ObjectivesIntegrated neighbourhood teams (INTs) are central to health system reforms in England, aiming to deliver local, coordinated, and personalised care. Understanding the factors that influence their successful functioning is crucial for informing local policy and practice. This rapid evidence synthesis aimed to answer the research question: What factors influence service integration and delivery by INTs operating across health, care, and voluntary sector organisations?MethodsIn February 2025, we searched Medline and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for relevant UK-based primary research and international evidence syntheses published within the last 10 years. The database searches were complemented by searches in Google Scholar and the Google search engine. Eligible studies reported evidence on factors shaping the successful functioning of local and neighbourhood-level integrated teams. Data were rapidly synthesised qualitatively.ResultsDatabase searches identified 5139 articles (4954 after duplicates were removed). Of these, 26 were eligible for inclusion, comprising nine primary studies and 17 evidence syntheses published between 2015 and 2025. The findings were highly consistent. Key factors supporting INT functioning included a clear, shared vision; effective leadership; strong working relationships based on trust and mutual respect; clarity on interprofessional roles and responsibilities; appropriate and sustained resources and funding; opportunities for staff learning and development; co-location, dedicated time for multidisciplinary team meetings; and interoperable information technology systems to support data sharing.ConclusionsThere is strong agreement on key relational and organisational factors that support INT functioning. Our practical framework can be used to support policymakers, commissioners, and professionals when planning and implementing INTs.

Abstract Background In response to the global prevalence and societal impact of mental health problems, innovative healthcare policies have improved access to psychological therapy interventions. Yet, the indirect effects of these access policies on labour force participation gaps related to mental health problems remain unclear. This study assessed the relationship between one of the first major policies to improve access to psychological therapies, the NHS Talking Therapies service, and the economic activity of individuals with long-term mental health problems. Methods In this retrospective observational study, we derived a national sample of the English working-age population from Annual Population Survey data for the period 2015–2020 (N = 535068). Data included information on economic activity and health status, but not the use of healthcare services. The outcome of the study was labour force participation. The volume of appointments per referral received by NHS Talking Therapies services across healthcare commissioning regions in England was used to measure the regional supply of psychological therapy interventions. We used linear regression models, adjusting for a comprehensive set of individual and area-level controls, to estimate the association between the regional supply of psychological therapy interventions and labour force participation for those with and without a long-term mental health problem at the population level. Results We find a labour force participation gap of 36% between individuals reporting long-term mental health problems and otherwise similar individuals with no reported mental health problems. Holding all else equal, we find an increase in the regional supply of NHS Talking Therapies of one appointment per referral is associated with a 0·92 percentage point (CI: 0·0018 − 0·0165) reduction in the probability of labour force participation gap. Results of sub-sample analyses suggest this association was driven by individuals who were not claiming benefits, aged between 45 and 65, and reported male gender. Conclusions Policymakers should consider the indirect effects of policies that improve access to psychological therapy interventions as a potential moderator of the labour force participation gap related to long-term mental health problems.

Objectives People with type 1 diabetes may be at increased risk of disordered eating, which may increase risk of elevated poor outcomes and high-risk complications. Type 1 diabetes disordered eating (T1DE) services were set-up to integrate diabetes and mental healthcare to better support people with T1DE and improve longer-term outcomes. A rapid evaluation was conducted to explore the implementation of T1DE services. Specifically, we aimed to: describe service delivery models; investigate staff experiences of impact and delivery of implementation; explore patient experiences of T1DE services; and to report health outcomes and associated costs.Design Rapid evaluation using mixed methods (service mapping, staff and patient interviews, staff survey, analysis of clinical and economic data). Health outcome data was reported at baseline and 6 months.Setting This study explored the implementation of five new T1DE services and three existing services.Participants Staff working within T1DE services and patients who received care from T1DE services.Results Assessment of our mixed methods study identified four key findings: (1) T1DE delivery models: The T1DE services displayed modest variation in models of delivery, but similarities were more evident, with a focus on direct delivery to patients involving joint meetings between diabetes and mental health staff. Nevertheless, some services also took on a ‘consultation’ role, providing advice and support to wider staff outside the service also managing these patients. Delayed implementation of the services slowed the formation of fully integrated teams and the ability of services to operate at scale. (2) Staff experience: Workforce issues were a crucial aspect of T1DE pilots. Managing this patient population is associated with high levels of anxiety for staff. Nevertheless, once formed, staff reported a very positive experience of working in integrated teams. (3) Patient experience: Although only a small sample of patients were interviewed, they reported a profoundly different experience to their previous care, which was now perceived as supportive and relationship focused. Although such improvements were aligned with the integrated care model underlying T1DE, it was less clear how such changes in patient experience would feature in decisions about commissioning. (4) Health outcomes and associated costs: There were 139 patients accepted onto the care pathway. Improvements were seen for all health outcomes. Compared with baseline measures, there was a mean 0.97% reduction in HbA1c (glycated haemoglobin) from 11.2% to 10.2% at 6 months. Improvements were also seen in other outcomes, including the diabetes eating problem scale and the diabetes distress scale. However, the number of patients on the care pathway with follow-up at 6 months was relatively small (n=29–47) and definitive statements about clinical or cost-effectiveness were not possible.Conclusions Overall, T1DE services were well received by both staff and patients. Due to a number of logistical challenges, the implementation of services was slower than anticipated, resulting in a limited number of patients on the care pathway. Securing local funding for existing services, once national pilot funding ended, was identified as a significant challenge. In order to ensure services are sustainable and commissioned at a local level, consideration may need to be given to alternative service delivery models.

