sound levels at different times of day; (2) daily number of events above defined noise thresholds (2018 only). National Health Service digital hospital admission records and Office for National Statistics mortality records for 2014-18 for cardiovascular outcomes, plus individual-level confounders available from healthcare records. Confounder data including road traffic noise (Leicester modelled), rail noise and air pollution (Department for Environment, Food and Rural Affairs), area level deprivation and ethnicity (UK Census). The morning shoulder period (06.00-07.00 hours) was the noisiest of all eight bands (mean: 50.92 dB). The morning shoulder period also had the third highest number of noisy events (flights) > 60 dB per day, with three events across postcodes on average. However, the highest number of noisy events occurred in daytime (highest between 07.00 and 15.00 hours, second highest 15.00 and 19.00 hours). To identify areas with high variability in aircraft noise exposure (due to changes in flight paths because of wind direction and airport operations), we used coefficients of variation (CoV). The period 24.00-04.30 hours had the highest mean CoV (67.33-74.16), followed by 04.30-06.00 hours and 23.00-24.00 hours. Postcodes in the least deprived quintiles of Carstairs index or avoidable death rate had the lowest noise levels. In case-crossover analyses, we observed increased risk for cardiovascular disease hospital admissions for evening noise 19.00-23.00 hours (odds ratio 1.005, 95% confidence interval 1.000 to 1.010 per 5 dB), but not for other periods or mortality. Further analyses suggested that increased risks were occurring in postcodes with low CoV for noise. We found effect modification by age, sex, ethnicity, deprivation and season. The industry standard noise model, the Aviation Environmental Design Tool, used does not take account of wind direction, which may have led to some exposure misclassification. We developed a comprehensive dataset of daily aircraft noise variability. We found small associations between cardiovascular hospitalisations (but not deaths) and evening aircraft noise levels, particularly in areas with low variability of noise. More studies are needed to understand the effect of noise variation and respite/relief on cardiovascular disease. This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/192/13) and is published in full in Public Health Research; Vol. 12, No. 13. See the NIHR Funding and Awards website for further award information.

Emotional literacy programme in special schools for children with a learning disability in England: the ZF-SEND feasibility RCT.

Children with a learning disability experience a range of inequalities and adverse life events that put them at greater risk of mental health problems. The construct of emotional literacy has been shown to be a moderating factor of how life stress affects mental health. Teaching emotional literacy in schools may therefore be an effective way to promote positive mental health. There is an identified need for adapted emotional literacy programmes in special schools. To evaluate whether it is feasible to conduct a large-scale randomised controlled trial of the effectiveness and cost-effectiveness of an emotional literacy programme (Zippy's Friends special educational needs and disabilities) for children with a learning disability in special schools. The key aims were to assess the acceptability and feasibility of participating in the trial, data collection and the Zippy's Friends special educational needs and disabilities intervention through quantitative and qualitative data collection. A feasibility, cluster randomised controlled trial that aimed to recruit and randomise 12 special schools to either deliver the intervention over 1 academic year or continue with practice as usual and to collect data from 96 pupils at baseline (pre randomisation) and 12 months post randomisation. Special schools in England and Scotland. Pupils with a learning disability, aged 9-11 years, attending special schools in England. Follow-up interviews were conducted with 8 pupils, 4 parents/carers and 11 school staff members. Zippy's Friends for Special Educational Needs and Disabilities is a manual-based, classroom-based emotional literacy programme focused on a problem-solving approach to develop and improve children's emotional literacy. The mainstream programme has been adapted for children with a learning disability by simplifying the activities, shortening the sessions and introducing more repetition. Feasibility and acceptability of: (1) participation in the research trial; (2) the collection of the outcome measure data and (3) the Zippy's Friends for Special Educational Needs and Disabilities intervention. A total of 8 schools and 53 pupils were recruited. Retention of schools after randomisation (100%) and retention of pupils (100%) met the prespecified progression criteria. For recruitment of schools (20.5% of those approached), pupil engagement with the intervention (50%) and collection of outcome and service use data (62.3%) the criteria were partially met. Fidelity of the intervention delivery (48%) fell just below the progression criteria. Thus, the feasibility and acceptability outcome progression criteria were largely met, suggesting that progression to a full trial is warranted with amendments to the study design. This feasibility trial was conducted during the COVID-19 pandemic, resulting in unusually high absences of pupils and teachers, different classroom arrangements (bubbles) and unprecedented stress and emotional challenges for pupils, parents and teaching staff. The findings are therefore specific to that period and all three main outcomes of this feasibility trial were adversely affected. The findings of this study indicate that a large-scale randomised controlled trial is feasible provided that a number of amendments to the study design are made to improve: (1) the timing of the project to suit the demands of special schools' yearly timetable; (2) recruitment and (3) outcome and service use data collection. On the basis of the current findings, an application for a full trial will be prepared and submitted with a number of amendments. This trial is registered as ISRCTN83610691. This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR129064) and is published in full in Public Health Research; Vol. 12, No. 15. See the NIHR Funding and Awards website for further award information.

