BACKGROUND: Innovations, especially those involving digital technologies, are expanding rapidly in health and social care in many countries around the world, but the extent to which the needs of underserved populations are considered is unclear. The aim of this study was to explore if and how socioeconomic health inequalities are considered in the design and delivery of health and social care innovations in the United Kingdom. METHODS: A qualitative study using 23 semi-structured interviews with a range of stakeholders involved in the development and delivery of innovations in health and social care in England and Scotland exploring 20 areas of innovation. Data were analysed thematically. RESULTS: Of 20 innovation areas, only one explicitly focused on reducing health inequalities for people living in deprived areas. The remaining broadly fell into three groups: (1) ‘Aspirational intent’ where stakeholders hoped their work would benefit people living in deprived areas but active planning was not involved; (2) ‘Stymied intent’ where stakeholders were aware of health inequalities but faced systemic and structural constraints that limited their opportunities to tailor innovations to the needs of deprived populations; and (3) ‘No intent’ where stakeholders (over half of those interviewed) were apparently unaware or indifferent to health inequalities. The lack of consideration for innovations utilising digital technologies holds particular risks for widening health inequalities. Two additional cross-cutting themes - ‘The influence of funding’, and ‘The role of the third sector’ - were identified. Stakeholders reported including a focus on health inequalities when funders explicitly prioritised it. Conversely, a lack of funding significantly hindered stakeholders’ abilities to address health inequalities. The involvement and contribution of the third sector in tackling or mitigating the effects of health inequalities was commonly reported as an under-utilised and under-funded resource. CONCLUSIONS: Our study suggests that socioeconomic health inequalities are seldom explicitly considered in the funding, design, delivery, policy translation and implementation of service innovations. Present innovation trajectories therefore risk widening rather than narrowing health inequalities, especially for digitally-based innovations.

BACKGROUND:People with alcohol dependence (AD) frequently experience oral health problems, but their dental attendance is poor, with limited evidence to the reasons why from their perspective. OBJECTIVE:To explore perceived barriers, motivators, and facilitators to accessing primary dental care in people with AD. METHODS:Qualitative study consisting of remote one-to-one and group semistructured interviews with a convenience sample of adults with lived experience of AD in northern England. Data were audio-recorded, transcribed, and coded. A reflexive thematic analysis method was used; use of COM-B model informed data interpretation. RESULTS:Twenty adults with lived experience of AD participated in 18 one-to-one interviews and 1 group interview (of 3 participants). Barriers to access were fear and physical, social, and environmental factors (physical effects of AD, financial barriers, nonprioritization of oral health). Motivators to access were pain and prioritization of oral health. Facilitators to access were patterns of alcohol use (i.e., sobriety) and dental service provision within recovery services. CONCLUSIONS:Fear of "the dentist" is a major barrier to accessing dental care, and pain is the primary motivator, among people with AD, although neither are unique to this population. Fear and physical, social, and environmental barriers to access contribute to problem-oriented attendance, which negatively affect oral health outcomes. Opportunity to facilitate attendance increases when a person is in remission from AD through their physical capabilities improving. Increasing capability and opportunity can influence attendance beyond the automatic motivation of pain. Provision of dental care within recovery services could facilitate access to care. Understanding the "web of causation" is key to developing any intervention to improve dental access in people with AD. Further research is needed from the perspective of other adult populations with lived experience of AD, as well as of dental professionals, to gain deeper insight into barriers, facilitators, and possible solutions. KNOWLEDGE TRANSFER STATEMENT:The results of this study can help dental professionals understand factors affecting access to primary care in people with alcohol dependence to provide knowledge that may reduce stigma surrounding the disease. Results also demonstrate areas for intervention development for public policy.

