Introduction:Co-production is an important practice for addressing health disparities and developing equitable services with underserved communities. Co-production aims to ensure that underserved communities are central to the design of services that reflect community needs. African and Caribbean heritage communities (ACHC) face heightened risks of HIV due to stigma, discrimination, social, economic and structural factors, leading to significant health inequities. Despite a national target to end new HIV transmissions by 2030, HIV remains prevalent. Common Ambition Bristol (CAB) is a co-production project aiming to increase HIV knowledge and testing. CAB's Project Delivery Group (PDG) involves ACHC community members and sexual health staff working in equal partnership to improve sexual health services for ACHC. Methods:A longitudinal qualitative evaluation explored the process of CAB's co-production over time. Interviews were conducted with members of CAB's PDG at three time points. Interviews examined PDG views and experiences of the co-production process. Data were analysed thematically. Results:Five themes are reported which relate to equitable power-sharing and inclusive decision-making: (1) Acknowledging power imbalances and negotiating roles, (2) Appreciating commonalities and the importance of language, (3) Benefits of sharing lived and sexual health experiences, (4) Negotiating different opinions safely and (5) Co-production: the messy middle. Conclusions:Findings underscore the potential of co-production to drive meaningful progress in health equity. Key elements of co-production which promote equitable power-sharing and effective decision-making are: (1) acknowledging and addressing unequal power structures which may affect group dynamics; (2) fostering reciprocal learning from lived experience and sexual health expertise; (3) recognising and appreciating personal and sexual health commonalities; (4) negotiating and developing ways to ensure equitable decision-making and (5) agreeing a shared language which reflects 1-4.

Background Cognitive–behavioural therapy is an effective treatment for depression. A key question is how to increase access. Engagement with cognitive–behavioural therapy-based computerised interventions is poor, and programmes are inflexible and impersonal. Innovative use of technology and integration of online materials could increase engagement and widen access. Objectives To develop and evaluate a novel approach to delivering cognitive–behavioural therapy for depression integrating therapist-led sessions and online cognitive–behavioural therapy materials. Design and methods The INTEgrated theRApist and online CbT for depression research programme comprised four work packages. The first developed the online therapy platform and materials, and training for therapists. This comprised a series of studies: a systematic review and network meta-analysis to compare the effectiveness of different types and components of cognitive–behavioural therapy; a Delphi study focused on the effective components of cognitive–behavioural therapy; a decision model to evaluate the cost-effectiveness of different formats of delivering cognitive–behavioural therapy; a survey of accredited cognitive–behavioural therapy therapists asking about their use and views of different resources used in cognitive–behavioural therapy; and iterative design work aimed at understanding the design requirements for the platform. The prototype platform was then evaluated in a pilot study, with subsequent final refinement. The second and third work packages evaluated the clinical and cost-effectiveness of the intervention compared with usual general practitioner care in a multicentre randomised controlled trial (with a parallel economic evaluation) over 12 months in primary care patients with depression. The fourth examined the intervention’s acceptability through a nested qualitative study of patients, therapists and supervisors. Setting The randomised controlled trial was based in United Kingdom primary care in Bristol, London and York. Participants Patients aged ≥ 18 years experiencing depressive symptoms in primary care were eligible for the randomised controlled trial. Interventions In the randomised controlled trial, participants were individually randomised to: (1) integrated cognitive–behavioural therapy (in addition to usual general practitioner care); or (2) to continue with usual general practitioner care. Main outcome measures The primary outcome for the randomised controlled trial was depressive symptoms measured using the Beck Depression Inventory, version 2 at 6 months post randomisation. Secondary outcomes included response and remission (based on Beck Depression Inventory, version 2 score), depressive symptoms (Patient Health Questionnaire-9), anxiety symptoms (Generalised Anxiety Disorder-7), function (Work and Social Adjustment Scale), quality of life (EuroQol-5 Dimensions, five-level version), and costs of interventions and wider services. Results Work package 1: the network meta-analysis found no evidence of effect for any content components or combinations of components. There was uncertainty around estimates of cost-effectiveness for different treatment modalities and intensities. Effective components of cognitive–behavioural therapy were identified through the Delphi study, and resources used by therapists identified through a survey of United Kingdom cognitive–behavioural therapy practitioners. Key requirements of an online platform identified through iterative design work were: (1) overcoming depression-related barriers; (2) supporting engagement; (3) reinforcing learning and skill acquisition. In a pilot study with 18 primary care patients, patients said that the integrated approach made therapy more accessible. Therapists commented on the flexibility of the approach. Not all participants engaged