Background:Alcohol and tobacco are risk factors for non-communicable disease and deaths in England. People using both substances have increased health risks. While increasing tax on each product has been shown to reduce consumption and harm, little research has examined effects of changing both taxes together. Objectives:Work package 1: describe potential tobacco and alcohol tax policies; work package 2: analyse purchasing patterns across population subgroups; work package 3: estimate industry tax-pass-through; consumer response to price changes for 12 products; work package 4: simulate impact of 33 policy options, United Kingdom Government 2021 proposals to restructure alcohol duty and (after project end date) 2023 alcohol duty reform. Design:Work package 1 reviewed literature and interviewed stakeholders to identify policy options. Work package 2 analysed repeat cross-sectional survey data on purchasing. Work package 3 used quantile regression on market research data to estimate tax pass-through and a two-stage Tobit model to estimate consumer responses (own-price and cross-price elasticities) for 12 products (beer, cider, wine, spirits and ready-to-drinks, split off-trade/on-trade; cigarettes, roll-your-own tobacco). Work package 4 developed tax modelling for the Sheffield Tobacco and Alcohol Policy Model (v2.1.0) to analyse work package 1 policy options. Later, version v2.4.2 was used to analyse emerging policy on alcohol duty reforms. Setting:Effects of United Kingdom tax policies in England, covering 2017-50. Participants:Life course simulation of individuals aged 18-89; 2017-50. Interventions:Tax policies changes: (1) specific duty per product, (2) duty escalators for alcohol and tobacco, and Minimum Excise Tax on tobacco, (3) hypothetical strength-based alcohol taxes, (4) United Kingdom Government's 2021 proposals for alcohol duty reform and (5) analysis of United Kingdom Government's implemented Alcohol Duty Reform 2023. Outcome measures:Changes in participation in drinking or smoking, amounts consumed, expenditures, Government tax revenues, retailer revenues, risks of hospitalisation and death from over 60 clinical conditions, National Health Service secondary costs, quality-adjusted life-years, mortality and health inequalities. Results:Work package 1 identified policy options. Work package 2 showed variations in expenditure by subgroup. Work package 3 showed that retailers increased prices of expensive products by more than expected after tax rises, keeping cheap product prices lower. Work package 3 showed statistically significant participation and consumption price responsiveness for all 12 products. Work package 4 compared 33 policies, showing that higher tax increases, especially for cider and hand-rolled tobacco, are effective at reducing smoking rates, drinking and deaths over 20 years. Effects were largest for people living in more deprived areas. Tailored modelling (after project end date) examined United Kingdom Government's 2023 implemented alcohol duty reform, estimating a small reduction in alcohol consumption and deaths. In contrast, a policy to increase cider taxes to be in line with beer could result in a 30 times larger reduction in deaths. Limitations:Uncertainty in estimates remains. Data used were collected pre-coronavirus disease discovered in 2019. Sales data were from legal retailers; illicit tobacco was not examined. Each sub-study has its own data limitations. Conclusions:Combined increases in tax on tobacco and alcohol could potentially be more effective at reducing disease, National Health Service costs, deaths and health inequalities than raising tax on only one product. Potential trade-offs could exist between health benefits and effects of tobacco and alcohol tax increases on financial burden for those who continue consuming both products. Future tobacco or alcohol tax analyses should factor in inter-linkages between both commodities. Future work:We are adapting modelling infrastructure to deliver responsive within-days modelling for new government proposals and budgets. Further work on price elasticities in other countries would be useful. Future analyses will incorporate post-coronavirus disease discovered in 2019 data. We are extending modelling to other United Kingdom countries, and pricing policies beyond tax (e.g. minimum pricing). We are extending analyses to no and low alcohol products and to evaluate observed impacts of the government's alcohol duty reforms. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 16/105/26.
Background Exposure to particulate matter is linked to increased mortality, respiratory and cardiovascular diseases, including lung cancer, ischaemic heart disease and asthma, among other adverse health outcomes. Emissions of particulate matter from agriculture occur directly from farming activities and from reaction of ammonia with acidic pollutants to form fine particles (PM 2.5 : particles with diameter of 2.5 μm or less). In the United Kingdom, ammonia has slightly increased in recent years, in contrast to other PM 2.5 sources. In addition, NH 3 emissions can contribute to nitrogen deposition, which, in excess of critical thresholds, may result in biodiversity loss. Objectives Our objectives were to assess the effectiveness and cost-effectiveness of inter-related interventions to: (1) assess the annual health impacts of air pollution (PM 2.5 ) from intensive livestock agriculture and farming on the general population; (2) valuate the effectiveness and cost-effectiveness of the specific interventions at the national level; (3) assess impacts on ecosystems; and (4) examine the extent to which rural residents are concerned about agriculture and their health. Design and methods We performed a health impact assessment based on PM 2.5 exposures associated with three levels of agricultural intervention. We also performed an economic analysis, capturing valuation of health and productivity, and costs to the national health service, as well as an assessment of ecosystem impacts based on nitrogen deposition and biodiversity loss. A survey of rural residents’ health was undertaken to investigate links between self-reported health and agriculture. Interventions The three intervention scenarios comprised 19 individual mitigation actions at a farm level, each with differing uptake levels in low, medium and high scenarios. Main outcome measures The health impact assessment and economic analyses included all-cause mortality, and incidence of lung cancer, ischaemic heart disease, cerebrovascular disease, and childhood asthma incidence. The ecosystem analysis examined biodiversity loss, and the rural residents survey addressed respiratory, gastrointestinal, and neurological diseases. Results Modest changes in PM 2.5 concentrations across the United Kingdom associated with the low, medium and high intervention scenarios resulted in relatively small impacts compared to national baseline levels of mortality and morbidity (i.e. −0.01% to −0.05%). Overall, United Kingdom-wide avoided costs ranged from £78.1 to £93.4M, with much lower annual avoided costs to the national health service. All habitats had a relative increase in biodiversity under all scenarios with expected benefits of £3.4–4M. There were 450–500 respondents in each of the 2 waves of the rural resident surveys. No associations were identified between any self-reported disease occurrence and farm-related variables. Limitations Our approach used several different models, requiring important assumptions and uncertainties. Respondents to the residents’ survey tended to be aged over 45 and female and findings are applicable primarily to this demographic. Conclusions Based on the modest modelled changes in PM 2.5 concentrations associated with the intervention scenarios, we estimated small impacts with human health, as well as economic and ecosystem effects. We found no evidence of self-reported health issues in relation to farms or farming practices. Future work Impacts from alternative farming interventions should be assessed to maximise PM 2.5 reductions in the United Kingdom. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR129449.