Overview of the Canadian Clinician Investigator Trainees' Research Presented at the 2024 CSCI-CITAC Joint Meeting.

The 2024 Annual Joint Meeting (AJM) and Young Investigators' Forum of the Canadian Society for Clinical Investigation (CSCI) and Clinician Investigator Trainee Association of Canada (CITAC) was held on April 11, 2024, in Vancouver, British Columbia. Hosted in collaboration with the University of British Columbia (UBC) and the International Congress on Academic Medicine (ICAM), this meeting marked a significant opportunity for clinician investigator trainees to present their research and connect with national and international peers. The event included 70 trainees, consisting of 58 MD+ (MD/PhD, MD and PhD, MD-MSc, MD and MSc) and 12 Clinician Investigator Program and/or Surgeon-Scientist Training Program trainees. The keynote speaker, Dr. Marco Marra, delivered a presentation titled "From C. elegans Genetics to Precision Cancer Genomic Medicine, via the Human Genome Project: Reflections on a Collaborative Scientific Journey." Dr. Kenneth Rockwood (Dalhousie University) received the CSCI Distinguished Scientist Award, and Dr. Bertrand Routy (Université de Montréal) received the CSCI Joe Doupe Young Investigator Award. Over 60 abstracts were showcased, most of which are summarized in this review, and six were selected for oral presentations. Following the AJM, trainees participated in ICAM's three-day health research program, where three AJM attendees were recognized among the top four presenters and were invited to the 2024 Canada Gairdner Awards Gala, with one of our AJM attendees winning the competition and being named the next Lindau Nobel Laurate Meetings Nominee.

Clinical and cost-effectiveness of parenting intervention for mothers experiencing psychosocial stress: insights from the early closure of the Mellow Babies RCT.

Problems in children's early social and emotional development are likely to have major long-term consequences for the individual and society: maternal emotional well-being is associated with better outcomes. Interventions designed to improve both maternal mental health and the mother-child relationship are thus likely to benefit both maternal health and child development. To establish the clinical and cost-effectiveness of the Mellow Babies parenting intervention for women experiencing psychosocial stress and their 6- to 18-month-old babies. Secondary aims included understanding the process of recruitment, retention and engagement in both the trial and the intervention. This was a single-centre randomised controlled trial, employing 1 : 1 randomisation with participants allocated to receive Mellow Babies plus usual care, or usual care only. Community settings in the Highland Council region of Scotland. We aimed to recruit 212 mothers to provide evaluable data for 170 participants (90% power to detect an effect size of 0.5 for the primary outcome). Eligible mothers lived within the Highland Council region; were aged ≥ 16 years; had primary caregiving responsibility of a baby aged 6-18 months and scored above threshold for anxiety (≥ 11) and/or depression (≥ 7) on the Hospital Anxiety and Depression Scale. Mellow Babies is a 14-week group-based parenting programme specifically designed for mothers with psychosocial difficulties. Sessions run for 5 hours each and include 4-10 participants. Maternal Hospital Anxiety and Depression Scale scores at 8 months post randomisation and when the child reaches 30 months. Health economic (service use and quality of life) and child development (language development and mental well-being) outcomes were also examined. Due to the COVID-19 pandemic, the trial did not recruit to target: 106 women were recruited (53 per arm). It was not possible to explore the clinical and cost-effectiveness of Mellow Babies. Baseline, follow-up and process evaluation data were analysed to allow optimal learning from the study. Direct communication (letter) combined with health visitor referral was a better means of recruitment. Despite relatively low sociodemographic disadvantage, there was a high prevalence of mental ill health. Retention to follow-up and within the intervention was good (75% to study end point), and data were well-completed. Quality-of-life ratings increased at 8 months post randomisation, then decreased somewhat at 30 months of age, but remained above baseline. Qualitative interviews highlighted barriers and facilitators of engagement with the intervention groups. There was no observed difference in baseline characteristics or outcomes between participants recruited before and after the pandemic, although the logistical impact on the trial was profound. The study was not sufficiently powered to answer the main outcome questions. The occurrence of the COVID-19 pandemic severely hampered the current trial. This trial was not able to answer questions on clinical and cost-effectiveness. Learning from this trial could inform a new re-designed trial including cluster randomisation and based within a larger and more varied population. There is still a need for a definitive trial of Mellow Babies. It would likely be most fruitful to conduct a cluster randomised trial, with full buy-in from key health service stakeholders and front-line practitioners, to maximise recruitment, engagement and participation. The trial is registered as ISRCTN47575326. This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 15/126/05) and is published in full in Public Health Research; Vol. 12, No. 17. See the NIHR Funding and Awards website for further award information.

