OBJECTIVE:Conducting health research with adolescents involves navigating complex challenges at both organisational and individual levels. As part of evaluating the EACH-B (Engaging Adolescents with Changing Behaviour) intervention-a school-based randomised controlled trial aimed at improving diet and physical activity in adolescents, we explored researchers' insider experiences of programme implementation. The study investigates real-world implementation challenges and protocol adaptations in the EACH-B trial to provide practical guidance for public health interventions in schools. Applying the Consolidated Framework for Implementation Research (CFIR), data were collected through semi-structured interviews and focus groups with 10 members of the research team. RESULTS:Researchers identified significant barriers within the 'Inner' settings (internal research processes) and 'Outer' settings (external school environment and policy landscape). Research delivery was hindered by post-pandemic school priorities-specifically academic recovery and mental health support which limited the feasibility of maintaining adolescent engagement and school access. Researcher-led adaptations emerged as a critical, yet often hidden, component of maintaining trial fidelity. The study concludes that reflexive 'insider' perspectives and flexible designs are essential to align research with shifting school priorities. These adaptive strategies provide a blueprint for more resilient and feasible public health interventions.

Abstract BACKGROUND Sedentary behaviour independently contributes to cardiovascular disease risk. In healthy adults, prolonged uninterrupted sitting acutely elevates blood pressure, whereas light-activity breaks attenuate this response. Whether such strategies confer similar benefits in high-risk populations, such as chronic stroke survivors, remains unanswered. OBJECTIVES To determine whether non-ambulatory, seated heel-raise interruptions every 10 minutes would attenuate central systolic blood pressure (cSBP) during 3 hours of prolonged sitting in individuals with chronic stroke. We hypothesized that the experimental (heel-raise interruption) condition (EXP) would significantly mitigate the cSBPresponse relative to uninterrupted sitting (CON). METHODS Using a randomized crossover design, 15 chronic stroke patients (69.3 ± 10.8 y; 10 male) completed two 3-hour conditions: CON and EXP (10 seated bi-lateral heel raises at 1 rep·s ⁻ ¹ every 10 minutes). Central and peripheral blood pressures were assessed pre- and post-each condition using the SphygmoCor XCEL. Condition × Time interactions were tested using repeated-measures ANOVA. RESULTS The primary hypothesis was confirmed: a significant Condition × Time interaction was detected for cSBP (p < 0.05; η p² = 0.28), with EXP eliciting a smaller increase than CON (5.6 mmHg [−6.4, 17.6] vs. 9.6 mmHg [−2.4, 21.6]). CONCLUSIONS Heel-raise interruptions every 10 minutes attenuate the cSBP response to prolonged sitting in chronic stroke patients and reduce cardiac workload. Frequent, non-ambulatory activity breaks represent a practical secondary prevention strategy for this population, though higher intensity or frequency may be required to fully protect vascular function.