Background:Household overcrowding is a growing problem in England. It increases the risk of health outcomes including infections, injuries and poor mental health. For councils to monitor overcrowding at household level, methods are required to identify which homes are overcrowded and how it affects residents. Measures may need to be tailored for families, where overcrowding limits children's ability to play, study and socialise. Study aim:To establish the feasibility of developing a method to identify households with families at high risk of overcrowding affecting their well-being. Objectives:Describe effects of household overcrowding on family well-being through discussions with people with experience of overcrowding. Operationalise a method in one council, by combining publicly available and council-held data, to identify households with families at risk of the health effects of overcrowding. Understand the wider applicability of this method to other councils and its implications for population-level intervention design. Methods:An explanatory sequential mixed-methods design was used with resident and community engagement throughout. First, interviews and focus groups were conducted with parents with lived experience of overcrowding and community representatives and service professionals in two boroughs of London. From discussions with these groups, a description of overcrowding affecting households with families was shared with one London local authority. Informed by this information, this local authority obtained and combined relevant population and housing data to generate two measures of household overcrowding in households with dependent children. The first measure replicated the 'bedroom standard', the most used overcrowding metric. The second measure assessed overcrowding by space available to families. A logistic regression was conducted to examine associations between overcrowding and repairs for damp and mould was undertaken. The methods and illustrative results on overcrowding prevalence from one council were shared with other councils, housing associations and researchers to understand its wider applicability. Results:Analysis of data from 47 parents (n = 25) and staff (n = 22) illustrated how effects of living in overcrowding can be influenced by the space available, and the number of bedrooms in the home, by the condition of the property (particularly damp/mould) and children's age. Using data available to councils, we identified overcrowding in families comparable to national estimates of overcrowding using the 'bedroom standard' and the 'space standard'. While prevalences were similar using space and bedroom standards [34.6% (95% confidence interval: 34.0% to 35.3%) vs. 36.1% (95% confidence interval: 35.4% to 36.8%)], each identified distinct cohorts of households). Using one of the local measures, we found overcrowded council homes had 1.31 times (95% confidence interval: 1.14 to 1.50, p < 0.001) higher risk of needing damp and mould repairs than households not in overcrowding. Stakeholder discussion with 30 participants across six English regions emphasised the importance of local measures for identifying populations at risk and for evaluating impacts of local policies and interventions. Discussion:This project demonstrated the feasibility of generating locally derived measures of overcrowding at household level that are granular enough to: (1) examine variations in overcrowded by household composition and (2) evaluate potential impacts of other policies/services on overcrowded households. Limitations:The project was limited in its geographical transferability; the qualitative research was conducted in two boroughs of London and the quantitative research in only one borough. There were also limitations to data access and quality on population data and housing data which affected the robustness of overcrowding indices. Future work:Household-level identification of overcrowding is needed to develop and evaluate public health interventions to support families living in overcrowding. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR154776.
Background:Inequitable access to health care increases morbidity and mortality among people experiencing homelessness. Peer advocates ('peers') with lived experience may help others to access health care. Objectives:To evaluate the impact and cost-consequence of Groundswell's Homeless Health Peer Advocacy programme on healthcare access, the processes through which it operates and the impact for peer advocates themselves. Ethics and design:A participatory mixed-method design with three components: qualitative study (A), prospective cohort (B), and cost-consequence analysis (C) using cohort and programmatic data. Ethical approval: Dulwich Research Ethics Committee (Integrated Research Application System 271312). Setting:London, United Kingdom (2019-23) coinciding with COVID-19 and disruptions to the National Health Service, Homeless Health Peer Advocacy and housing services. Participants:Homeless Health Peer Advocacy clients and non-clients (A-C); Homeless Health Peer Advocacy staff, volunteers and homelessness-sector stakeholders (A). Intervention:Peer advocates accompany clients to healthcare appointments and provide support to address barriers to access. Main outcome measures:Primary: probability of 'did not attend' at a scheduled outpatient appointment within 12 months of cohort enrolment. Secondary: number of inpatient admissions and accident and emergency visits. Data sources:(A) In-depth interviews and focus groups; (B) Structured questionnaires and National Health Service Hospital Episode Statistics; (C) Groundswell programme data and cohort findings. Results:Qualitative (A): Peer advocacy empowered clients by building cultural health capitals (skills and communication that support healthcare interactions) and strengthening social and economic resources. Advocates themselves gained social, cultural, human and physical resources, though benefits were greatest for those with some pre-existing stability. Cohort (B): Compared with non-clients, Homeless Health Peer Advocacy clients showed no difference in did not attend rates (rate ratio 0.97, 95% confidence interval 0.67 to 1.42) or accident and emergency visits (mean difference 0.86, 95% confidence interval -0.06 to 1.79) for the other pre-specified outcomes. Clients had 1.14 more inpatient admissions (95% confidence interval 0.52 to 1.75). Sensitivity analyses with imputed data suggested higher numbers of outpatient attendances, outpatient 'did not attends', accident and emergency visits and admissions among clients. Secondary analyses suggested differences by levels of anxiety and depression. Cost-consequence (C): Median annual cost per client was £353 (£176 per scheduled engagement). Evidence of National Health Service cost saving was inconclusive. Limitations:The COVID-19 disrupted both Homeless Health Peer Advocacy delivery and National Health Service services. Non-randomised design may have introduced bias. Conclusions:Homeless Health Peer Advocacy enhances clients' cultural health capital and helps peer advocates achieve their goals. We cannot state whether peer advocacy reduces 'did not attends' or demonstrate cost savings, but it was associated with more inpatient admissions and, in sensitivity analyses, more outpatient appointments. Future work:Research should explore how peer advocacy addresses stigma in health care and hostel settings and develop outcome measures that capture wider systemic change. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/44/40.
Background:People leaving prison face significant barriers to reintegration, often resulting in homelessness, which exacerbates health issues and increases recidivism. Critical time interventions aim to support vulnerable individuals during significant life transitions by providing time-limited, emotional and practical support. While effective in other contexts, the impact of housing-led critical time interventions for people leaving prison in the United Kingdom remains unclear. The PHaCT study was a pilot randomised controlled trial of a housing-led critical time intervention for people leaving prison at risk of homelessness. This study aimed to determine whether a full-scale randomised controlled trial of the critical time intervention model in prison leavers at risk of homelessness was feasible. Methods:The pilot was a parallel two-arm, individual-level randomised controlled trial of a pre-existing critical time intervention intervention with an integrated process evaluation and embedded exploratory health economic evaluation. Recruitment occurred in fours male prisons across England and Wales with participants followed up in the communities. Prisons were randomised by site to either receive the critical time intervention or receive usual support, and participants were recruited within 12 weeks of their release. The locations were predetermined by where the intervention was already being delivered by the intervention provider (critical time intervention teams). Critical time intervention included pre-engagement, transition to community, try-out and transfer of care phases, each lasting 3 months. Data collection methods included baseline surveys, follow-up assessments at 3, 6 and 9 months, qualitative interviews, and session observations. Routine data linkage was explored separately to assess feasibility. Progression criteria included recruitment, retention, process evaluation and fidelity. Results:Thirty-four male participants (mean age 38 years) were recruited, with 19 assigned to the intervention and 15 to control. The study achieved a high recruitment rate of 92%, but retention was a significant challenge, with only 18% of participants retained at 9 months follow-up. The process evaluation found critical time intervention was acceptable to staff and participants, but ethical concerns around randomisation and informed consent were raised. Fidelity to the critical time intervention model was generally high, though contextual instability in housing and criminal justice systems posed challenges. Data collection methods for health economics and data linkage were feasible and acceptable. Limitations:The approval to access prisons was lengthy and support provided by Clinical Research Networks was delayed. Contextual instability within the housing and criminal justice systems, including a lack of social housing, high recall rates, the removal of the requirement to have a probation officer and the emergency early release of people in prison, further complicated the trial. Ethical concerns around randomisation and informed consent affected trial acceptability. Conclusions:The trial methodology faced significant challenges. Low retention rates, ethical concerns by intervention delivery staff around randomisation and contextual instability suggest that a full-scale randomised controlled trial is not feasible. Implications/future work:The findings highlight the need for systemic changes within the research support provided to prison-based studies, housing and criminal justice systems to support research in prisons and interventions for people leaving prison. Decision-makers should prioritise policies that increase the availability of affordable housing and provide post-release support. Future research should explore alternative study designs and more intensive recruitment and retention strategies. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR134281.