Background Community resilience is a relevant concept in public health, but its empirical relationship with health outcomes remains underexplored. This study examines whether a Community Resilience Index (CRI) is associated with population health outcomes in England, and whether it offers explanatory added value beyond the Index of Multiple Deprivation (IMD).Methods The CRI comprises 44 indicators reflecting community-level resilience to chronic stressors. Associations between CRI scores and five health outcomes, deaths of despair, cardiovascular disease (CVD) mortality, COVID-19 mortality, excess all-cause mortality during two waves of COVID-19 and self-rated health were assessed at local authority district level. IMD was adjusted to remove health-related indicators. Linear regression models assessed the explanatory power of the CRI and IMD, using likelihood ratio tests to compare model fit. Interaction and stratified analyses explored effect modification by IMD.Results Higher CRI scores were associated with lower Deaths of Despair and CVD mortality, and higher self-rated health; these associations remained significant after adjusting for IMD. CRI was not significantly associated with COVID-19 outcomes. IMD remained the stronger predictor of health outcomes, but CRI significantly improved model fit. The interaction between CRI and IMD was significant for deaths of despair and self-rated health. Stratified analyses showed the CRI-deaths of despair association was strongest in more deprived areas.Conclusions Community resilience is associated with health outcomes in England. While not a substitute for deprivation-based measures, resilience indices offer complementary insight into structural and social factors shaping health. Resilience-building efforts may be particularly impactful in areas of greatest disadvantage.

Background Primary care is widely recognised as essential for the prevention and management of chronic conditions and has been a major focus of China’s health system reform. However, evidence on its effects remains mixed. This study examined whether primary care visits was associated with preventing the development of additional chronic conditions that are considered preventable or manageable in primary care, and with reducing hospital outpatient and inpatient care utilisation among people already living with these conditions. Methods We used data on 11,425 individuals across four survey waves between 2011 and 2018 from the China Health and Retirement Longitudinal Study. We estimated the effects of primary care visits using the individual fixed-effect model with inverse-probability-of-treatment weighting to account for selection bias. Results An additional primary care visit was associated with a lower number of additional chronic conditions acquired in the following wave (-0.011, 95% CI: -0.017 to -0.004). This association was stronger among urban residents (-0.016, 95% CI: -0.027 to -0.005), respondents with at least primary school education (-0.014, 95% CI: -0.024 to -0.003), and those with a single chronic condition (-0.018, 95% CI: -0.034 to -0.002). By contrast, among individuals with at least one such chronic condition, primary care visits were not significantly associated with hospital outpatient visits (-0.010, 95% CI: -0.029 to 0.009) or inpatient admissions (0.010, 95% CI: -0.020 to 0.040). Conclusion In China, among adults aged 45 years and older, greater primary care use may help prevent the development of additional chronic conditions, but it does not appear to reduce short-term hospital use among people with existing conditions. Primary care strengthening may therefore contribute more to long-term chronic disease prevention than to immediate reductions in hospital utilisation. Further reforms should focus not only on increasing use, but also on improving the quality and targeting of primary care.