Background Globally, the health of young people is in decline, with increasing rates of mental health issues, obesity and sedentary lifestyles. Existing health behaviour change interventions for this group face challenges in engagement and implementation. Effective, targeted interventions are needed to improve lifelong health outcomes for young people. Objective To develop, implement and evaluate a multicomponent health behaviour change intervention aimed at improving diet and increasing physical activity in young people in the United Kingdom. Design and methods A person-based approach drawing on systematic and literature reviews and qualitative data (interviews, group discussions and participatory ‘game jams’) was used to develop the Engaging Adolescents in Changing Behaviour intervention, which was tested using a cluster-randomised trial. A pilot trial informed modifications to recruitment, data collection and app usage processes. Schools selected two Year 8 classes (12–13 years old) to participate, with randomisation at the school level. Baseline and 12-month follow-up data on diet, physical activity and general well-being were collected from students, and demographic data were provided by schools with parental permission. An economic model was designed to estimate future effects on health outcomes of the intervention, and mixed-methods process evaluation examined participant perspectives (students, parents and teachers), LifeLab® attendance and app download statistics. Setting and participants Of our planned sample of 2300, we collected baseline data from 2065 students from 45 of 49 recruited and randomised secondary schools across Hampshire and the south coast of England. Four schools dropped out before baseline data collection, and we followed up 55% of students at 1 year. The process evaluation involved 88 of these students, 23 teachers and 11 parents. Intervention The Engaging Adolescents in Changing Behaviour intervention had three components: experiential science education for students at LifeLab, teacher training to support students’ health behaviours and a gamified smartphone app for students to encourage better diet and physical activity. Main outcome measures Diet quality (standard deviation scores), total physical activity (minutes/day). Secondary outcomes included further diet and physical activity outcomes, self-efficacy for health behaviours and general well-being, assessed using both objective and self-report methods. Data were analysed using linear mixed-effects models and binary regression, accounting for clustering. Results Development work indicated that effective interventions should support young people’s autonomy, competence and relatedness while making healthier choices accessible and appealing. Digital platforms and social media were identified as key for engagement. Pilot findings prompted adjustments to school recruitment, data collection and app presentation for the main trial. At baseline, the intervention group had a mean diet quality score that was 0.22 standard deviation (95% confidence interval −0.05 to 0.51) higher than in the control group. At follow-up, the difference between groups was −0.02 standard deviation (95% confidence interval −0.32 to 0.27), and after adjustment for the baseline, diet quality score was −0.10 standard deviation (95% confidence interval −0.29 to 0.09). For the total physical activity outcome, the baseline difference between groups was minimal; at follow-up, the difference was 1.19 minutes/day (95% confidence interval −15.5 to 17.9) and after adjustment for baseline was 8.65 minutes/day (95% confidence interval −7.79 to 25.1). Minor differences were observed in secondary outcomes. Index of Multiple Deprivation scores of schools in intervention and control groups showed no baseline differences. Overall, 88% of eligible students attended LifeLab, and 42.5% downloaded the app. Students and teachers reported positive experiences with LifeLab and teacher training, though COVID-19 impacted in-person delivery for some schools. Students valued learning about their health but engaged minimally with the app. Parents viewed the intervention positively but often lacked communication from their children or schools about it. Teachers were eager to support health initiatives but had limited opportunities during the school day. A Markov model was produced to estimate the cost-effectiveness of LifeLab Plus, but our findings did not warrant such an analysis. Limitations Most students did not engage with the app due to its lack of appeal and insufficient motivation to revisit it. Only 55% of students participated in the follow-up and provided data on the diet quality score, and only 28% had complete physical activity data at baseline and follow-up. Thus, the power of the trial was reduced, making it difficult to detect differences between groups. Trials in school settings tend to include more advantaged children, as opt-in consent favours parents who complete forms. Even opt-out consent does not fully address this issue, as disadvantaged students are more likely to miss school during data collection. Demographic data collection required parental opt-in, introducing further bias. Conclusions The trial detected no significant impact of the intervention on diet and physical activity among secondary school students. Substantial baseline differences in diet and physical activity between intervention and control groups introduced noise, complicating conclusions about intervention effects. While schools are suitable settings for health interventions, randomised trials may not be ideal for evaluating large-scale, real-world interventions. Intervention design, particularly for smartphone applications, requires greater attention to foster sustained engagement. Future work Although the Engaging Adolescents in Changing Behaviour intervention did not improve diet or physical activity, it provided valuable insights. Interventions must support young people’s autonomy, competence and relatedness and offer them meaningful opportunities to support their aspirations in life. Health topics have to be important to young people to be engaging, and research has to be coproduced. Our current and future research focuses on evaluating the impact of this participatory approach on health and well-being and aims to translate findings into policy through collaborations with local authorities and Integrated Care Systems in Wessex. Exploring alternative designs for evaluating large-scale public health interventions is another important research agenda. Trial registration This trial is registered as ISRCTN74109264. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0216-20004) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 8. See the NIHR Funding and Awards website for further award information. Plain language summary Young people in the United Kingdom have the worst diets of any age group and insufficient exercise, increasing risks of conditions such as heart disease and diabetes later in life. Since health habits formed in adolescence can last a lifetime, researchers are trying to find ways to help young people adopt healthier behaviours. Interactive programmes, called interventions, can improve health habits but are difficult to design and implement with young people. The Engaging Adolescents in Changing Behaviour programme developed and tested a school-based intervention for healthier choices among students. A method of assessing the money that could be saved on health care if this intervention was successful was developed. To inform the programme, researchers consulted young people, parents and teachers, finding that: young people valued health but felt it had to fit into their social lives and activities the environment around young people made it hard for parents and teachers to support young people’s healthy habits effective interventions must respect adolescents’ need for independence and a social life while making healthy choices enjoyable and accessible. The intervention involved 2065 students (aged 12–13 years at baseline and 13–14 years at follow-up) from 45 schools in Hampshire and Southern England. Forty-nine schools were recruited and randomly allocated to intervention or control, but four schools (two intervention and two control) subsequently dropped out. Half of the schools implemented the programme, while the others continued regular activities as a comparison group. The Engaging Adolescents in Changing Behaviour intervention included: teacher training for supportive health discussions LifeLab (in-school lessons and a trip to a health education facility for an experiential science day) the Engaging Adolescents in Changing Behaviour gamified smartphone app to promote eating better and exercising more. Students completed diet and activity questionnaires and wore activity trackers for a week. Data were collected again a year later, alongside feedback from participants, parents and teachers. Findings revealed no meaningful improvements in diet quality or physical activity between intervention and comparison groups, though small differences in well-being and food choices were noted. We may not have found any effect of the intervention because i) there were differences in initial diet scores between groups, ii) only being able to see 55% of the original group of students a year after the intervention and iii) feedback that the app was not engaging enough to compete with social media for young people’s attention. Because we did not see any impact of the intervention, we were unable to carry out a cost-effectiveness evaluation. Key recommendations: continue partnering with schools despite logistical challenges ensure digital interventions work alongside other digital activities like social media rather than compete. Scientific summary The health of young people across the world is in decline, and most existing health behaviour change interventions have failed to shift young people onto more positive health trajectories. The National Institute for Health and Care Research (NIHR) funded the Engaging Adolescents in Changing Behaviour (EACH-B) programme to examine whether a multicomponent intervention could improve health behaviour outcomes for young people on the south coast of England. We developed the intervention, evaluated its effectiveness using a cluster-randomised controlled trial and conducted a process evaluation of the delivery, implementation and mechanisms of impact of the EACH-B intervention. Programme research stream and work package aims and objectives Research stream (RS) 1 [work package (WP) 1.1, WP1.2, WP1.3]: to find the best methods for helping young people make healthier choices by looking at previous research and talking to experts. To build a health economic model to estimate the costs and benefits of existing interventions. Research stream 2 (WP2.1, WP2.2, WP2.3, WP2.4): to develop an intervention that young people, parents and teachers found helpful in improving diet and increasing exercise. Research stream 3 (WP3.1, WP3.2): to test the intervention to see how well it works, whether it offered good value for money and the best way of implementing it in schools. Methods Research stream 1 Work package 1.1: three systematic reviews were conducted to inform the economic modelling (RS1) and intervention development (RS2). The first synthesised evidence from quantitative studies on the effectiveness of digital interventions to improve diet quality (www.sciencedirect.com/topics/medicine-and-dentistry/diet-quality) and increase physical activity (PA) (www.sciencedirect.com/topics/psychology/physical-activity) in adolescents, to identify effective intervention components and to assess the cost-effectiveness of these interventions. The second focused on the literature investigating the effectiveness of health education interventions delivered in school settings to prevent overweight and obesity and/or reduce body mass index (BMI) in adolescents, and to explore the key features of effectiveness. The third systematic review examined the influence of community and consumer nutrition environments on young people’s food purchasing and dietary behaviours in high-income countries was conducted. The protocol paper described the design of the EACH-B trial to test the intervention. Work package 1.2: a Markov model, considering mental health, earnings, type 2 diabetes (T2D) and pregnancy outcomes over 20 years, was developed using published literature and sensitivity analyses to assess the cost-effectiveness of a school-based intervention for improving diet and PA in young people. The model was designed to be used with data produced in WP3.2 to test cost-effectiveness. Work package 1.3: stakeholders were identified and regular meetings set up throughout the duration of the programme. Opportunities to contribute to consultations, briefings and policy documents were sought. A stakeholder consortium was formed in the last 3 years of the programme. Research stream 2 Work package 2.1: a review examined the reasons for the ineffectiveness of existing behaviour change interventions. Findings informed questions asked in group interviews with young people aged 13–14 years. Semistructured interviews with parents of adolescents were also conducted, exploring parental involvement in adolescent health interventions. Another study analysed quantitative adolescent dietary data and qualitative interviews with parents, teachers and adolescents to examine energy drink consumption and associated factors. A further study conducted focus groups with adolescents aged 11–18 years to explore the interplay between social and food environments in adolescent food choices. Work package 2.2: the content of the intervention was designed using findings from RS1 and RS2. Components of the intervention were developed using data collected in WP2.1 and drawing on evidence review from RS1. Work package 2.3: the smartphone application, referred to as ‘the app’ or ‘LifeLab Plus’, was developed by game designers at Glasgow Caledonian University