Unlocking data: Decision-maker perspectives on cross-sectoral data sharing and linkage as part of a whole-systems approach to public health policy and practice.

Secondary data from different policy sectors can provide unique insights into the social, environmental, economic and political determinants of health. This is especially pertinent in the context of whole-systems approaches to healthy public policy, which typically combine cross-sectoral collaboration with the application of theoretical insights from systems science. However, the sharing and linkage of data between different sectors are still relatively rare. Previous research has documented the perspectives of researchers and members of the public on data sharing, especially healthcare data, but has not engaged with relevant policy and practice decision-makers. We sought to work collaboratively with decision-makers relevant to healthy public policy and practice in Scotland to identify practical ways that cross-sectoral data sharing and linkage could be used to best effect to improve health and reduce health inequalities. We facilitated three sequential stakeholder workshops with 20 participants from local and central government, public health teams, Health and Social Care Partnerships, the third sector, organisations which support data-intensive research and public representatives from across Scotland. Workshops were informed by two scoping reviews (carried out in June 2021) and three case studies of existing cross-sectoral linkage projects. Workshop activities included brainstorming of factors that would help participants make better decisions in their current role; reflective questions on lessons learnt from the case studies; and identifying and prioritising recommendations for change. Findings were synthesised using thematic analysis. Scotland; public and third sector data. Based on the workshops, and supported by the reviews and case studies, we created a visual representation of the use of evidence, and secondary data in particular, in decision-making for healthy public policy and practice. This covered three key overarching themes: differing understandings of evidence; diverse functions of evidence; and factors affecting use (such as technical, political and institutional, workforce and governance). Building on this, workshop participants identified six guiding principles for cross-sectoral data sharing and linkage: it should be pragmatic; participatory; ambitious; fair; iterative; with holistic and proportionate governance. Participants proposed 21 practical actions to this end, including: a strategic approach to identifying and sharing key data sets; streamlining governance processes (e.g. through standardised data sharing agreements; central data repositories; and a focus on reusable data resources) and building workforce capacity. To make these possible, participants identified a need for strong political and organisational leadership as well as a transparent and inclusive public conversation. Participation from some stakeholders was limited by workload pressures associated with the COVID-19 pandemic. No consensus was reached on the impact, effort, and/or timing of some recommendations. Findings were closely informed by the Scottish context but are nonetheless likely to be relevant to other jurisdictions. There is broad consensus among key stakeholders that linked cross-sectoral data can be used far more extensively for public health decision-making than it is at present. No single change will lead to improved use of such data: a range of technical, organisational and political constraints must be addressed. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR133585.

The effects and costs of an anti-bullying program (KiVa) in UK primary schools: a multicenter cluster randomized controlled trial.