Background:Poor diet is a leading risk factor of non-communicable diseases. Product placement strategies in retail outlets can influence customers' food preferences. The United Kingdom government introduced legislation in October 2022 restricting chain retailers from using location promotions on unhealthy food and drinks. High-quality scientific evidence is needed to inform the inclusion of healthier product placement approaches into these regulations. In the context of Brexit, COVID-19 and the cost-of-living crisis, this study assessed whether positioning an expanded fresh fruit and vegetable section near store entrances in discount supermarkets, which do not routinely market produce this way, improved store sales, household purchasing and diet. Methods and limitations:This natural experiment had a prospective matched controlled cluster design, involving 36 stores (18 intervention and 18 control) across England. The intervention was implemented continuously for 6 months. Control stores were matched on store sales, customer profiles and neighbourhood deprivation. Participants were women, aged 18-60 years, with loyalty cards and were assigned to their primary store (n = 280 intervention and n = 300 control). Weekly store sales and household data from loyalty cards were provided by the collaborating supermarket chain. Dietary quality, household food waste and demographic characteristics were collected through questionnaires. A process evaluation and economic evaluation were completed. Results:Store-level sales of fruit and vegetables were greater in intervention stores than predicted at intervention implementation and 3 and 6 months' follow-up, equivalent to ≈ 2525, ≈ 1940 and ≈ 1450 extra portions per store per week, respectively. Effect sizes were somewhat stronger in stores where the produce section moved forwards more than 14 m. The proportion of households purchasing fruit and vegetables were somewhat protected among intervention compared to control participants after 3 and 6 months. Changes in dietary quality were small but generally in the expected direction for health benefit. Changes in frequency of household fruit and vegetable waste were negligible at 3 months' follow-up but increased at 6 months. The intervention was implemented according to the study protocol, with marked differences in the positioning of fresh fruit and vegetables between intervention and control stores post-intervention implementation. Fresh fruit and vegetable availability increased post intervention in intervention compared with control stores. Interviews with store staff demonstrated that changes in staff attitudes had a positive reinforcing effect on intervention implementation. Assessment of the policy context showed that stakeholders across the food system largely support the United Kingdom government's unhealthy placement ban; some felt it does not go far enough. Future work:This study shows that positioning produce sections near supermarket entrances can improve the nutrition profile of store sales and may improve household purchasing and diet. The United Kingdom Food (Promotion and Placement) Regulations could be refined to require a produce section near supermarket entrances to increase its health impact. Future research should continue to build the evidence for which healthy eating interventions are effective in retail outlets. Further evaluations of real-world supermarket intervention studies using robust scientific study designs are required, alongside process and economic evaluations, to provide evidence for policy intervention to improve retail food environments in the United Kingdom and internationally. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/44/46.
Background:Agriculture dominates United Kingdom ammonia emissions, from livestock manure exposed to the atmosphere via livestock housing, storage, land and grazing. Ammonia significantly contributes to the formation of PM2.5 (particles with diameter of 2.5 μm or less) concentrations in Europe which are associated with adverse human health outcomes. Ammonia emissions contribute to nitrogen deposition, whereby reactive compounds of nitrogen are deposited into the biosphere, potentially resulting in biodiversity loss. Recent research has not found sufficient evidence for effectiveness of interventions to reduce ammonia emissions and little evidence on the cost-effectiveness of interventions. The current study aimed to address this knowledge gap. Aim:The study aimed to assess effectiveness and cost-effectiveness of two agricultural interventions to mitigate ammonia emissions - improved housing for farmed animals and improved manure application. Methods:Emission measurements were made at five farms (dairy, pig, poultry). Information on uptake of mitigation measures, barriers and enablers for implementation were determined through an online survey and focus groups with farmers, supplemented by stakeholder interviews. Chemical transport and dispersion modelling estimated population exposures to air pollution at local and national levels under three scenarios (low, medium, high intervention uptake). A health impact assessment estimated health effects associated with the scenarios, and data on self-reported health issues were collected via an online survey of rural residents. Economic evaluation methods estimated cost-benefits of the scenarios and impact on ecosystems. Results:Farmers favour mitigation measures which are cheaper, and build on existing practices, such as amending diet or extending the grazing season. However, these are less effective in decreasing ammonia emissions. Scenarios based on realistic current, and future, uptake levels of measures showed little impact on air quality, partly due to the ammonia-rich United Kingdom atmosphere minimising conversion of ammonia emissions to particulate matter. Consequently, minimal impact of mitigation measures was evident on health outcomes and costs. There was no evidence that self-reported health symptoms from rural residents were related to living near a farm, type of farm or seasonality of farm activities, consistent with results of local dispersion modelling which estimated that most emissions from animal housing dispersed within 1 km. Limitations:Impacts of COVID-19 and the United Kingdom's withdrawal from the European Union on the agricultural industry affected the recruitment and availability of farms and farmers, resulting in fewer field measurements than planned. A lower response to the farmers' survey was mitigated by the quality of data provided by participants and the successful series of focus groups. Conclusions:The study highlights the need for enhanced communication with the farming community to encourage implementation of more effective mitigation measures, such as air scrubbers, or those relating to slurry storage, currently perceived to be too expensive and complex. Greater clarity on benefits is essential so that farmers understand not only what they need to do but also how and why. Future work:Further investigation of the health impacts of ammonia emission should focus on those exposed on the farm, or resident nearby animal houses. Further modelling development of key atmospheric processes is also indicated to minimise uncertainties associated with the regional modelling. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR129449.
Background:High levels of smoking among people who experience imprisonment contribute to their high mortality and morbidity rates and to inequalities. Scotland's prisons became smokefree in 2018. However, questions remain about how to prevent high relapse to smoking post release. Objectives:Summarise evidence on supporting people to reduce tobacco-related harms post release. Understand experiences, opportunities and challenges for reducing tobacco-related harms for people leaving smokefree prisons and for families. Feasibility test a household-targeted intervention to support people released from smokefree prisons to reduce tobacco-related harms. Update cost-effectiveness of smokefree prison policy. Partnership-working with key stakeholders. Design and methods:Scoping reviews; qualitative; health economic modelling. Setting/participants:Prisons in Scotland; staff, people in prison, family members. Results:Our scoping reviews show that evidence on interventions to support people leaving smokefree prisons to remain tobacco-free is weak. There is no evidence on smoking rates among people released from smokefree prisons allowing vaping. Significant barriers remain for people from underserved communities to create smokefree homes. Our modelling highlights that offering effective smoking cessation support to people leaving smokefree prisons would be cost saving at both the personal and societal levels. The challenges people face on release from prison and variability in throughcare support often render smoking relapse prevention a low priority for them, their families and service providers. However, in terms of long-term prevention of ill health and premature death, the high rates of relapse to smoking (~50-80%) continue to fuel inequalities. Supporting people leaving smokefree prisons to remain abstinent will help governments to achieve ambitions to create smokefree societies. Progress may be achieved by greater integration of support for tobacco-harm reduction with services addressing interconnected needs, such as harmful use of other substances and underlying mental ill health. Limitations:The extensive impact of coronavirus disease discovered in 2019 in prisons into 2023, alongside challenges due to overcrowding and staffing pressures, limited the opportunities for partnership working and the number of interviews we could conduct. This meant that we were unable to test the feasibility of delivering a household-based intervention to reduce tobacco-related harms in this population. Conclusions:Progress in developing suitable interventions to prevent very high relapse-to-smoking rates following release from smokefree prisons is required. Helping people released from smokefree prisons to remain abstinent from tobacco post release could deliver considerable benefits. However, in the face of substantial challenges, preventing relapse to smoking has become entrenched as a low priority - for many service providers, people leaving smokefree prisons and their families. Greater success in reducing tobacco-related harms among this often-overlooked population may be achieved through more holistic models of service delivery. Aspirations for countries to become tobacco-free may require a rethink of what is needed to support underserved populations in whom smoking remains entrenched. Future work:Further research is required to better understand what approaches are feasible and effective for maintaining smoking abstinence following release from prison, including development and evaluation of integrated/holistic approaches which tackle smoking/vaping behaviours in the context of use of other substances and needs. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131613.