and tested by young people. Think-aloud interviews were conducted with young people testing prototypes of the app to capture immediate reactions to aspects of the intervention. Work package 2.4: focus groups were conducted with secondary school teachers to explore their perceptions of how they could use Healthy Conversation Skills (HCS) to support students to make lifestyle changes, what additional training needs they had and how the final HCS training programme could best be delivered in the school context. Following a pilot of the HCS training, further interviews were conducted with teachers who took part (see Report Supplementary Material 6). Research stream 3 Work package 3.1: the EACH-B trial was piloted in six secondary schools in the Southampton area, randomised to intervention or control. A process evaluation was conducted to assess the implementation of the intervention, the influence of context on the trial and the mechanisms of impact underlying the intervention. The research team analysed data from the UK National Diet and Nutrition Survey to develop a short, 20-item food frequency questionnaire (FFQ) to use in the EACH-B trial. Principal component analysis was used to identify key dietary patterns and create diet quality scores. Work package 3.2: in total, 49 schools were recruited to the main trial, and 45 took part in both baseline and follow-up measures. Schools were randomised to receive the EACH-B intervention or not. Two middle-ability classes were chosen to take part by teachers in each school. Outcomes were dietary change (measured by the 20-item FFQ) and PA change [measured using GENEActiv™ (ActivInsights, Cambridge, UK) accelerometers]. Secondary outcomes were self-reported PA, behavioural regulation and self-efficacy for diet and PA, quality of life and well-being. A mixed-methods process evaluation was also conducted, following the format of that carried out with the pilot trial (WP3.1). Interviews and focus groups were conducted with students, teachers and parents from 11 schools (5 intervention and 6 control) that took part in the trial. Quantitative data were collected describing numbers of students who attended LifeLab and downloaded and used the app. Results Research stream 1 Work package 1.1: the systematic review of digital interventions found that the most effective digital interventions incorporate education, goal-setting self-monitoring and parental involvement. We found too little data on the cost-effectiveness of digital health interventions to be able to draw conclusions. The systematic review and meta-analysis of school-based adolescent health interventions suggested that school-based health education interventions have the potential to lower BMI towards a healthier range in adolescents. Multicomponent interventions involving teachers and parents and digital components are promising. The systematic review of influences of the community and consumer nutrition environment on the food purchases and dietary behaviours of young people found no clear associations between exposure to healthy community nutrition environments and dietary outcomes. However, most of the studies reviewed (57%) reported that greater exposure to unhealthy food outlets was associated with less healthy food purchases and dietary intakes. Results for consumer environments were inconsistent. Work package 1.2: a Markov model was developed to extrapolate short-term observed effects on diet, activity and/or BMI to estimate future effects on the incidence of T2D and cardiovascular disease. While the intention was to apply the model to estimate the cost-effectiveness of LifeLab Plus, our findings did not warrant such an analysis. The published model has utility beyond the present study, however, and could be applied by others undertaking such complex intervention research. Work package 1.3: stakeholders were engaged systematically throughout the programme to ensure buy-in to the intervention and insights for subsequent implementation. Significant achievements were the Innovation-to-Commercialisation fellowship for Woods-Townsend, WP1.3 lead. This involved intense stakeholder engagement to understand the implementation aspects of the programme, including conversations with a wide variety of stakeholders to explore the potential for scale-up and roll-out of EACH-B. Insights from EACH-B fed into the ukactive ‘Generation Inactive 2’ report, the Southampton City Council’s scrutiny review of their Childhood Obesity Policy and the formation of the Pathways to Health (www.pathways-to-health.org/) Consortium, a grouping of more than 30 organisations in Southampton that is committed to improving young people’s health and well-being. Research stream 2 Work package 2.1: The article summarising the findings of a review of factors involved in reducing intervention effectiveness identified three issues: a focus on mean effect sizes, assumptions about the value young people place on health, and overemphasis on cognitive mechanisms in interventions. The article suggests that interventions should consider both rational and emotional influences on health behaviours. Subsequent qualitative work (n = 54, 13- to 14-year-olds) identified that young people valued being with friends, being active and being healthy without compromising other priorities. Health alone is not a motivating factor for them. They prioritised social experiences over food quality, valued familiar food outlets and chose food promotions that aided quick decision-making. Energy drink consumption among young people (n = 2587 adolescents aged 11–18) was associated with poorer dietary quality and higher deprivation. Qualitative data from 74 adolescents, 24 parents and 15 teachers revealed that young people drink energy drinks because of peer influence and low cost and believe voluntary bans on their sales are ineffective. In additional interviews, parents (n = 24) saw themselves as gatekeepers and role models for healthy behaviour but struggled with balancing their influence and their children’s increasing autonomy. Work package 2.2: guiding principles for intervention content were that it (1) persuades adolescents that healthy eating and PA can be a positive experience with positive outcomes, (2) enhances Self-Efficacy for Healthy Eating and Physical Activity and persuades users that it can be easy and (3) supports adolescents to seek support from their social network with healthy eating and PA. The logic model developed for the funding application which described the programme and outlined the hypothetical mechanisms of the intervention was modified based on the data collected in RS2 (Figure 1). Work package 2.3: a description of the app development process is described in a paper entitled, ‘Enhancing the relevance of nutrition and physical activity interventions for adolescents: design and development of the LifeLab Plus App’ (see Report Supplementary Material 5). Findings from the qualitative research and coproduction activities informed the integration of behaviour change components into each element of the app, for example, the ‘Gutsy’ game, to maximise engagement. The paper concludes that theoretical and evidence-informed approaches, while crucial for initial development, were not sufficient to deliver an app that was meaningful and relevant to adolescents. Genuine coproduction and testing with target users is an essential step in app development. Work package 2.4: the qualitative research explored teachers’ perceptions of their roles in supporting their students to make healthy choices. Interviews with 15 secondary school teachers and focus groups with another 14 revealed that they were enthusiastic about talking to their students about health in supportive and encouraging ways and found opportunities to have these sorts of conversations. Teachers had ideas about strategies that could help them to support their students’ health but felt powerless because they witnessed the way environmental, individual, financial and social factors made it more difficult for students to make healthy choices. They felt school cultures and systems did not facilitate health behaviour change but, in fact, actively made it harder for teachers to support their students. Research stream 3 Work package 3.1: the results of the study developing the shortened version of the FFQ showed a strong correlation (0.87) between the 20-item and 139-item scores. Both scores correlated with nutritional biomarkers. The study concluded that the 20-item questionnaire could effectively assess diet quality in large-scale studies with young people. The pilot demonstrated that the trial could be conducted in schools, though some minor modifications were made before the main trial started. Just as the main trial started, schools were shut as part of the first COVID-19 lockdown period of the COVID-19 pandemic, and further modifications had to be made to accommodate that. Work package 3.2: despite using a minimisation algorithm, baseline imbalances existed in this cluster-randomised school trial, notably a 0.22 standard deviation (SD) difference in diet quality score – a primary outcome –almost as large as the 0.25 SD the study aimed to detect. This complicated analysis, as cluster-randomisation at the school level, with only 45 schools and over 2000 students, is prone to imbalance. Income Deprivation Affecting Children Index score (a measure of area household deprivation for children) also differed at baseline in control and intervention groups. The intention-to-treat analysis, including adjustment for clustering, showed minimal difference between groups in the primary outcomes at follow-up. However, follow-up rates were only 55% for the diet quality score and 28% for the PA measure. Further analyses incorporating adjustment for the baseline values of the outcome being assessed also revealed minimal group differences. The intervention group had a mean diet quality score that was 0.10 SD [95% confidence interval (CI) −0.29 to 0.09] lower than in the control group, and 8.65 minutes/day (95% CI −7.79 to 25.1) more total PA than in the control group. Both these differences are small. Secondary outcomes highlighted some effects, notably reduced risk for high crisp consumption [relative risk (RR) = 0.75 (95% CI 0.63 to 0.89)] and similar or lower fizzy drink consumption [RR = 0.77 (95% CI 0.58 to 1.03)], but baseline diet imbalances cast doubt over these findings. In the intervention group, there was a higher proportion [RR = 1.42 (95% CI 0.99 to 2.03)] of students meeting the 60-minute daily activity guideline than in the control group, yet other activity outcomes showed no differences. Compliance challenges also arose: LifeLab day attendance varied, and app engagement was low, with only 228 students using the app an average of 2.2 sessions with a duration per session of 17.7 minutes. There was no way of assessing the fidelity of the HCS component of the intervention or of the LifeLab delivery in schools. The COVID-19 pandemic was the backdrop to this research, and its effects on the findings are hard to assess. Quantitative data from the process evaluation of the main trial showed that 87.9% of eligible students attended the LifeLab facility and 42.5% of eligible students downloaded the smartphone application. Students and teachers had positive experiences of LifeLab and the teacher professional development, despite the COVID-19 pandemic preventing in-person delivery for some schools. Parents had positive views of research and were enthusiastic about the EACH-B intervention, but most said they did not know about the study from their children or school. Students valued learning about their own health and bodies, and teachers were enthusiastic about supporting their students to make healthier choices, but opportunities to talk to students about health during the school day were limited. Conclusions The EACH-B programme successfully developed and tested an intervention to improve diet and PA among 12- to 14-year-olds. Stakeholder engagement and evidence synthesis informed programme design, and the programme produced a range of outputs, including 18 peer-reviewed publications, 47 conference presentations and 4 doctoral theses. Engaging Adolescents in Changing Behaviour highlights the challenges of cluster-randomised trials in schools, particularly baseline imbalances affecting data interpretation. The study aimed to recruit 50 schools and 2300 students; 49 were recruited and randomised, and 45 provided data at both baseline and follow-up, and 2065 students were seen at baseline. Only 1127 (55%) students provided data at follow-up, however. Dropout rates were higher among disadvantaged students and exacerbated by an opt-in consent process, which limited participation. Engagement with two of the intervention components was low. Despite this, the EACH-B programme has advanced understanding of youth health interventions and influenced policy, underscoring the need for engagement-driven, adaptable and collaborative approaches. Key insights from the programme highlight that interventions must support young people’s autonomy, competence and relatedness to be effective. The programme’s impact extends beyond research, notably through the UK Research and Innovation-funded Pathways to Health Consortium, which integrates young people into local policy decision-making. Another major output is the NxtGen Researchers Training Programme, which equips young people with research and advocacy skills. This led to the Young People’s Manifesto for Change, containing 12 policy recommendations to be endorsed by the Hampshire and Isle of Wight Integrated Care Board. NxtGen Researchers continues to run and is in the process of being accredited by the Royal Society for Public Health. Trial registration This trial is registered as ISRCTN 74109264. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (NIHR award ref: RP-PG-0216-20004) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 8. See the NIHR Funding and Awards website for further award information.