Background To drive improvements in health care quality and to reduce inequalities, pay-for-performance (P4P) schemes have become widespread internationally. In recent years, most local commissioning bodies in the United Kingdom (UK) have developed their own local general practice incentive schemes. Aim To examine the use and effectiveness of local incentive schemes and their alignment to the national Quality and Outcomes Framework (QOF). Design and Setting This was a systematic review of qualitative studies related to local incentive schemes with a P4P structure within UK general practice in the UK after 2004. Methods Searches were conducted via OVID across the Embase and MEDLINE databases. Risk of bias was assessed using the EPOC criteria and a narrative synthesis was undertaken. Results 17 studies were identified focused on 14 local incentive schemes. All studies were from England, except one from Scotland. 5 studies included only tailored indicators, and 7 studies included both aligned and tailored indicators. Quality assessment suggested the current evidence was of mixed quality. All studies demonstrated positive impacts on process measures but health outcome measures were only evaluated in 9 studies showing inconsistent findings. 8 studies addressed impact on health inequalities and no studies addressed cost-effectiveness, patient reported outcomes or experience measures. Conclusion There is an emerging evidence base that local incentive schemes in general practice lead to improvements in process measures, although methodological quality of studies is mixed. Future studies should utilise more robust methods to evaluate effectiveness and examine impacts on health inequalities, cost-effectiveness and variation by practice.

Background: Falls are the primary cause of fatal and nonfatal accidental injuries in older adults. The World Falls Prevention Guidelines recommend balance-challenging, functional exercise programs as a key strategy for falls prevention, but access, uptake, and adherence to these programs in community settings remain suboptimal. Keep-On-Keep-Up (KOKU), a digital, National Health Service-approved program, was codeveloped with older adults and therapists to provide progressive, evidence-based exercises and to raise awareness of falls prevention strategies. Objective: This trial aims to investigate the effectiveness and cost-effectiveness of the KOKU digital strength and balance program for improving balance, enhancing physical function, and reducing falls risk among community-dwelling older adults. Methods: This is a 2-arm, parallel-group randomized controlled trial. A total of 196 community-dwelling older adults 60 years and older will be randomized to either the intervention group, comprising a digital strength and balance program (KOKU) alongside standard care (strength and balance exercise advice and a falls prevention leaflet), or to a control group, receiving standard care only. Participants receiving the intervention will be asked to exercise 3 times per week following the tailored and progressive program. Randomization will take place after recruitment and baseline data collection. The trial's primary outcome measure is balance function (Berg Balance Score) at 12 weeks post randomization. Secondary trial outcomes include lower limb strength, health care utilization and health-related quality of life, self-reported concerns about falling, self-reported physical activity, falls risk, pain, mood, fatigue, self-reported falls, and acceptability and usability of the KOKU program. Intention-to-treat analysis and a cost-effectiveness analysis will be employed for trial data analysis. Qualitative interviews and focus groups will be undertaken with around 10 care providers and 13 participants to further understand views of the intervention and trial processes. Results: This study began recruitment in July 2024 and concluded in March 2025, recruiting a total of 202 participants (102 intervention group and 100 control group). Following protocol publication, data compilation and analysis will be conducted, with results anticipated to be published in 2027. Conclusions: This trial will provide important evidence on whether a digital strength and balance program can improve balance and related outcomes in older adults compared with usual care.

AIMS:The NHS Diabetes Prevention Programme (DPP) is a behaviour-change programme aimed at adults diagnosed with non-diabetic hyperglycaemia (NDH), who are at higher risk of developing type 2 diabetes mellitus (Diabetes). This paper explores the heterogeneity in the effectiveness of the DPP by age, sex, BMI, and practice location deprivation (IMD). METHODS:Matched cohort analysis with random-effects parametric survival models, evaluating the association between referral to the DPP and conversion to diabetes, with interactions fitted for age, sex, BMI, and IMD. RESULTS:18,470 patients referred to the programme were matched to 51,331 controls. None of the interactions of patient characteristics with referrals were statistically significant. For women, the difference in the HR of conversion to diabetes, compared to men, was HR = 0.94 (95% CI: 0.81, 1.08, p = 0.38); For those aged [18-34], HR = 0.79 (95% CI: 0.34, 1.84, p = 0.58) and aged [75-84] HR = 0.86 (95% CI:0.66, 1.12, p = 0.26) compared to those aged [55-64]. The HR for conversion was 0.88 (95% CI:0.62, 1.26, p = 0.49) for those with a BMI ≥ (25-29.9) kg/m2 and HR = 0.76 (95% CI:0.54, 1.06, p = 0.10) in those with a BMI ≥ 30 kg/m2 compared to BMI < 25 kg/m2. Finally, for the most deprived IMD quintile, compared to the least deprived, the difference in the conversion was HR = 1.31 (95% CI: 0.98, 1.73, p = 0.06). CONCLUSIONS:The DPP was effective in reducing conversion rates from NDH to diabetes as shown in our previous study results. The intervention appeared to be similarly effective by age, sex, BMI, and deprivation.