Background:Net Zero policies rarely consider air quality and physical activity health cobenefits, cost-benefit analysis, exposure indoors and exposure inequalities. Objectives:To calculate the air quality, health and economic costs and benefits of United Kingdom Net Zero policy, impacts on inequalities and consult the public on the acceptance of Net Zero policy. Design and methods:We used sophisticated emissions and air quality models, Life Table health impact analysis, United Kingdom Government cost-benefit methods and estimated exposure inequalities. We compared 2030 and 2040 United Kingdom PM10, PM2.5, nitrogen dioxide and ozone predictions using existing air quality policy, or Business as Usual, with Net Zero policy. We predicted Net Zero 2050 pollutant concentrations. Interventions:Business as Usual scenarios were from United Kingdom Government projections and Net Zero scenarios were from the Climate Change Committee's sixth Carbon Budget. We used the Balanced Net Zero and Widespread Innovation Pathways for road transport, building heating and active travel. Main outcome measures:United Kingdom air pollution, including exposure inequalities, mortality, morbidity and economic costs and benefits. Results:Air quality: Under Business as Usual, nitrogen dioxide and particulate matter reduced by 2030 due to new vehicles. The 2040 Balanced Net Zero Pathway and Widespread Innovation scenarios showed further reductions, driven by electric vehicle uptake, reduced vehicle kilometre travelled compared with Business as Usual, and low-carbon building heating. Particulate matter reductions from buildings was two and three times greater than from road transport, for Widespread Innovation and Balanced Net Zero Pathways, respectively. Balanced Net Zero Pathway+ 2050 predictions showed additional air pollution benefits. Exposure inequalities analysis: In 2019, urban central professionals experienced 14 µg m-3 higher nitrogen dioxide concentrations than rural elderly. At 1.5 µg m-3, PM2.5 concentrations varied less across geodemographic groups. Despite future improvements in nitrogen dioxide, inequalities persisted, but were less pronounced, due in part to Net Zero policies. Indoor air pollution: Removing gas cooking at home for Net Zero may result in greater nitrogen dioxide reductions than changes in outdoor air pollution. Health and active travel impacts: Compared with Business as Usual, Balanced Net Zero Pathway gave 4.9 (95% confidence interval 1.0 to 9.0) million life-years gained across the United Kingdom, to 2154, including 1.1 (95% confidence interval 0.7 to 1.6) million life-years gained from active travel. Avoided chronic obstructive pulmonary disease and childhood asthma cases were 201,000 (95% confidence interval 150,000 to 250,000) and 192,000 (95% confidence interval 64,600 to 311,000). Monetised morbidity benefits of £52.1B (95% confidence interval 36.4 to 67.8) added significantly to mortality benefits of £77.9B (95% confidence interval 42.9 to 90.8). Total yearly air pollution and active travel benefits were £153B (95% confidence interval 122 to 184), rising to £278B (95% confidence interval 228 to 334), including outcomes with weaker evidence. Costs/benefits: Building sector Balanced Net Zero Pathway air quality health benefits were £21.3B (95% confidence interval 16.4 to 26.2) by 2050 and were £98.4B (95% confidence interval 75.7 to 121.1) by 2154. Transport benefits were £9.1B (95% confidence interval 7.0 to 11.2) by 2050 and were £36.5B (95% confidence interval 28.1 to 44.9) by 2154. Balanced Net Zero Pathway building sector operating costs alone did not achieve break-even, but with greenhouse gases reductions (lower benefits) break-even was achieved by 2052. Air pollution health benefits reduced the building sector time to break-even by between 3.1 (95% confidence interval 2.5 to 4.7) and 6.3 (95% confidence interval 4.7 to 7.6) years. Public engagement: Conversations reflected an intergenerational commitment to Net Zero policies, although there was uncertainty about an individual's impact. Limitations:Uncertainties in future air quality and meteorological conditions; through lack of evidence, being unable to use multipollutant models and indoor air pollution, missing indoor health and monetised benefits; some health outcomes with weaker health evidence strongly influenced the results. The COVID pandemic prevented us from exploring social acceptance as planned. Conclusions:This study identified health and economic cobenefits through reductions in greenhouse gases, air pollution, inequalities and increased exercise. Future work:To separately evaluate the health and monetary impacts of indoor and outdoor air pollution; to understand the overlapping effects of PM2.5 and nitrogen dioxide health impacts; to develop effective ways of communicating the health and economic benefits and to increase the social acceptability of Net Zero. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR129406.