Background The Engaging Adolescents in Changing Behaviour trial tested the impact of an adolescent diet and physical activity intervention involving: teacher training in Healthy Conversation Skills, a health education module (LifeLab) and a gamified smartphone application (‘the app’). The process evaluation described in this paper examined the implementation, context and mechanisms of impact of the intervention (the core elements of the Medical Research Council guidance on process evaluation of complex interventions), to identify how and why participants did or did not engage with each element of the trial and the intervention.Methods A mixed-methods approach was employed. 51 interviews with students, teachers and parents from 11 secondary schools were conducted and analysed using thematic analysis. Quantitative data reported numbers of students who attended LifeLab and downloaded and used the app.Results 87.9% of eligible students attended LifeLab and 45.7% of eligible students downloaded the app. Students (n=72) and teachers (n=16) had positive experiences of LifeLab and the teacher training, despite the pandemic preventing in-person delivery for some schools. Students engaged in a limited way with the app. Parents (n=11) had positive views of the research but little knowledge of the intervention. Students valued learning about their own health, and teachers were enthusiastic about supporting their students’ health but struggled to find opportunities to do so.Conclusions Schools are appropriate settings in which to implement health interventions, but the research must benefit teachers and students. Most students did not engage with the app because they were not presented with it in a way that motivated them to use it. Careful consideration of the design of apps is required to encourage students to use them. Parents should be involved in research in ways that are accessible to them.