Childhood bullying is a public health priority. We evaluated the effectiveness and costs of KiVa, a whole-school anti-bullying program that targets the peer context. A two-arm pragmatic multicenter cluster randomized controlled trial with embedded economic evaluation. Schools were randomized to KiVa-intervention or usual practice (UP), stratified on school size and Free School Meals eligibility. KiVa was delivered by trained teachers across one school year. Follow-up was at 12 months post randomization. Primary outcome: student-reported bullying-victimization; secondary outcomes: self-reported bullying-perpetration, participant roles in bullying, empathy and teacher-reported Strengths and Difficulties Questionnaire. Outcomes were analyzed using multilevel linear and logistic regression models. Between 8/11/2019-12/02/2021, 118 primary schools were recruited in four trial sites, 11 111 students in primary analysis (KiVa-intervention: n = 5944; 49.6% female; UP: n = 5167, 49.0% female). At baseline, 21.6% of students reported being bullied in the UP group and 20.3% in the KiVa-intervention group, reducing to 20.7% in the UP group and 17.7% in the KiVa-intervention group at follow-up (odds ratio 0.87; 95% confidence interval 0.78 to 0.97, p value = 0.009). Students in the KiVa group had significantly higher empathy and reduced peer problems. We found no differences in bullying perpetration, school wellbeing, emotional or behavioral problems. A priori subgroup analyses revealed no differences in effectiveness by socioeconomic gradient, or by gender. KiVa costs £20.78 more per pupil than usual practice in the first year, and £1.65 more per pupil in subsequent years. The KiVa anti-bullying program is effective at reducing bullying victimization with small-moderate effects of public health importance. The study was funded by the UK National Institute for Health and Care Research (NIHR) Public Health Research program (17-92-11). Intervention costs were funded by the Rayne Foundation, GwE North Wales Regional School Improvement Service, Children's Services, Devon County Council and HSBC Global Services (UK) Ltd.

Improving Access to Specialist Eye Care for Indigenous Australians via Telehealth: An Observational Cohort Study.

Background: Indigenous people are often neglected in eye health research and service delivery programs, despite having a greater burden of vision loss, most of which is avoidable. The objective of this work was to improve access to specialist eye care for Indigenous Australians living in rural and remote areas, by providing direct access to expert diagnostic services based in metropolitan areas through a tele-ophthalmology system. Methods: Over a four-year study period, 13 remote communities in Queensland and the Northern Territory were identified that had limited or no access to eye screening services. Relationships with health service providers in the communities were established to codesign a sustainable model of service delivery and referral pathways to ensure that patients identified with eye issues received appropriate treatment. Results: Over the course of the study, screening records from 378 patients were uploaded to a web-based telehealth system and diagnosed by ophthalmologists. From these examinations, 64 new cases of diabetic retinopathy (DR) were identified (including 2 cases of proliferative DR and 4 cases of severe nonproliferative DR), and diabetic macular edema was noted in 18 patients. The majority of participants screened had no eye problems, which enables the removal of these patients from the queues of overwhelmed specialist lists, improving service efficiency. The study also demonstrates capacity building of healthcare workers to perform eye screening and improved patient health awareness where the retinal cameras were used as an educational tool. Conclusions: A valuable screening service has been established in the target areas, where access to ophthalmic services has been improved for residents of the study screening locations. Routine eye examination (instead of opportunistic eye examination) is feasible for early detection of some eye diseases for remote and rural patients.

Challenges and guidance for implementing social distancing for COVID-19 in care homes: a mixed methods rapid review.