BACKGROUND:Evidence supports the effectiveness of alcohol brief interventions (ABI) in health-care settings but the acceptability of conducting ABIs in wider community venues such as supermarkets, hospital atriums and train stations remains unclear. This study examines the acceptability of conducting ABIs for older adults in community settings. METHOD:ABIs were conducted in community venues in five sites across the United Kingdom as part of the Drink Wise, Age Well program. ABIs used the Alcohol Use Disorders Identification Test-Consumption to measure alcohol use, with personalised feedback delivered in relation to alcohol intake. Data on age, gender, ethnicity, alcohol use and intention to change drinking was collected. Qualitative interviews to explore the acceptability of delivering ABIs within community venues were conducted with a sub-set of ABI recipients (n = 16) and practitioners (n = 12). Data were analysed using Framework Analysis. RESULTS:A total of 3999 people received an ABI. Fifty-eight percent of ABI recipients were female. The largest age group was 50-54 years (28%). Almost 80% (n = 3180) of ABI recipients were drinking at hazardous levels. Of hazardous drinkers that were asked (n = 2726), 40% reported intentions to change their drinking. Qualitative analysis indicted that ABIs conducted in community venues were acceptable and considered to be valuable in raising awareness of alcohol-related risks. DISCUSSION AND CONCLUSIONS:Community venues represent a promising context to engage older people in alcohol intervention, with the potential to lead to reductions in alcohol consumption.

Mental health problems are the leading cause of childhood disability worldwide, resulting in poor outcomes for children and young people that persist into adulthood. It is essential that those young people most at risk of developing mental health problems receive effective preventative interventions. Whilst there have been a number of systematic reviews which have examined the effectiveness of secondary prevention interventions for specific groups of children and young people, or to address identified mental health concerns, no review has engaged with the breadth of this literature. We conducted a systematic review of systematic reviews to map this complex field of secondary preventative interventions and identify effective interventions to prevent mental health problems in children and adolescents aged 3–17 years. The review protocol was registered on PROSPERO. We searched five electronic databases from inception to February 2023. The certainty of the evidence was appraised using the AMSTAR 2. We included 49 unique systematic reviews each including between 2 and 249 (mean 34) unique studies; the majority of which were reviews which included only or mostly randomised controlled trials (70

Background: Understanding the lived experiences of people dying with frailty is essential to develop models of care that are appropriate to meet the needs of this growing population. Aim: Synthesise qualitative evidence on the experiences of people dying with frailty. Design: Systematic review of qualitative literature and thematic synthesis. PROSPERO registration CRD42019141907. Data sources: Fourteen electronic databases (CINAHL, Cochrane, Embase, EThOS, Google, Medline, NDLTD, NHS Evidence, NICE, Open grey, Psychinfo, SCIE, SCOPUS and Web of Science) searched from inception to May 2024. Studies were included if they reported on the lived experiences of people dying with frailty, and used an explicit measure of frailty for their sample. Quality was appraised using the Saini and Schlonsky checklist. Results: Of 6,340 unique articles, 19 met inclusion criteria, describing the views of 138 people dying with frailty, 186 relatives /informal carers, and 240 professional caregivers. We identified three themes: ′Identifying with frailty and dying′, ′Emotional needs′, and ′Support with daily living′. There was wide variation in people′s understanding of frailty, and of their proximity to death. Emotional responses to physical symptoms often had a greater impact on lived experiences than the symptoms themselves. People frequently reported a desire to live in the present, with priorities focused more on living than dying. Conclusion: Approaches to palliative care for people dying with frailty should address emotional, as well as physical needs, and facilitate maintenance of existing daily routines. Ensuring that care planning accounts for individual understandings of frailty, and prognostic uncertainty may be particularly helpful. Keywords Frailty, palliative care, end-of-life care, lived experience, care needs, qualitative ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement DS and BKB were supported by NIHR School For Primary Care Research launching fellowships, EW was supported by Newcastle University institutional funding, BH is funded by the Applied Research Collaboration. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Background Patient and public involvement in research is required by many applied health research funding bodies. However, co-production, where patient/public contributors are involved in partnership at every stage of study design/conduct, is unusual; particularly with potentially ‘vulnerable’ and marginalised groups. Little evidence reports the practicalities or outcomes of such work. The aim of this study is to evaluate involvement of peer researchers (PRs) with lived experience of co-occurring alcohol and mental health problems in old age to co-produce qualitative research, and co-design new initiatives in health services to support this patient population. Methods Eight PRs with lived experience co-produced qualitative research (interviews, workshops) to inform intervention development. PRs informed project conception/design, co-facilitated interviews/workshops, and contributed to data interpretation and dissemination. Their involvement/contributions were evaluated via an impact log and realist evaluation. Results PRs identified a gap in patient care that meant they were left unsupported by existing care systems. They contributed to effective recruitment materials and pathways via their insights and networks, ensuring recruitment was successful. PRs supported collection of rich qualitative data by promoting participants’ openness through rapport developed by shared experiences; and probing interviewees in view of their own experiences to deepen understanding. During data analysis, PRs identified intricacies and themes within data that were not recognised by the academic research team. PRs identified unmet support needs from interview data; and potential initiatives to address these through their own experiences with recovery and related services. PRs contributed to impactful dissemination activities, augmenting study findings through their own experiences; particularly targeting practitioners and policymakers to inform changes in commissioning and practice. PRs’ personal networks, skill-sets, external roles (e.g. as peer support workers within alcohol/mental health services) and insights supported these activities. Proactive management of PRs’ mental health, digital exclusion and confidence issues were important; and required clear buddying/distress protocols, good working relationships, empathy, encouragement, training and resources (financial/technological) to ensure inclusion and effective involvement. PRs benefited from involvement; emphasising how their role contributed to recovery from their alcohol/mental health problems, and positive self-identity following their experiences of these stigmatising conditions; building confidence and a perception that they were actively contributing to society; as well as financial reimbursement to contribute to household finances. Discussion PRs’ involvement ensured the study addressed a gap in care for this marginalised patient group; successful conduct and rich data and analysis. Supporting PRs’ work in view of their support needs was central to effective involvement.