Purpose: With a rising incidence of childhood-onset Crohn's disease (CD), linked to genetics, environmental, and lifestyle factors, there is a need to further understand the physical (in)activity behaviors of young people with the condition. We explored the barriers and facilitators to physical activity and exercise in children and young people with CD from the perspectives of patients, caregivers, and specialist clinicians. Methods: Five children, 7 caregivers, and 6 specialist clinicians completed semistructured interviews in this UK-based qualitative study. Recordings were transcribed verbatim, and emergent themes were inductively derived. Results: Three overarching themes were constructed: (1) navigating barriers to a physically active lifestyle with CD, (2) building knowledge and support for a physically active lifestyle with CD, and (3) creating an enabling environment for a physically active lifestyle through family and social support networks. Conclusion: Young people living with CD, their caregivers, and clinicians clearly value the importance of physical activity and exercise but face several disease-specific barriers that can hinder long-term participation. Targeted educational and practical support is needed to address these challenges. Involving those with lived experience is essential in designing effective resources and home-based support programs that meet their needs.

Contact with nature can contribute to health and wellbeing, but knowledge gaps persist regarding the environmental characteristics that promote these benefits. Understanding and maximising these benefits is particularly important in urban areas, where opportunities for such contact is limited. At the same time, we are facing climate and ecological crises which require policy and practice to support ecosystem functioning. Policies are increasingly being oriented towards delivering benefits for people and nature simultaneously. However, different disciplinary understandings of environments and environmental quality present challenges to this agenda. This paper highlights key knowledge gaps concerning linkages between nature and health. It then describes two perspectives on environmental quality, based respectively in environmental sciences and social sciences. It argues that understanding the linkages between these perspectives is vital to enable urban environments to be planned, designed and managed for the benefit of both environmental functioning and human health. Finally, it identifies key challenges and priorities for integrating these different disciplinary perspectives.