Background:Variation in the way information about potential trial intervention benefits and harms is conveyed within patient information leaflets can cause avoidable information-induced ('nocebo') harm, research waste, and may be unethical. Objectives:1. To develop stakeholder-informed principles to guide how to describe information about potential trial intervention benefits and harms within patient information leaflets. 2. To test whether using these principles are feasible for testing in trials that measure whether they improve recruitment and adverse event rates. 3. To develop and disseminate guidance on how to implement the principles. Methods:We used a mixed methodology consisting of three work packages. Work package 1 involved a modified Delphi survey and consensus meeting to develop the principles for harmonising the way information regarding potential benefits and harms are shared. Work package 2 involved testing whether the principles could be used to transform existing patient information leaflets by recruiting host trials to compare standard patient information leaflets with patient information leaflets developed using the principles 'principled patient information leaflets'. We also set up an infrastructure to test whether they could reduce variation, impact trial recruitment and reduce reported adverse events. Work package 3 involved developing and disseminating guidance for using the principles. Results:For work package 1, 250 participants completed the Delphi survey and 7 principles were agreed upon: (1) all potential intervention harms should be listed, (2) potential harms should be separated into 'serious' and 'less serious', (3) if not all potential harms are known, this needs to be explicitly stated, (4) all potential benefits should be listed, (5) potential benefits and harms associated with trial participation need to be compared with those associated with non-participation, (6) suitable visual representations should be added where appropriate, and (7) information about potential benefits and harms should not be separated by more than one page. For work package 2, we developed principled patient information leaflets for five host trials and interviewed two members of each host trial team. Two host trials agreed to compare the patient information leaflets with principled patient information leaflets using Studies Within a Trial, and we published a protocol for a meta-analysis that will synthesise the results. For work package 3, 25 participants attended a hybrid workshop and recommended that researchers and Research Ethics Committee members should use the principles to design and evaluate patient information leaflets. We produced a guidance booklet and website, which are currently being used by some Health Research Authority Research Ethics Committees. Conclusions:A strong consensus was reached regarding seven principles that can harmonise the way information about the potential benefits and harms of trial interventions is shared. The principles are likely to reduce research waste and avoidable information-induced harm, and may enhance clinical trial ethics. Limitations:Due to COVID-19, the National Institute for Health and Care Research review of ongoing trials that resulted in funding termination for several trials, and highly pressured trial staff with limited capacity to add Studies Within a Trial to their trials, we had to modify our second objective. Whereas we initially intended to actually conduct the Studies Within a Trial, we replaced this with: a protocol for a meta-analysis of Studies Within a Trial, additional research on the need to reduce variation, additional dissemination work, and a paper on the ethical requirement to mention potential benefits and harms of trial interventions in patient information leaflets. Future work:Future work could apply these results to explore how to harmonise the way potential benefits and harms are shared during verbal conversations between researchers and patients during the informed consent process. Funding:This award was funded by the Medical Research Council and the National Institute for Health and Care Research (NIHR) Better Methods, Better Research programme (MRC Award Reference: MR/V020706/1) and is published in full in Health Technology Assessment; Vol. 29, No. 43.