Background Children and young people (CYP) who have experienced statutory care are among the most disadvantaged in society and have higher prevalence of mental disorders than the general population. This has been linked to experience of significant childhood adversity including abuse and neglect. Despite indications of high levels of mental health and wellbeing needs in this group, there remains a paucity of empirical research exploring this issue. With an increased chance of experiencing a range of poor health outcomes, it is imperative that key factors for supporting positive development in this group are identified. The aim of this qualitative study was to identify risk and protective factors associated with mental health and wellbeing of care experienced CYP from the perspective of children’s social care and mental health practitioners. Methods We conducted four focus groups with 23 practitioners from four local authorities (the organisations responsible for the provision of public services within a geographical area) between April and May 2022. A semi-structured topic guide exploring the nature, risk and protective factors of mental health and emotional wellbeing was used. Social care and mental health practitioners were purposively sampled by profession so that the final sample included representation from children’s welfare service including early help, community safeguarding teams and those working with children in care/out of home placements. Data were thematically analysed following an iterative six-step analysis approach and informed by the four levels of the socio-ecological model (SEM). Results At the individual level, risk factors included the CYP’s emotional health and functioning and included what practitioners described as the sense of shame. Interpersonal level risk factors were the most recurrent risk highlighted during the discussions. They included interactions and influence of the CYP’S personal relationships and adversity within the home environment. At the community level, risk factors consisted of the characteristics of the settings and institutions that increased the risk of the CYP developing mental health and wellbeing difficulties, particularly the school setting. At the societal level, risk factors included broader societal factors like poverty and unemployment. Practitioners maintained that not all care experienced CYP developed mental health difficulties, particularly if they possessed or developed certain protective factors, for example secure attachments and supportive networks. Conclusion Our study provides evidence suggesting that risk factors for mental health and wellbeing in care experienced CYP operate on multiple, interconnected levels of the SEM. It is imperative that support interventions take this into account and strengthen protective factors like secure attachments and supportive networks when developing interventions for care experienced CYP.

How can we ensure that peer review is more courteous and constructive? Rahul Rao and Beth Bareham discuss