Older people living in care homes are at high risk of poor health outcomes and mortality if they contract coronavirus disease 2019. Protective measures include social distancing and isolation, although implementation is challenging. To explore the real-life experiences of social distancing and isolation in care homes for older people, and to develop a toolkit of guidance and resources. A mixed-methods, phased design. Six care homes in England caring for older adults. Care home staff (n = 31), residents (n = 17), family members (n = 17), senior health and care leaders (n = 13). A rapid review to assess the social distancing and isolation measures used by care homes to control the transmission of coronavirus disease 2019 and other infectious diseases (phase 1), in-depth case studies of six care homes, involving remote individual interviews with staff, residents and families, collection of policies, protocols and routinely collected care home data, remote focus groups with senior health and care leaders (phase 2) and stakeholder workshops to co-design the toolkit (phase 3). Interview and focus group data and care home documents were analysed using thematic analysis and care home data using descriptive statistics. The rapid review of 103 records demonstrated limited empirical evidence and the limited nature of policy documentation around social distancing and isolation measures in care homes. The case studies found that social distancing and isolation measures presented moral dilemmas for staff and often were difficult, and sometimes impossible to implement. Social distancing and isolation measures made care homes feel like an institution and denied residents, staff and families of physical touch and other forms of non-verbal communication. This was particularly important for residents with cognitive impairment. Care homes developed new visiting modalities to work around social distancing measures. Residents and families valued the work of care homes to keep residents safe and support remote communication. Social distancing, isolation and related restrictions negatively impacted on residents' physical, psychological, social and cognitive well-being. There were feelings of powerlessness for families whose loved ones had moved into the care home during the pandemic. It was challenging for care homes to capture frequent updates in policy and guidance. Senior health and care leaders shared that the care home sector felt isolated from the National Health Service, communication from government was described as chaotic, and trauma was inflicted on care home staff, residents, families and friends. These multiple data sources have informed the co-design of a toolkit to care for residents, families, friends and care home staff. The review included papers published in English language only. The six care homes had a Care Quality Commission rating of either 'good' or 'outstanding'. There was a lack of ethnic diversity in resident and family participants. Care homes implemented innovative approaches to social distancing and isolation with varying degrees of success. A legacy of learning can help rebuild trust at multiple levels and address trauma-informed care for residents, families, friends and staff. Future work can include evaluation of the toolkit, research to develop a trauma-informed approach to caring for the care home sector and co-designing and evaluating an intervention to enable residents with different needs to transition to living well in a care home. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132541) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 45. See the NIHR Funding and Awards website for further award information.

Understanding and improving the quality of primary care for people in prison: a mixed-methods study.

People in prison are generally in poorer health than their peers in the community, often living with chronic illness and multimorbidity. Healthcare research in prisons has largely focused on specific problems, such as substance use; less attention has been paid to conditions routinely managed in primary care, such as diabetes or hypertension. It is important to understand how primary care in prisons is currently delivered in the United Kingdom and how it can be improved, in order to reduce health inequalities. To understand the quality of primary care in prison, including gaps and variations in care, in order to recommend how quality of prison health care can be improved. A mixed-methods study with six interlinked work packages. Predominantly the North of England. Between August 2019 and June 2022, we undertook the following work packages: (1) International scoping review of prison healthcare quality indicators. (2) Stakeholder consensus process to identify United Kingdom focused prison healthcare quality indicators. (3) Qualitative interview study with 21 people who had been in prison and 22 prison healthcare staff. (4) Quantitative analysis of anonymised, routinely collected data derived from prison healthcare records (~ 25,000 records across 13 prisons). (5) Stakeholder deliberation process to identify interventions to improve prison health care. (6a) Secondary analysis of the qualitative data set, focusing on mental health and (6b) analysis of the quantitative data set, focusing on health care of three mental health subgroups. Our scoping review found predominantly only papers from the United States of America and of variable rigour with the main finding being that performance measurement is very challenging in the prison healthcare setting. In collaboration with stakeholders, we prioritised, refined and applied a suite of 30 quality indicators across several healthcare domains. We found considerable scope for improvement in several indicators and wide variations in indicator achievement that could not be attributed to differences in prison population characteristics. Examples of indicators with scope for improvement included: diabetes care, medicines reconciliation and epilepsy review and control. Longer length of stay in prison was generally associated with higher achievement than shorter stays. Indicator achievement was generally low compared to that of community general practice. We found some encouraging trends and relatively good performance for a minority of indicators. Our qualitative interviews found that quality of health care is related to factors that exist at several levels but is heavily influenced by organisational factors, such as understaffing, leading to a reactive and sometimes crisis-led service. Our stakeholder deliberations suggested opportunities for improvement, ideally drawing on data to assess and drive improvement. Our mental health work package found that coded mental illness had mixed associations with indicator achievement, while the interviews revealed that mental distress is viewed by many as an inevitable facet of imprisonment. Our analyses of indicator achievement were limited by the quality and coverage of available data. Most study findings are localised to England so international applicability may differ. Marked variations in the quality of primary care in prisons are likely to be attributable to the local organisation and conditions of care delivery. Routinely collected data may offer a credible driver for change. This study is registered at researchregistry.com (Ref: 5098). This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/26) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 46. See the NIHR Funding and Awards website for further award information.