BACKGROUND: Improving communication between NHS primary and secondary care services should reduce inefficiencies, improve patient care, and provide a source of accurate data for audit and research. Using general practice (primary care) and adult hearing aid services (secondary care) as examples, this study aimed to investigate the: (i) information primary care want from secondary care services during referral processes and what information secondary care can provide, (ii) barriers and facilitators for coding and providing this information, and (iii) targets for interventions to improve communication. METHODS: Qualitative interview study. Twenty-nine semi-structured interviews were conducted with primary and secondary care staff in North West England, informed by the capabilities, opportunities, and motivations model of behaviour change (COM-B). A thematic analysis with findings mapped to the Theoretical Domains Framework (TDF) was used to identify barriers and facilitators to the recording and communication of hearing health information, as well as behavioural determinants to target in future interventions. RESULTS: Four key TDF domains were identified as potential determinants to target for future interventions: (1) time and resources (e.g., environmental context and resources) are stretched across the two sectors; (2) fatigue, tiredness, and cognitive overload affecting workflow (e.g., memory, attention, and decision processes), particularly adult hearing aid service administration; (3) adult hearing aid services are unaware if their letters are read by general practice, or if the level of information they send is appropriate (e.g., knowledge); and (4) difficulties communicating with general practice and a lack of feedback is causing reduced motivation from adult hearing aid services to make direct contact (e.g., beliefs about consequences). CONCLUSIONS: This study identified four theoretically-derived variables that are barriers to communication and record sharing, and highlights how these can be translated into potential interventions (e.g., simplified coding). Further work is required to test interventions developed using behaviour change theory.

An increasing number of people live with chronic disease or multi-morbidity. Current consensus is that their care requires an integrated model bringing different professionals together to provide person-centred care. Although primary care has a central role in managing chronic disease, and integration may be important in strengthening this role, previous research has shown insufficient attention to the relationships between primary care and integration. This review summarizes primary care involvement in integrated care interventions and assesses the effect of those interventions on a range of measures of primary care functions and wider outcomes. We searched Medline and Embase using terms for “integrated care”, “chronic disease” and “multimorbidity”. We included integrated care interventions involving different levels of care organizations or different care sectors. Risk of bias was appraised, and the contents of integrated care interventions assessed using the Sustainable intEgrated care modeLs for multi-morbidity: delivery, FInancing and performancE (SELFIE) conceptual framework. Effectiveness of integrated care interventions was assessed using meta-analysis of primary care functions (access, continuity, comprehensiveness and coordination) and wider outcomes (patient health and mortality, hospital admissions and costs). Sub-group analyses were conducted for different types of primary care involvement. From 17,752 studies screened, 119 studies on integrated care were identified, of which 69 interventions (58

BackgroundPeople of Black African and Black Caribbean ethnicity experience higher rates and poorer outcomes of type 2 diabetes (T2D) than people of White European ethnicity; these inequalities are compounded by poor healthcare access. Cultural tailoring of diabetes self-management education and support (DSMES) programs has the potential to improve healthcare engagement and clinical outcomes for ethnic minority groups. Healthy Eating & Active Lifestyles for Diabetes (HEAL-D) is a co-designed, culturally tailored group-based DSMES program for adults of Black African and Black Caribbean ethnicity. ObjectiveThis trial aims to evaluate the clinical and cost effectiveness of the HEAL-D intervention, compared to standard DSMES programs, in Black African and Black Caribbean adults living with T2D. MethodsA 24-month, multicenter, pragmatic, open-label, 2-arm, parallel-group, individually randomized group treatment trial will be conducted, with primary end point (glycated hemoglobin [HbA1c]) assessment at 12 months. Black African and Black Caribbean adults with T2D (n=300), recruited from 3 to 5 centers in the United Kingdom (including London, West Midlands, and Greater Manchester), will be randomized in a 1:1 ratio to HEAL-D (intervention) or a standard DSMES program (control). HbA1c, blood lipids, anthropometric outcomes, blood pressure, physical activity, and patient-reported outcome measures relating to psychological well-being and self-management support, lifestyle behaviors, and health economics will be collected at baseline and follow-up visits (6, 12, and 24 months). Cost-effectiveness will be assessed through a cost-utility analysis conducted from a health and social care perspective. A mixed methods process evaluation will provide a formative evaluation of delivery, intervention fidelity, and implementation of HEAL-D, and an embedded study within a project will assess the impact of multiple long-term conditions on uptake of, and engagement with HEAL-D, and the impact of HEAL-D on multiple long-term conditions. The trial received Research Authority and Research Ethics Council approval on April 22, 2024. ResultsFunding began in August 2023. Site “green light” was received on August 15, 2024, for London; November 29, 2024, for Manchester; and January 31, 2025, for the West Midlands. Recruitment commenced in August 2024 and is due to run for 11 months. As of March 26, 2025, a total of 76 participants have consented. Last patient, last visit is expected in June 2027; primary data analysis is expected to begin in July 2027. Final results are anticipated to be available in September 2027, and publication is expected by the end of 2027. ConclusionsThe HEAL-D trial will address whether a culturally tailored DSMES program, provided in-person or via videoconferencing, is clinically and cost-effective compared to standard DSMES at improving diabetes management in Black African and Black Caribbean adults. If effective, this would provide an evidence-based model of equitable DSMES services and improve the implementation of healthcare programs for ethnic minority groups. Trial RegistrationISRCTN 1434448; https://www.isrctn.com/ISRCTN14344948 International Registered Report Identifier (IRRID)DERR1-10.2196/71861