BACKGROUND:Risk of harm from drinking is heightened in later life, owing to age-related sensitivities to alcohol. Primary care services have a key role in supporting older people (aged ≥50 years) to make healthier decisions about alcohol.AIM:To examine primary care practitioners' perceptions of factors that promote and challenge their work to support older people in alcohol risk-reduction.DESIGN AND SETTING:Qualitative study consisting of semi-structured interviews and focus groups with primary care practitioners in Northern England.METHOD:Thirty-five practitioners (GPs, practice/district nurses, pharmacists, dentists, social care practitioners, and domiciliary carers) participated in eight interviews and five focus groups. Data were analysed thematically, applying principles of constant comparison.RESULTS:Practitioners highlighted particular sensitivities to discussing alcohol among older people, and reservations about older people's resistance to making changes in old age; given that drinking practices could be established, and promote socialisation and emotional wellbeing in later life. Age-related health issues increased older people's contact with practitioners, but management of older people's long-term conditions was prioritised over discussion of alcohol. Dedicated time to address alcohol in routine consultations with older people and training in alcohol intervention facilitated practitioners, particularly pharmacists and practice nurses.CONCLUSION:There are clear opportunities to support older people in primary care to make healthier decisions about alcohol. Dedicated time to address alcohol, training in identification of alcohol-related risks (particularly those associated with old age), and tailored interventions for older people, feasible to implement in practice settings, would help primary care practitioners to address older people's alcohol use.

BACKGROUND:Risk of harm from drinking increases with age as alcohol affects health conditions and medications that are common in later life. Different types of information and experiences affect older people's perceptions of alcohol's effects, which must be navigated when supporting healthier decisions on alcohol consumption.AIM:To explore how older people understand the effects of alcohol on their health; and how these perspectives are navigated in supportive discussions in primary care to promote healthier alcohol use.DESIGN AND SETTING:A qualitative study consisting of semi-structured interviews and focus groups with older, non-dependent drinkers and primary care practitioners in Northern England.METHOD:A total of 24 older adults aged ≥65 years and 35 primary care practitioners participated in interviews and focus groups. Data were analysed thematically, applying principles of constant comparison.RESULTS:Older adults were motivated to make changes to their alcohol use when they experienced symptoms, and if they felt that limiting consumption would enable them to maintain their quality of life. The results of alcohol-related screening were useful in providing insights into potential effects for individuals. Primary care practitioners motivated older people to make healthier decisions by highlighting individual risks of drinking, and potential gains of limiting intake.CONCLUSION:Later life is a time when older people may be open to making changes to their alcohol use, particularly when suggested by practitioners. Older people can struggle to recognise potential risks or perceive little gain in acting on perceived risks. Such perceptions may be challenging to navigate in supportive discussions.

Abstract Background alcohol may increase risks to late-life health, due to its impact on conditions or medication. Older adults must weigh up the potential risks of drinking against perceived benefits associated with positive roles of alcohol in their social lives. Health and social care workers are in a key position to support older people’s decisions about their alcohol use. Objective to systematically review and synthesise qualitative studies exploring health and social care providers’ views and experiences of older people’s drinking and its management in care services. Method a pre-specified search strategy was applied to five electronic databases from inception to June 2018. Grey literature, relevant journals, references and citations of included articles were searched. Two independent reviewers sifted and quality-appraised articles. Included study findings were analysed through thematic synthesis. Results 18 unique studies were included. Four themes explained findings: uncertainty about drinking as a legitimate concern in care provision for older people; the impact of preconceptions on work with older adults; sensitivity surrounding alcohol use in later life; and negotiating responsibility for older adults’ alcohol use. Discipline- and country-specific patterns are highlighted. Conclusions reservations about addressing alcohol could mean that service providers do not intervene with older adults. Judgements of whether older care recipients’ drinking warrants intervention are complex. Providers will need support and training to recognise and provide appropriate intervention for drinking amongst older care recipients.

Background alcohol presents risks to the health of older adults at levels that may have been safer' earlier in life. Moderate drinking is associated with some health benefits, and can play a positive role in older people's social lives. To support healthy ageing, we must understand older people's views with regards to their drinking. This study aims to synthesise qualitative evidence exploring the perceptions and experiences of alcohol use by adults aged 50 years and over.Methods a pre-specified search strategy was applied to Medline, PsychINFO, Scopus, Applied Social Sciences Index and Abstracts and Cumulative Index to Nursing and Allied Health Literature databases from starting dates. Grey literature, relevant journals, references and citations of included articles were searched. Two independent reviewers sifted articles and assessed study quality. Principles of thematic analysis were applied to synthesise the findings from included studies.Results of 2,056 unique articles identified, 25 articles met inclusion criteria. Four themes explained study findings: routines and rituals of older people's drinking; self-image as a responsible drinker; perceptions of alcohol and the ageing body; and older people's access to alcohol. Differences between gender, countries and social patterns are highlighted.Conclusions older people perceive themselves as controlled and responsible drinkers. They may not recognise risks associated with alcohol, but appreciate its role in sustaining social and leisure activities important to health and well-being in later life. These are important considerations for intervention development. Drinking is routinised across the life course and may be difficult to change in retirement.