Background:Men with obesity infrequently engage with weight management services. Objectives:To determine: (1) percentage weight loss at 12 and 24 months for text messages with or without financial incentives compared to control; (2) secondary outcomes; (3) cost-effectiveness; (4) moderators of effectiveness and (5) participant and stakeholder perspectives. Design and methods:Assessor-blinded randomised controlled trial. United Kingdom National Health Service perspective cost-effectiveness over 24 months and modelled lifetime horizon. Mixed-methods process evaluation. Setting and participants:Five hundred and eighty-five men with body mass index ≥ 30 kg/m2 enrolled (July 2021-May 2022) in Belfast, Bristol and Glasgow; final follow-up June 2024. Interventions:Random allocation to 12 months of behavioural text messages plus financial incentives (N = 196), same texts alone (N = 194) or 12-month waiting list control group offered 3 months of texts between 12 and 15 months (N = 195). A £400 financial incentive was lost if weight loss targets were not met. Main outcome measures:Weight change as a percentage of baseline weight at 12 and 24 months comparing control with (1) texts with financial incentives and (2) texts alone. Results:Of 585 men (mean age 51 years; mean weight: 119 kg), 227 (39%) lived in lower socioeconomic areas, 146 (25%) reported a mental health condition and 253 (40%) had multiple long-term conditions. Follow-up was completed by 426 (73%) at 12 months and 377 (64%) at 24 months. At 12 months, mean percentage weight changes (standard deviation) were -4.8% (6.1) (-5.7 kg), -2.7% (6.3) (-3.0 kg), and - 1.3% (5.5) (-1.5 kg) for the incentives, text-only, and control groups, respectively. Compared to control, weight loss was significantly greater with incentives [-3.2% (97.5% confidence interval -4.6 to -1.9; p < 0.001)] but not texts alone (-1.4%; confidence interval -2.9 to 0.0; p = 0.053). At 24 months, changes were -3.9% (-4.6 kg), -2.6% (-3.1 kg), and -2.2% (-2.6 kg), no significant between-group differences. Intervention costs were £243 for texts with incentives, £110 for texts alone. There were no significant differences between 24-month costs and quality-adjusted life-years. Long-term modelling found texts with incentives versus control were: quality-adjusted life-year difference (95% confidence interval): 0.02 (0.007 to 0.029); cost difference: £176 (£43; £311); incremental cost-effectiveness ratio: £9748 (£7705 to £11,791). For texts alone versus control: quality-adjusted life-year difference: 0.03 (0.015 to 0.037); cost difference: £16.5 (-£117; £152); incremental cost-effectiveness ratio: £628 (-£5914 to £5384). There were no moderator effects for socioeconomic, health or well-being status for either comparison versus control. The texts with incentives group had a higher engagement in weight goal setting, food changes, self-weighing, confidence, satisfaction and quality of life compared to the control. Limitations:Generalisability to women, diverse ethnic groups and people with low literacy is uncertain. Not generalisable to people with no mobile phone access. Retention was lowest in the text messages alone group. Conclusions:Texts with financial incentives have a modest but important effect to 12 months with clinically relevant weight loss maintenance to 24 months, are cost-effective and equally effective regardless of socioeconomic or health characteristics. Future work:Implementation, adapt for women, other cultures and longer-term follow-up. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR129703.
Background:The Public Health Review Team, University of Sheffield, was commissioned to deliver a programme of public health evidence synthesis projects. The review programme (2019-25) provided a unique opportunity to develop effective and efficient processes to maximise the value and impact of evidence synthesis for public health practitioners, policy-makers, commissioners and research funders. Objectives:The overall purpose of the programme was to deliver evidence reviews that could inform the commissioning of further primary research and directly inform public health policy and practice. This synopsis summarises the programme content and reflects on lessons learnt. Methods:Diverse appropriate methods were used for individual reviews to ensure the timely and efficient production of evidence synthesis products that were as useful as possible to the relevant stakeholders and decision-makers. These included an umbrella review (review of reviews), mapping reviews, systematic reviews, rapid reviews and evidence briefings. The majority of reviews were informed by both public and practitioner involvement, from defining the review questions and identification of relevant evidence to interpreting and disseminating the findings. Both established public panels and topic-specific groups with relevant lived experience recruited for individual projects were involved in the review process. This synopsis was produced by collating and synthesising information from across all 11 commissioned review topics. The review team informally reflected on the learning and generated a number of recommendations for future review programmes. Data sources:All review projects across the programme used online database searches to identify relevant peer-reviewed journal articles. For many topics, relevant data were identified from grey literature identified by topic experts and other stakeholders and from website searches. Results:Evidence synthesis outputs were generated across 11 different topics prioritised by the Public Health Research Programme Prioritisation Committee: gambling-related harm, working in later life, working from home, access to services for ethnic minority populations, parenting programmes, warmer homes, student mental health, housing insecurity, alcohol licensing, local interventions to reduce air pollution, health impact assessment to inform spatial planning. Individual project outputs were used to inform both primary research commissioning calls and public health policy development. Research reports, research summaries and other outputs, such as animations, webinars, posters and presentations, were widely shared with both public and professional audiences. The programme benefited from high levels of engagement from public panels and professional involvement as well as close engagement with topic experts and policy-makers. Future work:Experience from this programme is informing commissioning of further national evidence synthesis teams, and we continue to build on the learning to develop efficient approaches to the delivery of timely, high-quality reviews which are of maximum value to decision-makers. Limitations:This synopsis can only summarise some key aspects of the programme. Further work is underway to disseminate learning on the value of stakeholder engagement and other methodological aspects of public health evidence synthesis. Conclusion:Commissioning flexible evidence synthesis teams and ensuring effective engagement with stakeholders are efficient approaches to the delivery of timely, high-quality reviews that can optimise impact on population health and health inequalities. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR127659.
Background:Young people's engagement in gambling can be linked to gambling-related harm. There is a lack of independently funded and evidence-based school-based interventions that seek to prevent and reduce the harms associated with gambling. Objectives:To conduct a pilot cluster randomised controlled trial of a gambling prevention intervention (Preventing Gambling Related Harm in Adolescents) among young people aged 13-15 years to determine the utility of conducting a phase III randomised controlled trial assessing effectiveness and cost-effectiveness. Design and methods:Two-arm, pilot cluster randomised controlled trial with an embedded process evaluation, health economic scoping study and social network analysis. Setting:Six state schools across Scotland: four intervention and two control. Participants:Students aged 13-15 years (baseline: intervention N = 762 students, control N = 352 students. Follow-up: intervention N = 598 students, control N = 295 students). Intervention:Preventing Gambling Related Harm in Adolescents is a peer-led, social network intervention to prevent adolescent gambling and reduce gambling-related harm. Students, nominated by peers in their year group, attended a 2-day training workshop outside of school, which was delivered by trained youth workers. After completing the 2-day training workshop, students were then assigned the role of 'peer supporters'. Peer supporters then attended three in-school follow-up sessions, with the same youth workers, to refresh the learning they had received during the workshop. After the workshop and during the follow-up sessions, peer supporters were encouraged to have conversations about their learning on the topic of gambling and gambling-related harm with their friends and family. Social network maps were created by peer supporters to: (1) help them identify people to speak to and (2) record to who they spoke to about gambling and gambling-related harm. Main outcome measures:Progression to a full-scale Phase III cluster randomised control trial, using pre-set progression criteria. Progression criteria were: (1) successful recruitment of six schools; (2) five schools remain in the pilot study; (3) the intervention being delivered with 80% fidelity to the manual; (4) the process evaluation indicates the intervention is acceptable to students and staff and (5) 70% of students complete the student questionnaire at baseline and follow-up. Results:All five progression criteria were met. All schools were recruited and retained in the study and there were low levels of missing data on outcomes. The process evaluation indicated that Preventing Gambling Related Harm in Adolescents was acceptable to all stakeholders and was delivered with fidelity to the delivery manual. Some minor refinements to the intervention and trial methods would aid student perception of the real-world effects of gambling. Indicative costs to deliver two cycles of Preventing Gambling Related Harm in Adolescents in one school were £8313.00, with a mean cost per student of £28.08. Limitations:A limitation is student self-reported gambling behaviour. This relied on their interpretation of what gambling is, which varied. Conclusions:Delivery of the Preventing Gambling Related Harm in Adolescents intervention was both feasible and acceptable, indicating that the study could progress to a full-scale Phase III randomised controlled trial, with minor amendments to the intervention and trial processes. Future work:Preventing Gambling Related Harm in Adolescents should progress to a full-scale randomised controlled trial. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR150838.