Efficient, equitable health research depends on understanding why people decide to take part. The aims of this overview were to update the version published in 2020, identifying psychosocial influences on participation and mapping them to recruitment research and psychological theory. Searches were undertaken in February 2024. Qualitative, quantitative, and mixed-methods systematic reviews were identified, without language or date limits. Methodological quality was rated using AMSTAR-2, and low-quality reviews were excluded. Barriers and facilitators were identified inductively and mapped to the Theoretical Domains Framework (TDF) and COM-B model, and to empirical recruitment research. The update included 70 reviews, including 44 new reviews, covering a breadth of populations and settings, and drawing on 1940 primary studies (1428 unique). We identified 15 facilitators, most commonly: altruism, potential for personal benefit and trust. Incentives and convenient, low-burden research were also facilitators. Another 10 facilitators were new to this update. There were 16 barriers, most commonly: perceived risk, practical difficulties, and distrust of researchers. Many barriers applied to specific designs, particularly randomised trials. Factors that were barriers or facilitators include the influence of others and information quality. Barriers and facilitators were coded to the Motivation and Opportunity components of the TDF, particularly knowledge and social influences; only two factors were coded to a Capability. Psychosocial influences and empirical recruitment research had some overlap, but some barriers and facilitators had not been evaluated. Common barriers and facilitators to research participation were identified, some new to this update, which could be addressed through targeted recruitment strategies to increase the efficiency and generalisability of primary research. Factors affecting participation are not only personal; they are also normative and social. The priorities are to change the ways we recruit to research (perhaps tested in SWATs) and identify barriers and facilitators in areas not well covered in current research. PROSPERO CRD42017062738. Registered on April 2017.

People of black African and black Caribbean ethnicity experience higher rates and poorer outcomes of type 2 diabetes (T2D) than people of white European ethnicity; these inequalities are compounded by poor healthcare access. Cultural tailoring of diabetes self-management education and support (DSMES) programmes has the potential to improve healthcare engagement and clinical outcomes for minority ethnic groups. Healthy Eating & Active Lifestyles for Diabetes (HEAL-D) is a co-designed culturally tailored DSMES programme for adults of black African and black Caribbean ethnicity. HEAL-D provides group-based education, behaviour change support and participatory physical activity sessions, delivered either face-to-face (F2F) or online. Initial assessments of HEAL-D have demonstrated patient acceptability, but the clinical and cost effectiveness of HEAL-D have yet to be examined. To evaluate the effectiveness of the HEAL-D intervention, compared to standard DSMES programmes, on glycaemic control (assessed via HbA1c) at 12-months in black African and black Caribbean adults living with T2D. A 24-month, multi-centre, open-label, 2-arm, parallel-group, individually randomised group treatment trial will be conducted, with primary endpoint (HbA1c) assessment at 12-months. Black African and black Caribbean adults with T2D (n=300), recruited from 3-5 centres in the UK (including London, West Midlands and Greater Manchester), will be randomised in a 1:1 ratio to HEAL-D (intervention) or a standard DSMES programme (control). Baseline and follow-up visits (6, 12 and 24-months) will involve collection/measurement of HbA1c, blood lipids, anthropometric outcomes, blood pressure, physical activity, and patient reported outcome measures relating to psychological wellbeing and self-management support, lifestyle behaviours, and health economics. An internal feasibility assessment of recruitment, allocation and treatment engagement will occur in the first 6 months. Cost-effectiveness will be assessed through a cost-utility analysis conducted from a health and social care perspective. A mixed methods process evaluation will provide a formative evaluation of delivery, intervention fidelity and implementation of HEAL-D, and an embedded study within a project (SWAP) will assess the impact of multiple long-term conditions (MLTC) on uptake of HEAL-D, engagement with HEAL-D, and the impact of HEAL-D on MLTC. The trial received Health Research Authority approval on 22 April 2024. Site ‘green light’ was received on 15 August 2024 for London and 29 November 2024 for Manchester; approvals in the West Midlands are expected January 2025. Recruitment commenced in August 2024 and is due to complete by May 2025. As of 28 January 2025, 36 participants have consented. Last patient, last visit is expected in June 2027; final results are anticipated to be available in September 2027, and publication is expected by the end of 2027. The HEAL-D trial will address whether a culturally tailored DSMES programme, provided in-person or online, is clinically and cost-effective compared to standard DSMES at improving diabetes management in black African and black Caribbean adults. If effective, this would provide an evidence-based model of equitable DSMES services and improve the implementation of healthcare programmes for minority ethnic groups. ISCRTN 45319 (24/05/2024).