Assessing adherence to Government's sugar, salt, and calorie reduction targets of the top 20 UK restaurants' menus in 2024: a cross-sectional study

BackgroundTo address high obesity rates in adults and children, the UK government published voluntary targets for industry to reduce the sugar, salt, and calorie content of food products. Initial reports indicate little progress, however there has been limited assessment of the eating out, takeaway, and delivery sector. This study aims to assess the proportion of menu items that meet the government's sugar, salt, and calorie targets, from the 20 highest-grossing chained restaurants in the UK. MethodsWe identified the top 20 UK chained restaurants using data from market research company Euromonitor International. Nutritional information for 4054 products was collected directly from restaurant websites. Each product was assigned an overall category (eg, main meals, sides, etc.), and categories defined by the sugar, salt, and calorie targets. Findings36% (n=207) of products met sugar targets, 60% (n=1411) met salt targets, 72% (n=1592) met calorie targets, and 43% (n=1269) met all applicable targets. Categories with the highest proportion of products meeting the respective target were ‘Breakfast Items’ for sugar (73%, n=138), ‘Burgers’ for salt (100%, n=85), and ‘Salads’ for calories (96%, n=44) and all applicable targets (96%, n=44). Restaurants with the highest proportion of products meeting the respective target were Leon for sugar (63%, n=15), Burger King for salt (97%, n=32), Dominos for calories (95%, n=209), and Subway for all applicable targets (78%, n=62). InterpretationThe calorie targets were reasonably well adhered to whilst a large proportion of products still exceeded the target levels for sugar and salt. Ambiguities in the targets’ food categorisation makes their application somewhat subjective, risking low transparency and hindering a level playing field between companies. These findings can inform which companies and food groups need to be prioritised when implementing similar public health schemes in the future. FundingAOH is funded by the SALIENT project, which is funded by the ESRC (ES/Y00311X/1). RP is funded by a Royal Society and Wellcome Trust Sir Henry Dale fellowship (222566/Z/21/Z). RP is also supported by NIHR Oxford Health Biomedical Research Centre. HF is funded by the COPPER project. The COPPER project is funded by the NIHR Public Health Research programme (NIHR133887). The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care. LB is funded by NIHR Applied Research Collaborations (ARC) Oxford and Thames Valley. The funders had no role in the study design, data collection, analysis or interpretation. The views expressed are those of the author(s) and not necessarily those of the funders.

Fair Food Futures UK: using systems mapping to elucidate emerging organisational models adopted by community food organisations (CFOs) to respond to food insecurity in Bradford and Tower Hamlets, London, UK

BackgroundSince 2010, food insecurity has been growing significantly in the UK and this is posing a significant burden on healthcare services. During the Covid pandemic and into ‘cost of living crisis’. food banks grew rapidly and a variety of organisations (schools, community centres, faith groups) provided food support for the first time. Food banks have been thoroughly studied, but less is known about other forms of support in this varied and fast-growing ‘food support system’. MethodsSystems mapping derived from a scoping survey, workshops and interviews with CFOs staff and service users. Research question: What are the different organisational models, components and inter-dependencies of CFOs operating in two multicultural communities in the North (Bradford) and South (Tower Hamlets) of England? Across the two locations we 1) conducted a survey of CFOs (n=89); 2) developed systems maps with organisations’ staff (n=42) and users (n=25), using a group model building approach; 3) undertook interviews with staff and stakeholders (from n=36 organisations, identified via survey, snowballing and networking). We analysed survey data using descriptive statistics and interview and workshop transcripts using inductive thematic analysis. As service users were a minority in the sample, our findings are largely based on contributions of service providers. Ethical approval for this research project was obtained from the Research Governance Committee of the University of York Department of Health Sciences on May 15, 2023 HSRGC/2023/566/C. FindingsThree main themes were identified: 1) diversity, scale and complexity of the food support sector, 2) variety of approaches adopted to alleviate, reduce or prevent food insecurity; 3) practical and ethical challenges faced by CFOs in addressing residents’ complex needs. Three systems maps were also developed. InterpretationResidents’ food support needs are shaped by wider structural issues and awareness is growing that emergency responses are problematic. New models are emerging. These include: embedding advice services to address underlying issues; experimenting with membership models; and combining emergency responses with campaigning to reform the welfare system. FundingThe research described in this abstract has been funded by the NIHR Public Health Research Programme (NIHR151034). The views expressed are those of the authors and not necessarily those of NIHR or the Department of Health and Social Care.

