Innovation in addiction recovery in Scotland includes the transfer of effective models from other countries, such as San Patrignano, Italy and Basta, Sweden. Independence from Drugs and Alcohol Scotland (IFDAS) was founded to develop a new model for Scotland, based on social enterprise. Drawing on the San Patrignano programme theory, this prospective study investigates IFDAS stakeholders' perspectives on which mechanisms should be transferred, and which require adaptation of the delivery mode, for the Scottish context. Data collection included interviews with ten stakeholders with expertise including: drugs policy, social enterprise, alcohol and drug partnership practice and therapeutic community methods. Drawing on realist principles, data were analysed using inductive and deductive approaches and synthesised using frameworks. San Patrignano mechanisms identified for transfer include: the need for motivation, recovery peer mentors, visionary leadership and social enterprise. Adaptations from Basta include: extending abstinence to alcohol and creating a smaller, semi-permeable, residential community. Further adaptations to mechanism delivery include a 'step-wise' model of housing and work. Scottish contextual factors shaping adaptations include: the culture of alcohol misuse, social care standards, housing regulations and socio-cultural acceptability. This study contributes to the evidence on international transfer and adaptation of complex interventions and documents stakeholders' theory-informed decision making in the development of a new Scottish recovery model.

Birthweight has a well-established role on long-term cardiovascular outcomes. Cardiac magnetic resonance (CMR) with feature tracking strain analysis is the gold standard for assessing cardiac structure and function, and can detect subclinical dysfunction. This study investigated, using CMR, the long-term effects of birthweight on cardiac structure and function in young adults. This study assessed cardiac structure and function in the offspring of women enrolled during pregnancy in the Raine Study. Participants all underwent a CMR at 27 years; image segmentation and strain analysis were undertaken by blinded investigators. Participants were stratified into three birthweight categories for analysis: low birthweight (LBW <2,500 g), normal birthweight (NBW 2500–4000 g), and high birthweight (HBW ≥4000 g). A total of 496 participants were included in the final analysis: 40 in the LBW, 405 in the NBW, and 51 in the HBW group. Left ventricular mass index was significantly increased in the HBW compared with others (44.4 g/m2 vs 48.3 g/m2 vs 50.0 g/m2 for LBW, NBW, and HBW, respectively; p=0.005). Right ventricular stroke volume index, end systolic volume index, and end diastolic volume index also demonstrated significant increases from LBW to HBW (p=0.02; p=0.01; p<0.001, respectively). Left ventricular global longitudinal, radial and circumferential strain showed worsening function with HBW compared with LBW (p=0.02; p=0.03; p=0.045, respectively). Right ventricular global circumferential strain was significantly reduced in the HBW group compared with NBW (–8.6% vs –10.1%; p=0.0013). A higher birth weight is associated with subclinical structural and functional cardiac changes in young adulthood that may influence long-term cardiac outcomes.

Purpose: Sickle cell disease (SCD) is a hemoglobin disorder characterized by chronic hemolysis, inflammation, and oxidative stress. Requirements of vitamin B-6 are thought to be elevated in individuals with SCD due to increased red blood cell (RBC) turnover. Vitamin B-6 also has in vitro anti-sickling properties and is thought to reduce oxidative stress as a coenzyme in the glutathione antioxidant defense system. The aim of this study was to determine the status and dietary intake of vitamin B-6 in Canadian children with SCD. Materials and methods: Fasted plasma samples were collected at baseline from individuals with SCD in British Columbia, Canada participating in a folic acid supplementation trial (ClinicalTrials.gov: NCT04011345). Samples were analyzed for plasma B-6 concentrations using high-performance liquid chromatography. Marginal vitamin B-6 status was defined as plasma pyridoxal 5’-phosphate (PLP) concentrations of 20-30 nmol/L, while deficiency was defined as PLP <20 nmol/L. Dietary vitamin B-6 intake data was collected and analyzed from two non-consecutive dietary recalls using the Automated Self-Administered 24-hour (ASA24) Dietary Assessment Tool-Canada 2018 version. Medication use was collected from the medical chart. Supplement use was self-reported by questionnaire. Results: A total of 18 individuals (67% female; SCD type: HbSS n=16, HbSβ0-thal n=2) with a median (IQR) age of 10 (8, 14) years were included. The majority (89%) of participants were prescribed hydroxyurea (median (IQR) dose: 22.0 (19.5, 25.5) mg/kg/d)). Median (IQR) PLP concentrations were 30.2 (23.9, 51.9) nmol/L. A total of 33% of participants (n=6) had marginal vitamin B-6 status, and 17% (n=3) were deficient. Median (IQR) intake of vitamin B-6 from diet and supplements was 1.1 (0.8, 2.0) mg/d. Four participants (22%) did not meet the age- and sex-specific Recommended Dietary Allowance (RDA; Average daily intake sufficient to meet the requirement of ~97% of healthy individuals) for vitamin B-6, and 3 of them (17%) did not meet the Estimated Average Requirement (EAR; Average daily intake sufficient to meet the requirement of 50% of healthy individuals). There was no significant correlation between dietary intake of vitamin B-6 and PLP or total vitamin B-6 concentrations (r=0.12 and r=-0.07, respectively). Conclusion: Despite most participants having sufficient estimated dietary B-6 intakes, half had marginal or deficient vitamin B-6 status. Further research which investigates the estimated needs and utilization of vitamin B-6 in individuals with SCD is warranted. (Funding: Canadian Institutes of Health Research (CIHR)) The authors do not declare any conflict of interest