Abstract Background We sought to assess the feasibility of a stepped-wedge cluster-randomised trial testing the effectiveness of a complex mHealth intervention called REMORA: a co-designed smartphone app enabling daily, weekly and monthly symptom tracking integrated into electronic health records for people with rheumatoid arthritis (RA). Methods We conducted a mixed-methods feasibility trial using a convergent approach with some explanatory sequential elements. Patients were eligible to take part if they were older than ≥18 years of age, had (suspected) RA or undifferentiated inflammatory arthritis, and consented to take part from two outpatient departments. We analysed quantitative app and electronic health record data descriptively. We analysed qualitative data from interviews and clinic observations thematically. We assessed four feasibility domains: recruitment and consent (target: 15 patients per site), intervention uptake (≥70% of recruited participants completed on-boarding, i.e., registered with the app and submitted at least one symptom report), intervention adherence (>50% daily symptom reports provided), and measuring disease activity as the primary outcome (scores available for ≥80% of people with a follow-up clinic visit). Due to time constraints, we only recruited patients to the intervention group, leaving us unable to test the logistics of randomising sites in accordance with the trial’s cluster stepped wedge design. Results Of 130 people screened, 52 consented. Of those, 32 (62%) completed on-boarding. On-boarded participants provided symptom data on 2384/3771 (63%) of possible days. Among the 48 people who had ≥1 follow-up appointment, at least one disease activity scored was obtained for 46 (96%) of them. Factors related to intervention uptake formed the biggest threat to trial feasibility, including lack of clarity of communication and guidance, access to technology, and personal challenges (e.g., being busy or unwell). Conclusion We found that delivering a trial to test the effectiveness of integrated symptom tracking in rheumatology outpatient settings was feasible. The future REMORA trial will contribute to the much-needed evidence base for the impact of integrated symptom tracking on care delivery and patient outcomes, including decision-making, patient experience, disease activity, and symptom burden. Trial registration This feasibility trial was registered at https://www.isrctn.com/ on 23-Jan-2023 (ISRCTN21226438).

BACKGROUND:Deaf people who use a signed language experience poorer physical and mental health outcomes and inequalities in access and delivery of health services. OBJECTIVES:A scoping review was conducted to identify and synthesise current knowledge on the perspectives of Deaf people and their experience of healthcare. SEARCH STRATEGY:Databases PsycINFO, PubMed, Web of Science, and CINAHL were used for this review. INCLUSION CRITERIA:Any studies internationally of any design that involve Deaf signing populations that reported on patient experience within healthcare settings from a Deaf perspective were included in the review. DATA EXTRACTION AND SYNTHESIS:The abstract, title, and initial screening was followed by full text screening completed by two screeners independently. The extracted data included descriptive data and study findings. The Crowe Critical Appraisal Tool (CCAT) was applied, and findings were summarised using narrative synthesis. MAIN RESULTS:Across the 51 included papers, problems with language, communication and interaction featured prominently. Failure to meet Deaf people's needs has adverse impacts; examples of these include negative emotional state, disempowerment through lack of knowledge, and lack of confidence in healthcare systems. DISCUSSION AND CONCLUSIONS:The review uniquely focused on data generated from Deaf people regarding their experience, rather than third party commentary. It confirmed a less than optimal Deaf patient experience, clinical impacts of poor experience, and negative patient and healthcare systems outcomes. This supports the case for a reliable and valid measure in a signed language to capture Deaf patients' experience in healthcare.