The implementation of statutory relationships and sex education in English secondary schools: a qualitative study with school staff

BackgroundSchool-based relationships and sex education (RSE) is important for promoting the health and wellbeing of young people, but the quality and consistency of teaching in England has been variable. In an effort to strengthen provision, RSE was made statutory for all secondary schools in England from September 2020. Drawing on qualitative interviews with school staff, we assessed implementation of the new requirements in 25 schools. MethodsWe conducted semi-structured interviews with one staff-member leading delivery of RSE in 25 English secondary schools participating in the control arm of a trial of a multi-component, sexual-health intervention. Schools in central and southern England were recruited to the trial via email and phone call with interested schools. Interviews were transcribed and coded inductively by two researchers, then organised into themes informed by concepts from May's General Theory of Implementation. FindingsSchools were broadly representative of mainstream schools in England, although they were slightly larger and less disadvantaged than average. New guidance made sense to participants as a necessary and appropriate policy intervention. As curriculum leaders they were committed to implementing the guidance and reported that its incorporation into school regulatory procedures strengthened commitment to RSE among school leaders. Commitment to delivery could be undermined where: there were competing norms about the primacy of academic attainment; school capacity was stretched; teacher confidence and skill were limited; or individual staff or student attitudes and values did not align with teaching. Implementation varied across schools, influenced by the availability of material resources, which had increased in some schools but not others. Lack of specialist teaching staff and limited time for training were identified as ongoing challenges to high-quality delivery. Schools were increasingly engaged in reflexive monitoring to improve provision and ensure it met statutory guidelines and students’ needs. InterpretationThe priority of RSE has increased in English secondary schools but delivery continues to vary. Simply making RSE a statutory requirement is unlikely to achieve desired improvements in consistency and quality of provision. There is a need for: initial teacher training producing more subject specialist teachers; firmer guidance on the amount of timetabled lessons required; and ringfenced school-level funding for training and delivery. FundingNational Institute for Health Research (NIHR). PHR Project: NIHR131487 The views expressed in this output are those of the authors and not necessarily those of the NHS, the NIHR, MRC, CCF, NETSCC, the Public Health Research programme or the Department of Health. This funding source had no role in the design of this study and will not have any role during its execution, analyses, interpretation of the data, or decision to submit results.

A self-efficacy enhancement alcohol reduction intervention for men on-remand in prison: the APPRAISE feasibility pilot RCT.

As many as 70% of remand prisoners have admitted to being under the influence of alcohol when committing the crime leading to their imprisonment. Providing support and advice regarding alcohol consumption can be effective in some groups of people. There is little evidence regarding this for men on remand in prison. To pilot the study measures and evaluation methods to assess the feasibility of conducting a future definitive multicentre, pragmatic, parallel group, randomised controlled trial. A two-arm, parallel group, individually randomised pilot study of a self-efficacy-enhancing psychosocial alcohol intervention to reduce levels of alcohol consumption for males on remand in prison and on liberation. Two purposively selected prisons in Scotland and England. Adult men on remand in prison with an Alcohol Use Disorders Identification Test score of ≥8. The APPRAISE intervention delivery comprised four steps: Step 1: 1×40-minute face-to-face session, delivered by a trained practitioner from Change Grow Live in prison. Steps 2, 3 and 4: 20-minute sessions conducted by phone, on or as close as possible to days 3, 7 and 21 post liberation. Control: assessment, screening and referral onto further alcohol support options. Recruitment and retention rates, completion of follow-ups, outcome measures at 12 months and interventions delivered. The primary outcome for the pilot study was alcohol consumed in the 28 days prior to Time Point 2, assessed using the extended Alcohol Use Disorders Identification Test-C. Of 182 men on remand approached across two study sites, 132 were randomised (90 in England; 42 in Scotland) with 46 randomised to intervention and 44 to care as usual in England and 22 randomised to intervention and 20 to care as usual in Scotland. A total of 53 in-prison interventions were delivered. One day-3 post-liberation intervention was delivered, no day-7 and one day-21. At 12 months, of 132 randomised, 18 (13%) were followed up, 53 (40%) were not liberated; 47 (36%) were uncontactable and 14 (11%) had been released but could not be located. Data completeness was 96% at baseline and 8% at 12 months. The process evaluation reported good acceptability of the intervention with investment in time, capacity and space to support implementation identified. The economic study produced guidance on how to assess costs associated with implementing the APPRAISE intervention which could be applied more broadly. No adverse events or side effects were noted. A future definitive trial would be possible, but only if follow-up mechanisms can be addressed as well as full access to recidivism and health data. Collaboration with the probation service in future could offer the opportunity to develop a robust process and system to optimise follow-up post liberation. Dedicated resources to support the intervention delivery both in and out of the prison setting are recommended. Coronavirus disease discovered in 2019 impacted recruitment and follow-up, with access to prisons restricted. We were unable to deliver the post-liberation element of the intervention. We did not include probation services or other agencies in the trial. This trial is registered as Current Controlled Trials ISRCTN36066. This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/44/11) and is published in full in Public Health Research; Vol. 12, No. 11. See the NIHR Funding and Awards website for further award information.