with between-session tasks and some technical issues were experienced. Platform refinements were made prior to the randomised controlled trial. Work package 2: overall, 451 patients were recruited to the INTEgrated theRApist and online CbT for depression randomised controlled trial. Participants were predominantly female (n = 313, 69%) and, on average, aged 39 years. The mean Beck Depression Inventory, version 2 score at baseline was 32.8, indicative of severe depression. Most had a history of depression (nearly half having had five or more prior episodes of depression), were taking antidepressants (70%) and the duration of the current episode of depression was ≥ 2 years for 51% of participants. In the intervention group, 14 individuals (6.2%) had no therapy sessions and 137 participants (60.9%) completed therapy (received at least 9 sessions or reached an agreed end of therapy with their therapist in fewer than 9 sessions). Including the above 14 individuals, 88 (39.1%) either withdrew from therapy (n = 50) or were discharged for non-attendance (n = 38). In total 334 patients (171 integrated cognitive–behavioural therapy; 163 usual care) were included in the primary analysis. The intervention group had a Beck Depression Inventory, version 2 score that was, on average, 4.4 points lower (less depressed) than the usual care group at 6 months [difference in means: −4.4 (95% confidence interval −7.0 to −1.9); p = 0.001]. In repeated-measures analyses using data from 6 and 12 months, individuals in the intervention group had a Beck Depression Inventory, version 2 score that was, on average, 3.8 points lower than those in the usual care group (95% confidence interval −6.1 to −1.5; p = 0.001). The intervention group had a twofold increased odds of response and remission, fewer symptoms of depression (Patient Health Questionnaire-9) and anxiety (Generalised Anxiety Disorder-7), and improved functioning (Work and Social Adjustment Scale). Work package 3: the mean costs of integrated cognitive–behavioural therapy were £987 (standard error £14) per participant. The mean costs of usual care were estimated at £382 (standard error £57) in usual care group and £193 (standard error £42) in intervention group. In the primary analyses, costs from the National Health Service/Personal Social Services perspective were £753 (standard error £77) per participant in the usual care group and £1754 (standard error £127) in the intervention group, with adjusted incremental costs of £1009 (95% confidence interval £737 to £1286). The mean quality-adjusted life-years were 0.554 (standard error 0.017) in the usual care group and 0.597 (standard error 0.017) in the intervention group, with adjusted incremental quality-adjusted life-years at 0.033 (95% confidence interval −0.002 to 0.059). The incremental cost-effectiveness ratio was £30,576 per quality-adjusted life-year gain. Complete-case analysis from the National Health Service/Personal Social Services perspective showed a slightly more favourable picture with an incremental cost-effectiveness ratio at £22,421. Work package 4: through interviews with trial participants and therapists, we found that the integrated approach helped patients manage their depression. Platform benefits included the opportunity to review transcripts and to support homework tasks. Typing allowed reflection and a focused discussion. Less could be covered than during an in-person session. Patients who did not complete therapy struggled with typing and found cognitive–behavioural therapy too demanding. Limitations In the trial, the 6-month follow-up rate was slightly below the original target. Conclusions Integrated cognitive–behavioural therapy is an effective and acceptable treatment for patients with depression. There was uncertainty around the cost-effectiveness of the intervention. This novel mode of delivery could increase the availability of cognitive–behavioural therapy and access for those who find it difficult to attend appointments in person. Future work To examine whether effects are sustained long term and to understand which aspects of the platform lead to improvements. Study registration This study is registered as ISRCTN14850613 (phase 2 pilot study) and ISRCTN13112900 (RCT). 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-0514-20012) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 13. See the NIHR Funding and Awards website for further award information. Plain language summary There is a high demand for talking therapies such as cognitive–behavioural therapy for depression. Cognitive–behavioural therapy can be delivered by computers or online as written guidance that can be worked through with or without support. These computerised therapy packages are inexpensive and convenient but are not as effective or as engaging as having a therapist. They do not allow treatment to be tailored for the individual. We built an online therapy platform. This combined live therapist sessions with online materials to help patients practise outside the sessions. In the first session, patients and therapists met by videocall. Thereafter, they communicated by typing during live online therapy sessions. We worked with stakeholders to develop integrated cognitive–behavioural therapy. Patients could receive between 9 and 12 sessions of therapy. We evaluated integrated cognitive–behavioural therapy in three ways: We recruited 451 patients with depression and randomly allocated them to either integrated cognitive–behavioural therapy or to continue with usual general practitioner care. Those allocated to therapy were less depressed and more likely to have recovered after 6 and 12 months. This means we can be confident that this is a clinically effective treatment. We assessed whether integrated cognitive–behavioural therapy was good value for money. Although patients felt better, the treatment just failed to meet