The San Patrignano drug recovery community, Italy, is regarded as one of the most successful in the world. However, if this model is to be transferred to other countries, it is necessary to clarify its underlying mechanisms and how far their success is context dependent. This qualitative study investigated these features of the San Patrignano model. Data collection included semi-structured interviews with six key stakeholders and 10 days' observational field notes. Data were synthesised using frameworks and analysis was informed by realist principles. Individual level mechanisms include: commitment to change, removal from former social environment, communal living, peer mentor with lived experience and meaningful work. These operate in the context of a free of charge, long term (3-4 year) residential community. Organisational level mechanisms are: visionary leadership, staff dedication, social enterprise and adaptable learning. Organisational contextual factors include: a gap in suitable provision for drug recovery and the region's high level of social capital. Articulating the programme theory of the recovery model and its contextual dependency helps clarify which elements should be transferred and how far they need to be adapted for different socio-cultural settings. The recognition of context is crucial when considering transfer of effective complex interventions across countries.

AIM:To understand how the social networks of a new recovery community can help sustain recovery, focusing on processes of social identity change, in the context of the wider UK recovery movement.METHODS:A cross-sectional, mixed-methods social network analysis (SNA) of ego-network sociograms to map network transitions, using retrospective measures. Ten men were recruited from a peer-worker programme, in the South Ayrshire Alcohol and Drug Partnership (ADP), West of Scotland. Network measures were compared between two timepoints, just prior to current recovery and the present time. Measures included size and density, closeness of members, and their positive or negative influence, proportion of alcohol and other drug (AOD) using and recovery peers, and extent of separate subgroups. These were complemented with qualitative interview data.FINDINGS:There was a significant transition in network composition, with the replacing of AOD-using peers with recovery peers and a broader transformation from relationships being framed as negative to positive. However, there was no significant transition in network structure, with AOD-using and recovery networks both consisting of strong ties and a similar density of connections between people in the networks.CONCLUSIONS:The transition in network composition between pre-recovery and the present indicates a different set of social influences, while the similarities in network structure indicate that the recovery network replaced the role of the using network in providing close bonds. This helped reduce social isolation experienced in early-recovery and provided a pathway into more structured opportunities for volunteering and employment.

Introduction There is increasing interest in the transferability of parenting interventions from high-income countries (HICs) to low-income countries (LICs) in order to improve child development and health outcomes. This is based on the premise that associations between parenting practices and child outcomes are similar in both settings. Many parenting interventions in HICs are evidence-based, but less evidence exists on associations of parenting practices with child outcomes in LICs, in particular, sub-Saharan African (SSA) countries. This review synthesises evidence on the association of parenting practices with child outcomes in SSA in order to compare findings with those from HICs. Methods We searched electronic databases—Web of Science, ASSIA, Embase, IBSS and PsycINFO—to identify studies from SSA that reported quantitative associations between parenting practices and child health or psychosocial outcomes (eg, sexual and reproductive health (SRH), mental health, conduct disorders). Due to inconsistent conceptual framing of parenting across studies, we used a modified version of the international WHO classification of parenting dimensions to guide synthesis of the results. Results Forty-four studies met our inclusion criteria. They were conducted in 13 SSA countries and included cross-sectional and longitudinal studies, and were predominantly descriptive studies rather than intervention research. Synthesis of results showed that associations between patterns of parenting (‘positive’/‘harsh’) and child outcomes (including SRH, mental health and conduct disorders) in studies from SSA were broadly similar to those found in HICs. Conclusions These findings suggest that the impacts of parenting practices on child outcomes are similar across contrasting global regions and, therefore, parenting interventions from HICs might be successfully transferred to SSA, subject to appropriate adaptation. However, this review also highlights the paucity of evidence in this area and the urgent need for higher quality studies to confirm these findings to help develop effective parenting interventions in SSA.