Background:The National Institute for Health and Care Excellence guideline NG48 aims to maintain and improve the oral health of care home residents. However, evidence on oral health interventions among care home residents is weak. A co-design process with residents and care home staff refined National Institute for Health and Care Excellence guidance NG48 aspects to facilitate implementation. This study aimed to assess the feasibility of undertaking a large-scale definitive trial on this intervention. A parallel theoretically informed process evaluation explored factors affecting implementation. The feasibility of collecting data to inform a cost-consequence model was also explored. Methods:A pragmatic cluster randomised feasibility study with 12-month follow-up was undertaken in 22 care homes across two sites (London, Northern Ireland). Care homes were randomised into an intervention arm (n = 11) that received the National Institute for Health and Care Excellence guidance NG48-based complex oral health intervention, and a control arm (n = 11) that continued with routine practice. The complex intervention included a training package for care home staff in oral health promotion knowledge and skills; using the Oral Health Assessment Tool to assess residents' oral health needs; and a 'support worker assisted' daily toothbrushing regime with 1500 ppm fluoride toothpaste. Dentate residents aged 65 years or over without severe cognitive impairment were recruited, resulting in a sample of 119 participants. Assessments were undertaken at baseline and 12 months through clinical dental examination and questionnaires. A parallel process evaluation involved semistructured interviews to explore how the intervention could be embedded in standard practice. Rates of recruitment and retention and intervention fidelity were also recorded. Economic evaluation or cost-consequence indicators were collected through interviews with stakeholders, survey and questionnaire data. Results:Eighty-four per cent of care homes and 88% of residents agreed to participate; 86% of care homes and 69% of residents were retained at 12-month follow-up. Researcher-collected data on clinical and subjective measures had successful completion rates, but completion rates were very low for the weekly symptoms checklist collected by care home staff. The process evaluation highlighted that most care homes were keen to participate, as accessing oral care provision was challenging. The values and beliefs of managers and staff within each care home were key to intervention adoption. Collecting outcomes relevant for cost-consequence modelling is feasible, therefore, supporting an economic evaluation alongside the definite trial. Residents' quality of life was identified as a key outcome for stakeholders, including care home managers. Limitations:As ethical approval was granted for care home residents without or with mild cognitive impairment, the inclusion criteria excluded a considerable proportion of residents that had severe cognitive impairment, meaning that the findings are less generalisable to the wider population of care home residents. Attrition rates were high, and recruitment was affected by the coronavirus disease pandemic. Conclusion:The study documented the feasibility of undertaking a National Institute for Health and Care Excellence guidance NG48-based intervention in care homes. Recruitment and retention were feasible but challenging. A definitive trial should accommodate these challenges. Future work:A definitive trial should assess the effectiveness of the co-designed intervention, with more inclusive recruitment, improving retention, minimising missing data and outcome selection being important issues to consider. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/03/11.
Background:Childhood obesity is a major public health concern worldwide, yet the best way to prevent it remains unknown. Objective(s):To determine what types of intervention strategy are most effective at preventing the development of obesity in children aged 5-18 years, as measured by change in body mass index, and to determine whether interventions work differentially in children with different characteristics associated with inequities. Design:Systematic reviews and statistical evidence syntheses. Eligibility criteria:Randomised controlled trials of dietary and/or activity interventions that aimed to prevent overweight or obesity in children and young people aged 5-18 years and reported outcomes at least 12 weeks after baseline. Non-randomised evidence was identified through an overview of systematic reviews. Sources of inequity of interest were those defined by the PROGRESS (place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital) acronym: place, race/ethnicity, occupation (of parents), gender/sex, religion, education (of parents), socioeconomic status and social capital. Data sources:Updating of an existing Cochrane Review, searching bibliographic databases up to February 2023, including MEDLINE, EMBASE, PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials on the Cochrane Library, international trial registers and grey literature databases, and examining reference lists. Results subgrouped by inequity factors were sought directly from trialists. Review methods:Cochrane Reviews followed standard Cochrane procedures. The main statistical synthesis was informed by a novel analytic framework developed iteratively through discussions with children and young people, schoolteachers and public health professionals. Methodology was developed to analyse the data using multilevel metaregression. To examine the impact of inequity factors, we performed a two-stage meta-analysis of interactions, based on subgroup-level aggregate data collected directly from the trialists. We collected available information on intervention costs. Results:We included 172 trials in ages 5-11 and 74 in ages 12-18. In the main synthesis, of 204 trials from both reviews, we found interventions were effective on average (mean difference in standardised body mass index -0.037, 95% credible interval -0.053 to -0.022, which would correspond to a reduction in a proportion of 2.3% with obesity to a proportion of approximately 2.1%). Larger effects were associated with physical activity rather than dietary interventions, after 12 months of follow-up and in the older age group. The overview of non-randomised evidence included 24 systematic reviews, yielding mixed results. The investigation of inequity did not identify substantial differences in effectiveness according to place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital characteristics, and there was very limited information about costs. Limitations:We were able to examine only the interventions that had been evaluated in studies identified for inclusion in the systematic reviews, which does not cover all possible intervention approaches. Conclusions:Interventions to prevent obesity in children aged 5-18 have a small beneficial effect on body mass index on average but with considerable variation. A novel re-analysis of existing randomised trials failed to identify general intervention characteristics driving this variation. No evidence was identified to suggest that interventions increase (or decrease) health inequities. Future work:Future studies of the effects of interventions to prevent childhood obesity should routinely collect baseline characteristics around potential inequities. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131572.
Background:Research in Children's Social Care in the United Kingdom operates in a framework that was initially designed to support medical research within healthcare settings. Although adaptations to this framework have been made for social care settings, our experience suggested that significant systemic and organisational challenges to conducting large-scale randomised controlled trials in fostering services in the United Kingdom still remain, which work against the likelihood of such studies being completed successfully. A further challenge we faced was that that many fostering services were relatively inexperienced with research and lacked the infrastructure to support it. Objective:To report on the opportunities, obstacles and challenges faced when conducting a trial evaluating foster care support in a children's social care setting and to describe how those working on this research project came together to adapt the existing systems and processes and overcome the challenges. Design:The Reflective Fostering Study was a randomised controlled trial evaluating an intervention to help foster carers care for the children they look after. Setting and participants:Local authority and independent fostering services in the United Kingdom. The main study recruited 524 foster carers and kinship carers. The main study was evaluating the Reflective Fostering Programme, a group intervention designed to improve reflective functioning in foster and kinship carers. Results:The main challenges identified in this study were lack of infrastructure, both within fostering organisations and outside, a lack of capacity, and on occasion, unnecessary bureaucracy. Working with fostering sites, the Clinical Research Network and across collaborating partners, we were able to make changes to existing processes so that the governance and oversight of the study were proportionate and the workload for our sites was minimised. Identifying likely departments to obtain key approvals, working with local Clinical Research Networks and providing templates made the site set-up process faster and supported recruitment. Limitations:The challenges reported were those encountered by a study that took place in fostering services in the United Kingdom. The challenges faced, and solutions identified, may not be mirrored in other sectors of children's social care, or other countries. Conclusions:Carrying out high-quality clinical trials within fostering services in the United Kingdom can face significant barriers. There has been a move to address these issues, but our study suggests that more could be done so that research in these settings increases. Ongoing review of the regulatory framework, which is designed to ensure best practice for research in children's social care, could ensure that research governance is proportionate while upholding safeguarding. Without doing so, high-quality clinical trials within fostering services in the United Kingdom may face significant barriers. In the meanwhile, certain pragmatic steps can be taken by teams doing studies similar to ours, which can help to overcome some of the challenges faced. Future work:Based on our experience with this randomised controlled trial, we encourage other research teams to use some of the pragmatic suggestions set out in this paper and evaluate whether these impact on their ability to conduct high-quality clinical trials within fostering services in the United Kingdom. If further review or changes are made to the research governance framework, we encourage researchers to evaluate and report on the impact this has on the process of conducting studies in children's social care. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR127422.