IntroductionRegular physical activity is a strategy that is effective in the physical management of long term conditions. The COVID-19 pandemic, led to disruption of physical activity routines for many people with long term conditions. It is important, to understand the experiences of people with long term conditions regarding physical activity during COVID-19 to enable future identification of strategies to mitigate the impact of restrictions on health.ObjectiveTo explore perceptions and experiences of people with long term conditions of the impact of the UK Government physical distancing restrictions on their physical activity participation during the COVID-19 pandemic.MethodsA qualitative study, with in depth videoconference semi-structured interviews were conducted between January and April 2022, with 26 adults living with at least one long term condition in the UK. Data were managed in analytical matrices within Excel and data analysis was conducted using thematic analysis.ResultsTwo main themes were developed, explaining how participants managed their physical activity during COVID19 lockdowns, and based on those experiences, what they considered should be in place should another lockdown occur:1) COVID-19 and physical activity: Losses, opportunities and adapting to new formats; and 2) Micro, meso, and macro contexts: creating the right conditions for physical activity support in future pandemics.ConclusionsThis study provides information on how people with long term conditions managed their condition during the COVID-19 pandemic and generates new understanding of how physical activity routines changed. These findings will be used to inform stakeholder engagement meetings with individuals with long term conditions and local, regional, and national policy makers, to co-produce recommendations that will help people living with long term conditions remain active during and after COVID-19 and other pandemics.

ObjectiveTo understand the physical activity and mental health of individuals living with long-term conditions during the COVID-19 pandemic.DesignA sequential explanatory mixed-methods study with two phases: phase 1: quantitative survey and phase 2: qualitative follow-up interviews.SettingFor the quantitative phase, an online survey was launched in March 2021, using Microsoft Forms. For the qualitative phase, in-depth semistructured interviews were conducted via online.Participants368 adults over 18 years old living in the UK with at least one long-term condition completed the survey. Interviews were conducted in a subsample of participants from the previous quantitative phase, with 26 people. Data were analysed using thematic analysis.ResultsResponses from the survey showed that people with one long-term condition were significantly more physically active and spent less time sitting, than those with two or more conditions, presenting with significantly higher well-being (p<0.0001), and lower levels of anxiety (p<0.01), and depression (p<0.0001). Interviews found that people developed a range of strategies to cope with the impact of changeability and the consequences of their long-term condition on their physical activity.ConclusionsThe number of long-term conditions influenced physical activity and how people coped with their condition during COVID-19. Findings will inform policy developments in preparation for future pandemics to support and remain people to remain physically active and mental health.

Children living with palliative care needs are less engaged in play, despite its importance in their lives. The environment may have a crucial role in supporting these children's play. Understanding the importance and impact of environmental factors on children's play is essential to being able to support their participation in play. Data were collected from caregivers (mostly parents) of children living with life-threatening/limiting conditions, who were between 5 and 11 years old. Thirty-nine participants were recruited from two children hospitals and two hospices in Kuwait and in the United Kingdom. The participants' perspectives were explored using Q methodology. By-person factor analysis was used to explore the ranking of each statement. Content analysis was used to analyse the participants' verbal comments. The most important environmental factors were the need for others to share play and get assistance to facilitate play. However, this is not always possible as these conditions, the life-threatening/limiting conditions, may be socially isolating. Children also experience limitations in accessing play resources that match their abilities and meet their play needs. Being aware and responsive to children's play needs is essential for building appropriately supportive play environments for children living with life-threatening/life-limiting conditions.

Abstract Background During the COVID-19 pandemic the United Kingdom government released regular guidance on limiting the spread of COVID-19. People, including those with long term conditions, were told to use physical distancing, self-isolation and/or shielding during COVID-19 to protect themselves and others. A consequence of these interventions was to exacerbate poor lifestyle behaviours, namely less physical activity. Objectives To propose recommendations to support and sustain their physical activity of people with long term conditions during and after COVID-19 or other pandemics. Methods A mixed methods project was conducted. An online quantitative survey with 368 people in the United Kingdom was conducted, followed by 26 online semi-structured interviews. Results The study demonstrated that online resources are not accessible for all populations. During COVID-19 pandemic, provision of PA information was most commonly available online. Also, COVID-19 lockdowns meant the sudden loss of opportunities to be active along with the social interaction and motivation usually in place to support activity. Finally, physical activity guidelines should be more specific. Local and national government guidelines were identified as unclear for those living with long term conditions and should be more specific regarding what people who were shielding could and could not do. Conclusions Based on the findings, more suitable and accessible physical activity guidelines for people with long term conditions is recommended. Also, prioritizing vulnerable groups is recommended to support physical activity to avoid the worsening of emotional wellbeing, and quality of life. Finally, government and public health authorities should consider charities and long term conditions voluntary organizations to design bespoke physical activity recommendations and guidelines for those shielding at home and living with long term conditions. Key messages • Government and public health authorities design bespoke PA recommendations for those living with LTCs. • Simple strategies such as ‘move more and sit less’ or ‘breaking up sitting time’ could be promoted as safe and accessible options for those living with LTCs.

Overground robotic-assisted gait training (O-RAGT) has been shown to improve clinical functional outcomes in people living with stroke. The purpose of this study was to identify whether a home-based O-RAGT program, in combination with usual care physiotherapy, would demonstrate improvements in vascular health in individuals with chronic stroke, and, whether any changes in vascular outcomes would be sustained 3 months after completing the program. Thirty-four participants with chronic stroke (between 3 months and 5 years post-stroke) were randomized to either a 10-week O-RAGT program in combination with usual care physiotherapy, or to a usual care physiotherapy only control group. Participants' (n = 31) pulse wave analysis (PWA), and regional [carotid-femoral pulse wave analysis (cfPWV)] and local (carotid) measures of arterial stiffness were assessed at baseline, post-intervention, and 3-month post-intervention. Analysis of covariance demonstrated a significant reduction (improvement) in cfPWV between BL and PI for O-RAGT (8.81 ± 2.51 vs. 7.92 ± 2.17 m/s, respectively), whilst the control group remained unchanged (9.87 ± 2.46 vs. 9.84 ± 1.76 m/s, respectively; p < 0.05; ηp2 = 0.14). The improvement in cfPWV was maintained 3 months after completing the O-RAGT program. There were no significant Condition by Time interactions for all PWA and carotid arterial stiffness measures (p > 0.05). A significant increase in physical activity, as determined by the time spent stepping, was observed for O-RAGT between baseline and post-intervention assessments (3.2 ± 3.0–5.2 ± 3.3%, respectively) but not for CON (p < 0.05). The improvement in cfPWV, in combination with an increase in physical activity whilst wearing the O-RAGT and concomitant reduction in sedentary behavior, are important positive findings when considering the application of this technology for “at home” rehabilitation therapy for stroke survivors. Further research is needed to determine whether implementing “at home” O-RAGT programs should be a part of the stroke treatment pathway.Clinical trial registrationhttps://clinicaltrials.gov, identifier NCT03104127.