Background Although the Scottish Government's 2008 national drugs strategy (Road to Recovery) and HM Government's 2017 Drug Strategy emphasise recovery, drug-related deaths continue to increase. An alternative approach is being developed by Independence from Drugs and Alcohol Scotland (IFDAS) inspired by the successful drug recovery community in San Patrignano, Italy. In contrast to harm-reduction measures, a drug recovery community is a complex psychosocial intervention designed to address the wider social determinants of addiction. We aimed to assess the programme theory of the San Patrignano model to identify key mechanisms and stakeholders' perceptions of mechanisms considered essential to transfer to, and those that need adapting for, the new drug recovery community in Scotland. Methods This qualitative study consisted of semi-structured interviews with knowledge-rich stakeholders, purposively sampled from San Patrignano (n=6) or IFDAS (10); observational notes recorded during 10 days' immersion in San Patrignano; and notes from meetings and events in both sites. Stakeholders had professional knowledge in a range of areas including social enterprise, clinical expertise, therapeutic recovery community methods, and government social policy. All qualitative datasets were analysed inductively with findings grounded in the data. We drew on realist principles to analyse the mechanisms of change in relation to context, at both individual and organisational levels. Data synthesis was guided by framework analysis. Findings San Patrignano stakeholders reported six mechanisms related to recovery at the individual level (commitment to change, removal from former social environment, communal living, peer mentor with lived experience, structure and routine, meaningful work). Four mechanisms contributed to success at the organisational level (visionary leadership, staff dedication, social enterprise, and adaptable learning organisation). IFDAS stakeholders reported mechanisms being directly transferred (eg, peer mentor with lived experience, social enterprise) and those being adapted for the Scottish context. Interpretation This is one of the first studies to investigate transferability of a successful drug recovery community across different cultural contexts with the aim to prospectively identify essential mechanisms and adaptations required to enhance implementation of the new intervention in Scotland. This study will also contribute to formulation of generic principles on transferability of successful complex interventions across different sociocultural contexts. Funding UK Medical Research Council and Scottish Government Chief Scientist Office Complexity in Health Improvement programme (MC_UU_12017/14).

BACKGROUND:Digital health has the potential to support care delivery for chronic illness. Despite positive evidence from localized implementations, new technologies have proven slow to become accepted, integrated, and routinized at scale.OBJECTIVE:The aim of our study was to examine barriers and facilitators to implementation of digital health at scale through the evaluation of a £37m national digital health program: ‟Delivering Assisted Living Lifestyles at Scale" (dallas) from 2012-2015.METHODS:The study was a longitudinal qualitative, multi-stakeholder, implementation study. The methods included interviews (n=125) with key implementers, focus groups with consumers and patients (n=7), project meetings (n=12), field work or observation in the communities (n=16), health professional survey responses (n=48), and cross program documentary evidence on implementation (n=215). We used a sociological theory called normalization process theory (NPT) and a longitudinal (3 years) qualitative framework analysis approach. This work did not study a single intervention or population. Instead, we evaluated the processes (of designing and delivering digital health), and our outcomes were the identified barriers and facilitators to delivering and mainstreaming services and products within the mixed sector digital health ecosystem.RESULTS:We identified three main levels of issues influencing readiness for digital health: macro (market, infrastructure, policy), meso (organizational), and micro (professional or public). Factors hindering implementation included: lack of information technology (IT) infrastructure, uncertainty around information governance, lack of incentives to prioritize interoperability, lack of precedence on accountability within the commercial sector, and a market perceived as difficult to navigate. Factors enabling implementation were: clinical endorsement, champions who promoted digital health, and public and professional willingness.CONCLUSIONS:Although there is receptiveness to digital health, barriers to mainstreaming remain. Our findings suggest greater investment in national and local infrastructure, implementation of guidelines for the safe and transparent use and assessment of digital health, incentivization of interoperability, and investment in upskilling of professionals and the public would help support the normalization of digital health. These findings will enable researchers, health care practitioners, and policy makers to understand the current landscape and the actions required in order to prepare the market and accelerate uptake, and use of digital health and wellness services in context and at scale.