Background:Young people's mental health worsened during and since the coronavirus disease discovered in 2019 pandemic. School environments play a key role in young people's mental health. Learning Together for Mental Health is a whole-school intervention aiming to promote mental health in secondary schools, adapted from the previous Learning Together intervention which was found effective in reducing bullying and promoting mental health. Objective:To adapt Learning Together to increase focus on mental health so producing the Learning Together for Mental Health intervention and evaluate the appropriateness of conducting a Phase III trial of the Learning Together for Mental Health intervention regarding pre-defined progression criteria relating to the intervention and trial methods, and assessing intervention feasibility, reach and acceptability, feasibility of trial measures and procedures, potential mechanisms and possible harms. Design and methods:We conducted a feasibility study with baseline and follow-up surveys, process evaluation and economic-evaluation feasibility-testing. Setting and participants:One school participated in intervention adaptation. Our feasibility study included four state, mixed-sex secondary schools in southern England (one of which dropped out after baselines and was replaced with another). We recruited 640 year-7 (age 11-12) students at baseline survey and 566 year-10 (age 14-15) students at 12-month follow-up. Baseline and follow-up participants were different groups, as the focus was assessing feasibility for the age groups to be surveyed at baseline and follow-up in a Phase III randomised controlled trial. Twenty staff, 27 year-8 (age 12-13) students and 22 year-10 students participated in qualitative research as did two trainers and one external facilitator. Interventions:As part of our feasibility study, all schools received the Learning Together for Mental Health intervention for one academic school year. Main outcome measures:Pre-defined criteria for progression to a Phase III trial. Results:The intervention was successfully adapted from the previous intervention using public involvement. The trial met all criteria for progression to Phase III. The all-staff and in-depth restorative practice training were implemented with fidelity in all schools and all schools had at least two staff trained in-depth in restorative practice. Curriculum training was delivered with fidelity in three of four schools. The response rate to the baseline (needs) survey across the three participating schools was 79%. Progression required at least two schools to have delivered the curriculum with at least 50% fidelity, which was achieved; one of the two schools which delivered the curriculum reported over 80% fidelity and the other school reported over 75% fidelity. All students and staff across all four schools who completed the action group survey and 93% of senior leadership team members who completed the senior leadership team survey reported that Learning Together for mental health was a good way to promote student Mental Health. Potential mechanisms of action involve promoting student sense of school belonging and practical reasoning and skills. No harms were reported. Trial measures and procedures were feasible and acceptable to implement. Intervention and trial refinement are suggested. Limitations:Our study involved a small, purposive sample of schools and students which are not representative of those in England. Conclusions:With some minor amendments, Learning Together for Mental Health should be subject to a future Phase III trial of effectiveness. Future work:The intervention should be refined by making the curriculum optional and improving materials. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131594.
Background:Adverse sexual health, dating and relationship violence, and sexual harassment are significant public health concerns, especially among young people. Sexually transmitted infection rates are at a 10-year high, and dating and relationship violence affects nearly half of young people. Further education provides a population-wide setting for delivering dating and relationship violence and sexual health interventions, but only a few interventions have been shown to be effective in further education. Objectives:To optimise intervention materials and identify refinements for the Sexual Health and Healthy Relationships for further education (SaFE) intervention, an intervention to improve sexual health and reduce dating and relationship violence and sexual harassment among young people attending further education. Optimised materials were used in a pilot cluster randomised controlled trial of SaFE. SaFE had three components: (1) onsite access to sexual health and relationship services in further education settings provided by sexual health nurses for 2 hours, 2 days per week; (2) publicity about onsite services and (3) further education staff training on how to promote sexual health and recognise and respond to dating and relationship violence and sexual harassment. This paper reports on the optimisation of the SaFE intervention materials. Design and methods:A multistage iterative process was used to optimise further education staff training and publicity materials. This involved a series of consultation and focus group feedback sessions. Setting and participants:In Stage 1, feedback was collected from the SaFE Trial Management Group. Stage 2 involved: (1) two focus groups; one with four further education staff and one with three further education students at one further education institution and (2) stakeholder consultation with seven experts. Stage 3 saw consultation with the Trial Steering Committee who had independent oversight of the study. The operational feasibility of the training was evaluated in Stage 4 through a trial run with further education safeguarding and well-being teams. Stage 5 comprised a final review of intervention material by the Trial Management Group. Stage 6 gained online feedback from a young people's advisory group. The study was conducted in England and Wales. Results:In Stage 1, Trial Management Group reviewers recommended improving clarity and factual accuracy, reducing the length of slide decks and adding content on sending explicit images. Stage 2 feedback from further education staff and students focused on training content addressing comprehensiveness, structure and visual design and training delivery addressing preferred training formats and opportunities for scenario-based learning. The Trial Steering Committee in Stage 3 advised on managing participant disclosures and reordering content. Stage 4's trial run with further education staff identified redundancy in content, the incorporation of task-based exercises and varied learning approaches. Stage 5's Trial Management Group review led to the integration of multimedia elements and case studies. Stage 6 feedback from young people improved clarity and accessibility in publicity materials. Limitations:Low participation and self-selection in focus groups may limit the generalisability of the findings. The move to online engagement during COVID-19 may have hindered the depth of interaction. Recruiting from a single institution could introduce sampling bias. Conclusions:Fully optimised staff training and publicity materials were produced that were considered acceptable and consistent with the theory of change as agreed by the research team, Trial Steering Committee, stakeholder advisory group and further education students staff and young people. Future work:After the optimisation phase, the SaFE intervention was delivered in a pilot cluster randomised controlled trial with high fidelity to six further education settings in England and Wales. Future work could explore strategies to evaluate the effectiveness as well as improve scalability and sustainability of interventions like SaFE. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/149/12.