Abstract Background alcohol presents risks to the health of older adults at levels that may have been ‘safer’ earlier in life. Moderate drinking is associated with some health benefits, and can play a positive role in older people’s social lives. To support healthy ageing, we must understand older people’s views with regards to their drinking. This study aims to synthesise qualitative evidence exploring the perceptions and experiences of alcohol use by adults aged 50 years and over. Methods a pre-specified search strategy was applied to Medline, PsychINFO, Scopus, Applied Social Sciences Index and Abstracts and Cumulative Index to Nursing and Allied Health Literature databases from starting dates. Grey literature, relevant journals, references and citations of included articles were searched. Two independent reviewers sifted articles and assessed study quality. Principles of thematic analysis were applied to synthesise the findings from included studies. Results of 2,056 unique articles identified, 25 articles met inclusion criteria. Four themes explained study findings: routines and rituals of older people’s drinking; self-image as a responsible drinker; perceptions of alcohol and the ageing body; and older people’s access to alcohol. Differences between gender, countries and social patterns are highlighted. Conclusions older people perceive themselves as controlled and responsible drinkers. They may not recognise risks associated with alcohol, but appreciate its role in sustaining social and leisure activities important to health and well-being in later life. These are important considerations for intervention development. Drinking is routinised across the life course and may be difficult to change in retirement.

The number of older people drinking alcohol is increasing as the population ages. Risks of harm from drinking increase with age as alcohol effects health conditions and medications that are common in later life. Drinking can play a central role in older people’s social and leisure lives. Older people must negotiate perceived risks against benefits of drinking in determining their alcohol use, and other external factors may influence their drinking practices. Care providers are expected to support older people in making informed decisions around their drinking. This paper aims to explore older adults’ and their care providers’ perspectives of factors influencing alcohol use in later life and how these are determined. Twenty-four older adults and 35 care providers across the North of England took part in semi-structured interviews and focus groups. Data were analysed thematically, applying principles of constant comparison. Older people’s drinking routines developed across the life course and in response to late-life transitions. Alcohol was perceived as an earned and accessible pleasure, contributing to quality of life, which older people prioritised over longevity. Risks of future consequences were perceived as less tangible than symptoms or problems. Normalisation and moral positioning served to justify older people’s drinking practices. Risks attached to late-life drinking may be overlooked by older people and their care providers. Structured assessment of older people’s drinking could help identify undetected risks in older people’s alcohol use. Social, routine and moralistic justifications for risky alcohol use must be challenged to address risky drinking amongst older people.

Older adults may be at risk from even moderate levels of drinking, due to conditions and medications that are problematic when combined with alcohol. Current cohorts of older adults may have consumed alcohol regularly through most of their adult life. This represents additional risk of chronic disease linked to their drinking. Alcohol policy and practice has therefore turned to focus on this older group. However, in combatting alcohol use amongst older adults, we must first consider the roles of alcohol in their lives. This recently completed systematic review synthesises qualitative research evidence on older adults’ perceptions of non-dependent drinking in later life. Medline, PsychINFO, Scopus, ASSIA and CINAHL databases were systematically searched for relevant articles. The principles of thematic analysis were applied to synthesise findings. Twenty-four studies were identified from ten different countries, including the USA, Canada and the UK. Four key themes were: i) Routines and Rituals, ii) Self-image as a Responsible Drinker, iii) Alcohol and the Ageing Body, iv) Access to Alcohol. Differences in roles and patterns of drinking between genders and age groups, across cultures and socioeconomic status, are explored. Drinking creates social and leisure opportunities, which may have depleted due to retirement and other factors in later life. Health concerns and issues surrounding purchasing alcohol or getting to drinking settings are important considerations for older drinkers. These roles and practicalities are contrasted against those identified for younger age groups in other qualitative studies. Recommendations for alcohol-related policy and practice are presented given these findings.