Problem: The ‘dallas’ programme was a pan-UK programme designed to deliver a broad portfolio of digital tools and services for Healthcare self-management and preventive care through leveraging the potential of technologies. There is currently great interest in the factors which contribute to, or impede, the implementation of such complex interventions at scale and in real world settings. Approach: We conducted a longitudinal qualitative evaluation to help us chart the complex change processes within and across the ‘dallas’ programme during its lifecycle (May 2012 - May 2015). We have drawn on a rigorous socio-technical theory; Normalisation Process Theory (NPT), which has been used previously to investigate the implementation of e-Health interventions. We conducted a series of in-depth, e-Health Implementation Toolkit (e-HIT) -led interviews at ‘Baseline’ (n=17); ‘Mid-point’ (n=21); and ‘End-point’ (n=10) of the ‘dallas’ programme, with a purposive sample of key stakeholders from each of the four ‘dallas’ communities. Ethnographic data was gathered at ‘dallas’ Lead Stakeholders’ meetings/events held at key points during the evolution of the programme. Data were analysed using a Coding Frame work drawing from NPT and synthesis of results was guided by Framework Analysis. Findings: Data analysis showed that key stakeholders recognised the role that ‘dallas’ has played in enabling them to operationalise aspects of Service re-design to deliver more personalised, digital tools and services for citizens and health service users. The ‘dallas’ communities reported significant “distance travelled” towards sustaining new service models developed during the programme. For example, some communities were awarded EU Reference Site status, others had attracted significant onward funding, whilst other new models were being integrated into routine service provision. Several of the stakeholders also reported arriving at destinations that were unforeseen at the outset of the programme, such as a shift to aligning more closely with pro-active GP practices when implementing some Telehealth interventions. Consequences: As the ‘dallas’ communities progressed towards ‘End-point’ there was evidence of greater ‘Coherence’ across the four communities resulting in sharing of knowledge to help sustainability at a wider programme level. There was also active emergence of knowledge during real-world implementation of ‘dallas’. This resonates with the current literature on implementation of interventions in uncertain, complex systems such as Healthcare services in the real world. Importantly, the knowledge captured from the process evaluation of the unique ‘dallas’ programme will help identify underpinning factors that may contribute to, or impede, such complex eHealth implementations programmes in the future.

Context: Digital health has great potential but has proven slow to become accepted, integrated and routinized at scale. Here we have examined factors affecting readiness to implement digital health at scale, through the evaluation of a national digital health and wellbeing programme called ‘Delivering Assisted Living Lifestyles at Scale’ (dallas, 2012-2015, $52M). Objective: To identify barriers and facilitators to digital health and to make recommendations about how to promote uptake of digital health. Design: Longitudinal (3 years) qualitative study involving Interviews (n=126) with key stakeholders; Focus groups (n= 7) with professionals/public using dallas services; dallas leads meetings (N=12); ethnographic field work/participant observation in one community (n=16); and cross programme documentary evidence (N=215) used to evaluate the implementation of the dallas programme. Normalisation Process Theory underlying conceptual framework. Framework approach to analysis. Setting: UK wide general population. Participants: Key stakeholders: health professionals, managers, IT staff, industry, voluntary sector, and the public. Results: Issues influencing readiness for digital health were noted at three levels: Macro (market; infrastructure; policy), Meso (organisational) and Micro (professional/public). Factors hindering implementation included: lack of IT infrastructure both locally and nationally; uncertainty around information governance; lack of incentives to prioritise interoperability; lack of precedence on accountability within commercial sector; a market perceived as difficult to navigate; inadequate implementation resources; low IT skills and access across users (professional and lay); and concerns surrounding security and safety. Factors enabling implementation included: clinical endorsement; digital health champions; and public and professional willingness to embrace digital health. Conclusions: There is receptiveness to digital health, but substantial barriers to widespread use remain. Recommendations include: greater investment in national and local infrastructure, implementation of clear systems for accreditation and quality assurance, incentivisation of interoperability, and investment in upskilling of professionals and public would help support normalisation of digital health.

A personal child health record called the eRedBook was recently piloted in the United Kingdom. A qualitative exploratory case study was used to examine how public health nurses engaged or recruited parents and what factors hindered participation. Interviews and focus groups were conducted with those implementing the eRedBook and those taking part in the pilot study. A range of project documentation was also reviewed. Thematic analysis using the framework approach was applied to draw out themes. Numerous socio-technical factors such as the usability of the software, concerns over data protection and costs, poor digital literacy skills and a lack of Internet connectivity emerged. These barriers need to be addressed before the eRedBook is implemented nationwide.

The Delivering Assisted Living Lifestyles at Scale (dallas) program was a large-scale, nationwide deployment of digital health and wellbeing products and services in the UK. Telehealth, telecare, mobile apps, personal health records, and assisted living technology were implemented by four large multi-stakeholder consortia and a multidimensional evaluation was carried out across the lifecycle from examining co-design and redesign of services through to rolling out services via statutory, private and consumer routes. A flexible toolkit of descriptive, process and outcome measures was developed and iteratively refined throughout the program. This approach enabled a longitudinal mixed-methods evaluation, underpinned by a robust social theory of implementation called ‘Normalization Process Theory’. There remains uncertainty about the best approaches to real world digital health evaluation. This program provided a unique opportunity to develop the knowledge base and toolkit of qualitative and quantitative methods necessary to evaluate person-centered digital health technologies deployed at scale.