School food policy in secondary schools in England and its impact on adolescents' diets and dental health: the FUEL multiple-methods study.

School food standards are a legal requirement for state-funded schools in England and are designed to promote healthy eating in pupils. However, state-funded academies/free schools established between 2010 and 2014 are exempt from this legislation. To complement the school food standards, the government launched the School Food Plan in 2013, which outlines voluntary actions that schools can take to support healthy eating and increase school meal uptake. There has been little evaluation of the school food standards and School Food Plan in secondary schools. To compare implementation and costs of the school food standards and School Food Plan, and pupil dietary and dental outcomes in two groups of secondary schools: those mandated and those not mandated to comply with the school food standards legislation. An observational, multiple-methods study. We sampled state-funded secondary school academies/free schools, pupils aged 11-15 years, and school staff/governors with a role in food provision/education from the Midlands. We collected qualitative data in four schools. The primary outcome was pupil free sugar intake at lunch; across the school day; and during 24-hours. Secondary outcomes were additional nutritional outcomes and dental caries measures. We assessed school food standards/School Food Plan implementation and costs using researcher observation, document analysis, and surveys with staff/governors, schools and pupils. Dietary intake and dental outcomes were measured online using 24-hour dietary recall and surveys, respectively. In the qualitative study we conducted staff/governor interviews and pupil focus groups in a subsample of schools. We used multilevel analyses to explore variation in pupil outcomes across the school food standards-mandated and school food standards-non-mandated school groups. Data were analysed using the Framework approach. Thirty-six schools (13 school food standards-mandated, 23 school food standards-non-mandated), 2453 pupils and 151 staff/governors participated. On average, schools were compliant with 64% of school food standards and implemented 41% of School Food Plan actions, with no differences across school food standards-mandated/non-mandated schools. There was a wide variation in annual costs of the school food standards and School Food Plan reported by schools (mean of £195 per pupil). Pupils in school food standards-mandated schools had lower lunch intakes of free sugar than those in school food standards-non-mandated schools (adjusted mean difference = -2.78 g, 95% confidence interval -4.66 to -0.90 g). After further adjustment for total energy intake, there was no significant difference in free sugar intake, but the school food standards-mandated group had lower fruit and vegetable intake at all time points, and higher consumption of confectionery during the school day and sugar-sweetened beverages over 24 hours. There were no differences in dental outcomes between the two groups. Twenty-one staff/governors and 137 pupils participated in the qualitative study. Staff described balancing school food standards compliance with conflicting priorities related to financial viability. Some pupils felt that school food did not meet their needs for convenience, speed, value for money and taste, and disliked the lunchtime experience. Little time was afforded to healthy-eating education within the curriculum. There were large numbers of missing data for some study elements, including assessment of some School Food Plan actions and cost data. In the secondary school context, the current school food standards are difficult to comply with and the School Food Plan has not achieved the desired outcomes. We found no evidence to show that school food standards legislation has positively influenced nutritional intake. We need to develop healthy secondary-school food provision models that meet pupils' preferences, and better understand how to situate the food and healthy-eating agenda in secondary schools. This trial is registered as ISRCTN68757496. This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: 17/92/39) and is published in full in Public Health Research; Vol. 12, No. 12. See the NIHR Funding and Awards website for further award information.