This article consists of a citation of a published article describing research funded by the Health and Social Care Delivery Research programme under project number 16/48/07, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1186/s12913-023-09195-z The prevention of type 2 diabetes (T2DM) is a major concern for health services around the world. The English NHS Diabetes Prevention Programme (NHS-DPP) offers a group face-to-face behaviour change intervention, based around exercise and diet, to adults with non-diabetic hyperglycaemia (NDH), referred from primary care. Previous analysis of the first 100,000 referrals revealed just over half of those referred to the NHS-DPP took up a place. This study aimed to identify the demographic, health and psychosocial factors associated with NHS-DPP uptake to help inform the development of interventions to improve uptake and address inequities between population groups. Drawing on the Behavioral Model of Health Services Utilization we developed a survey questionnaire to collect data on a wide range of demographic, health and psychosocial factors that might influence uptake of the NHS-DPP. We distributed this questionnaire to a cross-sectional random sample of 597 patients referred to the NHS-DPP across 17 general practices, chosen for variation. Multivariable regression analysis was used to identify factors associated with NHS-DPP uptake. 325 out of 597 questionnaires were completed (54%). Only a third of responders took up the offer of a place. The best performing model for uptake (AUC=0.78) consisted of four factors: older age; beliefs concerning personal vulnerability to T2DM; self-efficacy for reducing T2DM risk; and the efficacy of the NHS-DPP. After accounting for these, demographic and health-related factors played only a minor role. Unlike fixed demographic characteristics, psychosocial perceptions may be amenable to change. NHS-DPP uptake rates may be improved by targeting the beliefs of patients about their risk of developing T2DM, their ability to carry out and sustain behaviours to reduce this risk, and the efficacy of the NHS-DPP in providing the necessary understanding and skills required. The recently introduced digital version of the NHS DPP could help address the even lower uptake amongst younger adults. Such changes could facilitate proportional access from across different demographic strata. This publication was funded by the Health and Social Care Delivery Research programme as a part of award number 16/48/07. https://doi.org/10.1186/s12913-023-09195-z This article reports on one component of the research award Evaluating the NHS Diabetes Prevention Programme (NHS DPP): the DIPLOMA research programme (Diabetes Prevention Long term Multimethod Assessment). For more information about this research please view the award page https://fundingawards.nihr.ac.uk/award/16/48/07

This article consists of a citation of a published article describing research funded by the Health and Social Care Delivery Research programme under project number 16/48/07, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1186/s12913-023-10002-y The National Health Service Diabetes Prevention Programme (NHS DPP) was commissioned by NHS England in 2016 and rolled out in three ‘waves’ across the whole of England. It aims to help people with raised blood glucose levels reduce their risk of developing type 2 diabetes through behaviour change techniques (e.g., weight loss, dietary changes and exercise). An independent, longitudinal, mixed methods evaluation of the NHS DPP was undertaken. We report the findings from the implementation work package: a qualitative interview study with designated local leads, responsible for the local commissioning and implementation of the programme. The aim of the study was to explore how local implementation processes were enacted and adapted over time. We conducted a telephone interview study across two time-points. Twenty-four semi-structured interviews with local leads across 19 sampled case sites were undertaken between October 2019 and January 2020 and 13 interviews with local leads across 13 sampled case sites were conducted between July 2020 and August 2020. Interviews aimed to reflect on the experience of implementation and explore how things changed over time. We identified four overarching themes to show how implementation was locally enacted and adapted across the sampled case sites: 1. Adapting to provider change; 2. Identification and referral; 3. Enhancing uptake in underserved populations; and 4. Digital and remote service options. This paper reports how designated local leads, responsible for local implementation of the NHS DPP, adapted implementation efforts over the course of a changing national diabetes prevention programme, including how local leads adapted implementation during the COVID-19 pandemic. This paper highlights three main factors that influence implementation: the importance of facilitation, the ability (or not) to tailor interventions to local needs and the role of context in implementation. This publication was funded by the Health and Social Care Delivery Research programme as a part of award number 16/48/07. https://doi.org/10.1186/s12913-023-10002-y This article reports on one component of the research award Evaluating the NHS Diabetes Prevention Programme (NHS DPP): the DIPLOMA research programme (Diabetes Prevention Long term Multimethod Assessment). For more information about this research please view the award page [https://fundingawards.nihr.ac.uk/award/16/48/07]