Unhealthy dietary habits and physical inactivity are major risk factors of non-communicable diseases (NCDs) globally. The objective of this paper was to describe the role of dietary practices and physical activity in the interaction of the social determinants of NCDs in Nepal, a developing economy. The study was a qualitative study design involving two districts in Nepal, whereby data was collected via key informant interviews (n = 63) and focus group discussions (n = 12). Thematic analysis of the qualitative data was performed, and a causal loop diagram was built to illustrate the dynamic interactions of the social determinants of NCDs based on the themes. The study also involved sense-making sessions with policy level and local stakeholders. Four key interacting themes emerged from the study describing current dietary and physical activity practices, influence of junk food, role of health system and socio-economic factors as root causes. While the current dietary and physical activity-related practices within communities were unhealthy, the broader determinants such as socio-economic circumstances and gender further fuelled such practices. The health system has potential to play a more effective role in the prevention of the behavioural and social determinants of NCDs.

Background: Play is central to children’s lives. Children living with palliative care needs experience disruption in their play. In this study, we sought to discover the characteristics and patterns of children’s play when receiving care in children’s hospital wards and hospices in Kuwait and the United Kingdom. Methods: A qualitative nonparticipatory observation design was used. Thirty-one children were observed, between the ages of 5 and 11 years, all diagnosed with life-limiting or life-threatening conditions and receiving palliative care. The data were analysed using content analysis. Results: The children’s illnesses were negatively impacting their ability to have typical play for their age and development. The children’s interactive play was with grown-ups and very rarely with other children. This was associated with isolation precautions, the child’s need for assistance and a lack of play resources that match children’s physical and cognitive abilities. This gave rise to their engagement in more sedentary, solitary play. The findings of the study did not indicate significant cultural differences between the two countries. Conclusion: Children living with palliative care needs may be socially isolated due to their illnesses and their play participation can be limited. Understanding the influencing factors that determine these children’s play is essential for implementing effective modifications to enhance their play routines.

To review the applicability and accessibility of physical activity guidelines for adults living with long-term conditions whilst shielding during the COVID-19. A narrative review with systematic methodology was conducted between 2015 and 2021, with two stages: 1) Search of electronic databases PubMed/Medline, Web of Science, PsycInfo, and Cinahl; 2) search of long-term condition organisations. Sixty-five articles were identified, where nine included specific guidelines during the COVID-19, 28 specific guidelines to individuals living with long-term conditions and 7 identified the utilization of online resources. Twenty-one long-term condition organizations websites were reviewed where all of them included a section regarding physical activity guidelines and seven referred to online and offline accessible resources during COVID-19. Accessibility and applicability were variable across academic databases and long-term conditions organisation websites. Findings could inform long-term condition policy and guidelines development to better and more relevant support people living with long-term conditions to be physically active.

Physical activity (PA) participation was substantially reduced at the start of the COVID-19 pandemic. The purpose of this study was to assess the association between PA, mental health, and wellbeing during and following the easing of COVID-19 restrictions in the United Kingdom (UK) and New Zealand (NZ). In this study, 3363 adults completed online surveys within 2–6 weeks of initial COVID-19 restrictions (April/May 2020) and once restrictions to human movement had been eased. Outcome measures included the International Physical Activity Questionnaire Short-Form, Depression Anxiety and Stress Scale-9 (mental health) and World Health Organisation-5 Wellbeing Index. There were no differences in PA, mental health or wellbeing between timepoints (p > 0.05). Individuals engaging in moderate or high volume of PA had significantly better mental health (−1.1 and −1.7 units, respectively) and wellbeing (11.4 and 18.6 units, respectively) than individuals who engaged in low PA (p < 0.001). Mental health was better once COVID-19 restrictions were eased (p < 0.001). NZ had better mental health and wellbeing than the UK (p < 0.001). Participation in moderate-to-high volumes of PA was associated with better mental health and wellbeing, both during and following periods of COVID-19 containment, compared to participation in low volumes of PA. Where applicable, during the current or future pandemic(s), moderate-to-high volumes of PA should be encouraged.