Background:The United Kingdom Soft Drinks Industry Levy was introduced in April 2018, resulting both in changes in sugar levels in drinks and purchases of drinks. Both mechanisms could impact on the incidence and prevalence of raised body weight, diabetes and diet-related diseases, and therefore, have implications for economic costs to the health sector. Objectives:To model future impacts of the Soft Drinks Industry Levy on population health and health sector costs and to estimate net monetary benefit to the health system. Design and methods:Proportional multistate lifetable modelling study - open and closed cohort analyses. Setting and population:All children and adults in the United Kingdom. Intervention:The Soft Drinks Industry Levy is a two-tier levy of £0.18/l on drinks with between 5 and 8 g of total sugars/100 ml and of £0.24/l on drinks with ≥ 8 g of total sugars/100 ml. Main outcome measures:We evaluated impact of the sugar reduction on: (1) prevalence of overweight and obesity, obesity-related diseases and dental health out to 2050 and (2) lifetime population health (measured in quality-adjusted life-years), change in costs to the health sector and the resulting net monetary benefit. Data sources:We estimated a per person reduction in sugar from a previously published interrupted time series analysis, which found an 8.0 g/household/week (95% confidence interval 2.4 to 13.6) reduction in sugar at 1 year after implementation. Our multistate lifetable model is parameterised using data from population health monitoring surveys, the Global Burden of Disease project, the Human Mortality Database and the Office for National Statistics. Health sector costs were obtained from Department of Health and Social Care budget allocations. Results:The model predicts that the Soft Drinks Industry Levy will reduce the prevalence of overweight and obesity in the United Kingdom by 0.18% points (95% uncertainty interval: 0.059 to 0.31) for males and by 0.20% points (0.064 to 0.34) for females. In the first 10 years of implementation, the reductions in sugar and overweight/obesity are predicted to prevent 270,000 (35,000-600,000) dental caries, 12,000 (3700-20,000) cases of type 2 diabetes, 3800 (1200-6700) cases of cardiovascular diseases and 350 (110-590) cases of obesity-related cancer. For the current United Kingdom population, it is estimated that the Soft Drinks Industry Levy will add 200,000 quality-adjusted life-years (63,500-342,000) over their lifetime and avert £174 million (£53.6-319) in their costs of health care (discounted at United Kingdom Treasury rates). At a United Kingdom Treasury value of £60,000 per quality-adjusted life-year, it is estimated that the Soft Drinks Industry Levy will produce a net monetary benefit of £12.2 billion (£3.88-20.8) for the health system. Limitations:Modelled results assume that the effect of the Soft Drinks Industry Levy remains constant into the future. The longevity of the effect of the Soft Drinks Industry Levy has not been tested. Conclusion:This study of the United Kingdom Soft Drinks Industry Levy tiered tax on sugar content provides further evidence that sugar-sweetened beverage taxes have the potential to achieve meaningful improvements in population health and reduce health sector spending. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 16/130/01.
Background:Suicide prevention is a national priority for United Kingdom government policy, and autistic people have recently been identified as a high-risk group in both the Department of Health and Social Care suicide prevention strategy and National Institute for Health and Care Excellence suicide prevention guidelines. No suicide prevention interventions have been developed specifically for autistic people. Safety plans are a simple, cost-effective, potentially life-saving intervention. Aims:To evaluate the feasibility and acceptability of the use of Autism Adapted Safety Plans for autistic adults and to undertake an external pilot to explore whether a larger future definitive trial is achievable. Methods:Stage 1 involved focus groups with autistic adults (n = 15), family members (n = 5) and service providers (n = 10) to inform adaptations to the Autism Adapted Safety Plans. Stage 2 was an interventional single-arm feasibility trial where autistic adults (n = 8) completed an Autism Adapted Safety Plans with a supporter (n = 8). Data on recruitment, completion of study measures and participant feedback informed final adaptations to the Autism Adapted Safety Plans and research methods prior to stage 3. Stage 3 was a pilot feasibility randomised controlled trial of Autism Adapted Safety Plans. Autistic adults were recruited via non-National Health Service organisations and self-referral. Participants were randomised without stratification to usual care ± Autism Adapted Safety Plans. The Autism Adapted Safety Plan was completed by the autistic adults with someone trained to support them. Research staff completing follow-up assessments were blind to participant allocation. Primary outcomes were feasibility and acceptability of the Autism Adapted Safety Plans to inform the parameters of a definitive randomised controlled trial. Participants were assessed at baseline, 1 and 6 months. Results:Stage 1 and 2 interviews highlighted the conditions needed to make the process of creating the Autism Adapted Safety Plans acceptable for autistic adults. Stage 2 also informed modifications to recruitment (to include self-referral) in stage 3. In stage 3, 53 participants consented, 49 were randomised to either Autism Adapted Safety Plans + usual care (n = 25) or usual care (n = 24). Sixty-eight per cent of participants were satisfied with the Autism Adapted Safety Plans and 41% rated it as usable. Feedback on the Autism Adapted Safety Plans and study processes employed in the trial were positive with suggested minor adaptations to some outcome measures. Retention of those randomised was 95% at 6-month follow-up. Completion rates for outcome measures were generally high (> 85%). Fidelity ratings for delivery of the Autism Adapted Safety Plans were 94% for therapeutic components and 91% for adherence to content. Conclusion:Autism Adapted Safety Plans are a potentially valuable intervention for autistic adults, provided that the process of creating it is flexible and sensitive to individual needs. The parameters of a future definitive trial of the clinical and cost-effectiveness of Autism Adapted Safety Plans are achievable, with minor recommended adaptations. Further testing of the Autism Adapted Safety Plans to assess its clinical and cost-effectiveness in National Health Service clinical services is urgently needed. Limitations:The sample size was below the initially intended sample of 70 participants due to difficulties with recruitment during the COVID-19 pandemic. As autistic participants self-referred into the study, data are not available regarding how many participants were approached to take part in the study. The majority of the study sample was White. Future work:A full definitive trial testing the clinical and cost-effectiveness of Autism Adapted Safety Plans in National Health Service clinical services is warranted. This fully powered trial will need to recruit a more diverse sample than was possible in the pilot trial. Results suggest that minor adaptations to the Autism Adapted Safety Plans could make this more personalised and accessible, such as through an app or website. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR129196.
Background:Childhood obesity is a public health policy priority. Policy-makers need an understanding of the costs of interventions to prevent childhood obesity alongside their effectiveness when tested in randomised controlled trials. It is not known what cost data have been included in published randomised controlled trials of childhood obesity prevention interventions. This study aimed to summarise these costs and identify associated economic evaluations published separately. Methods:This review summarises data extracted from studies included in two Cochrane systematic reviews of interventions to prevent obesity in children aged 5-11 and 12-18 years old. Eligible interventions could be delivered in any setting and studies were randomised controlled trials reporting (standardised or unstandardised) body mass index outcome data at a minimum follow-up of 12 weeks post baseline. Databases searched included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO. Searches were limited to between 1990 and 2023. Any cost data reported in the publications were extracted, in addition to citations of linked economic analyses. Data were tabulated and summarised using a narrative approach. Results:Of the 244 randomised controlled trials included in the Cochrane systematic reviews, 85 (35%) included costs related to the trial, intervention, school, health sector, out-of-pocket or productivity costs, or were linked to a full economic evaluation published separately. Of the studies reporting costs, five (6%) studies reported results of a full economic evaluation within the trial paper. The majority of research costs were incentives for participation, identified in 41 (48%) studies. Where these are not part of the intervention itself, these would not usually be included in economic evaluations. Thirty (35%) studies included intervention costs, although reporting was inconsistent. The payer of the intervention was unclear in most publications, making the attribution of costs to sectors difficult. Only one study reported healthcare resource use data, but some estimated the cost of obesity-related chronic conditions in linked decision models. Limitations and future work:The findings of this review are limited to randomised controlled trials only and interventions for children aged 5 years and over. Other study designs may provide important cost data. Future work could explore the cost data needs of public health policy-makers and the impact of including incentives on the effectiveness and cost-effectiveness in public health randomised controlled trials. Conclusions:This is a novel synthesis of costs reported in randomised controlled trials of interventions to prevent childhood obesity. Overall, the reporting of any type of costs was low (35% of studies). The most common type of reported costs were intervention costs (e.g. staff costs, materials and training) and participant incentives for data collection, although five studies included full economic evaluations. This study complements published systematic reviews of economic evaluations in this area by offering new insights into the prevalence, type and quality of cost information included in the effectiveness literature. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR131572.