Objectives: To assess the effect of a home-based over-ground robotic-assisted gait training program using the AlterG Bionic Leg orthosis on clinical functional outcomes in people with chronic stroke. Design: Randomized controlled trial. Setting: Home. Participants: Thirty-four ambulatory chronic stroke patients who recieve usual physiotherapy. Intervention: Usual physiotherapy plus either (1)10-week over-ground robotic-assisted gait training program (n = 16), using the device for ⩾30 minutes per day, or (2) control group (n = 18), 30 minutes of physical activity per day. Measurements: The primary outcome was the Six-Minute Walk Test. Secondary outcomes included: Timed-Up-and-Go, Functional Ambulation Categories, Dynamic Gait Index and Berg Balance Scale. Physical activity and sedentary time were assessed using accelerometry. All measurements were completed at baseline, 10 and 22 weeks after baseline. Results: Significant increases in walking distance were observed for the Six-Minute Walk Test between baseline and 10 weeks for over-ground robotic-assisted gait training (135 ± 81 m vs 158 ± 93 m, respectively; P ⩽ 0.001) but not for control (122 ± 92 m vs 119 ± 84 m, respectively). Findings were similar for Functional Ambulation Categories, Dynamic Gait Index and Berg Balance Scale (all P ⩽ 0.01). For over-ground robotic-assisted gait training, there were increases in time spent stepping, number of steps taken, number of sit-to-stand transitions, and reductions in time spent sitting/supine between baseline and 10 weeks (all P < 0.05). The differences observed in all of the aforementioned outcome measures were maintained at 22 weeks, 12 weeks after completing the intervention (all P > 0.05). Conclusion: Over-ground robotic-assisted gait training combined with physiotherapy in chronic stroke patients led to significant improvements in clinical functional outcomes and physical activity compared to the control group. Improvements were maintained at 22 weeks.

Background: Carotid-femoral pulse-wave velocity (cfPWV) is the reference standard measure of central arterial stiffness. However, it requires assessment of the carotid artery, which is technically challenging, and subject-level factors, including carotid artery plaque, may confound measurements. A promising alternative that overcomes these limitations is heart-femoral PWV (hfPWV), but it is not known to what extent changes in cfPWV and hfPWV are associated. Objectives: To determine, (1) the strength of the association between hfPWV and cfPWV; and (2) whether change in hfPWV is associated with change in cfPWV when central arterial stiffness is perturbed. Methods: Twenty young, healthy adults [24.0 (SD: 3.1) years, 45% female] were recruited. hfPWV and cfPWV were determined using Doppler ultrasound at baseline and following a mechanical perturbation in arterial stiffness (120 mmHg thigh occlusion). Agreement between the two measurements was determined using mixed-effects regression models and Bland-Altman analysis. Results: There was, (1) strong (ICC > 0.7) agreement between hfPWV and cfPWV (ICC = 0.82, 95%CI: 0.69, 0.90), and, (2) very strong (ICC > 0.9) agreement between change in hfPWV and cfPWV (ICC = 0.92, 95%CI: 0.86, 0.96). cfPWV was significantly greater than hfPWV at baseline and during thigh occlusion ( both P < 0.001). Inspection of the Bland-Altman plot, comparing cfPWV and corrected hfPWV, revealed no measurement magnitude bias. Discussion: The current findings indicate that hfPWV and cfPWV are strongly associated, and that change in cfPWV is very strongly associated with change in hfPWV. hfPWV may be a simple alternative to cfPWV in the identification of cardiovascular risk in clinical and epidemiological settings.

BACKGROUND:Living with a life threatening/limiting condition changes and challenges children's play. The environment is known to support participation in play, yet there is a lack of evidence highlighting its specific factors contributing to children's play. In this study, we investigated the perspectives of children living with life threatening/limiting conditions with regard to the environmental factors that are related to their engagement in play whilst receiving inpatient healthcare.METHODS:Twenty-seven children took part in this study. Participants were aged between 5 and 11 years, diagnosed with life threatening/limiting conditions and were receiving care at either a children's hospital or hospice in either Kuwait or the United Kingdom. Children were asked to rank-order a Q set according to their perceived importance. The used Q set composed of social and physical environmental factors. The data were analysed using factor analysis and content analysis.FINDINGS:Two shared viewpoints were identified, which represented children from both countries. For Factor 1, the children's need for social connectivity guided their answers regarding the environmental factors. For Factor 2, although children considered being surrounded by others important, their selections of the play conditions directed their play. For both factors, children had relatively little concern for outdoor and the type of play to engage in, with the exception of arts and crafts play activities, which were deemed important.CONCLUSIONS:Play settings are important to support rich, social play experiences and opportunities that match children's play preferences. Children living with life threatening/limiting conditions in Kuwait and the United Kingdom have relatively similar play needs.

Introduction: Non-communicable diseases (NCDs) are a rapidly emerging global health challenge with multi-level determinants popularly known as social determinants. The objective of this paper is to describe the individual and community experiences of NCDs in the two case districts of Nepal from a social determinants of health perspective. Method: This study adopted qualitative study design to identify the experiences of NCDs. Sixty-three interviews were conducted with key informants from different sectors pertinent to NCD prevention at two case districts and at the policy level in Nepal. Twelve focus group discussions were conducted in the selected communities within those case districts. Data collection and analysis were informed by the adapted Social Determinants of Health Framework. The research team utilised the framework approach to carry out the thematic analysis. The study also involved three sense-making workshops with policy level and local stakeholders. Results: Three key themes emerged during the analysis. The first theme highlighted that individuals and communities were experiencing the rising burden of NCDs and metabolic risks in both urban and rural areas. The other two themes elaborated on the participant's experiences based on their socio-economic background and gender. Disadvantaged populations were more vulnerable to the risk of NCDs. Further, being female put one into an even more disadvantaged position in experiencing NCD risks and accessing health services. Conclusion: The findings indicated that key social determinants such as age, geographical location, socio-economic status and gender were driving the NCD epidemic. There is an urgent need to take action on social determinants of health through multi-sectoral action, thus also translating the spirit of the recommendations made a decade ago by the Commission on Social Determinants of Health in addressing a complex challenge like NCDs in Nepal.