criteria for value for money. However, the average cost of integrated cognitive–behavioural therapy was similar to the cost of therapy in National Health Service talking therapy services. In-depth interview study: we asked patients and therapists about the treatment. They found it acceptable. Patients who completed the therapy valued being able to talk to a therapist and had learnt skills to manage their depression. Reviewing the record of therapy sessions helped them complete homework tasks and track progress. While less could be covered in a session compared with in-person therapy, the slower pace allowed room for reflection. This also meant therapists used more focused questions. Some patients found it difficult to express themselves through typing. Scientific summary Some text in this section is reproduced from Tallon D, Thomas L, Brabyn S, Ching BCF, Hahn JS, Jude B, et al. Integrated therapist and online CBT for depression in primary care (INTERACT): study protocol for a multi-centre randomised controlled trial. Trials 2023;24:421. https://doi.org/10.1186/s13063-023-07396-9). This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text. Background Cognitive–behavioural therapy (CBT) is an effective treatment for depression and recommended by the National Institute for Health and Care Excellence (NICE). A key question for commissioners and healthcare providers is how to increase access. Cognitive–behavioural therapy-based computerised CBT interventions form part of the stepped care pathway for depression but are not an alternative to high-intensity CBT as they lack flexibility and are impersonal. Cognitive–behavioural therapy delivered online using instant messaging is clinically and cost-effective. Developing materials that are integrated with modern technologies yet permit the therapist to tailor treatment to the individual is critical. Ready access to such materials could facilitate engagement with tasks that take place outside therapy sessions and increase effectiveness. In 2020–1, 90% of UK households had a home computer and 84% of over 16-year-olds private use of a smartphone. Innovative use of technological developments and integration of online materials into therapy offers the potential to increase engagement and widen access to populations that are difficult to reach (e.g. those who are disabled or have difficulty attending appointments for other reasons). Our intervention integrates therapist-led sessions and online CBT materials in a novel approach to the treatment of depression. Aims and objectives The aim of the INTEgrated theRApist and online CbT for depression (INTERACT) programme was to develop [work package (WP) 1] and evaluate (WPs2–4) an integrated approach to delivering CBT for depression in primary care (integrated CBT). The specific aims of the WPs are listed below. Work package 1: intervention development To identify clinical and cost-effective components of CBT to inform the development of the intervention. To develop an online platform to support the delivery of integrated CBT. To develop the online CBT materials. To develop a training package for therapists. Work package 2: randomised controlled trial To examine the clinical effectiveness of an integrated approach to delivering CBT for depression over 12 months’ follow-up. Work package 3: economic evaluation To examine the cost-effectiveness of the integrated CBT intervention. Work package 4: qualitative evaluation To explore patients’, therapists’ and supervisors’ views and experiences of using an integrated approach to delivering CBT for depression. To understand patients’ reasons for completing or not completing integrated therapy. To assess patients’, therapists’ and supervisors’ views on how this novel approach affects the therapist-patient relationship. Methods and results Work package 1: intervention development Systematic review and network meta-analysis of cognitive–behavioural therapy components We conducted a systematic review of randomised controlled trials (RCTs) in adults with depression, which included a CBT intervention, to compare the effectiveness of different types of therapy, different components and combinations of components and aspects of delivery used in CBT for depression. Outcomes were pooled using standard and component-level network meta-analysis (NMA). Among 91 studies included, there was strong evidence that CBT interventions resulted in a larger short-term decrease in depressive symptoms compared with treatment as usual (TAU). The standardised difference in mean change for face-to-face (F2F) CBT compared with TAU was −1.11 [95% credible interval −1.62 to −0.60]; for hybrid CBT was −1.06 (−2.05 to −0.08); and for multimedia CBT was −0.59 (−1.20 to 0.02). A wait list control was detrimental compared with TAU [0.72 (0.09 to 1.35)]. While multimedia and hybrid CBT may be as effective as F2F CBT, there was substantial uncertainty in the estimates of treatment effectiveness. We found no evidence of specific effects of any content components or combination of components. Delphi Study on effective components of cognitive–behavioural therapy We aimed to establish an expert consensus on the effective components of CBT for adults with depression. An international panel of CBT experts (n = 120) was invited to participate in an online survey. In round 1, experts rated the effectiveness of 35 items covering both content and process components of CBT. In a second round, experts rerated components to reach a consensus. Of those invited, 32 participated in round 1 and 21 also provided data in round 2. Consensus was achieved in relation to nine content components (that facilitate behaviour change) and three process components (procedures for therapy delivery). Generic therapeutic competences comprised five of the nine content components. There was less agreement about the effectiveness of cognitive components of CBT. Cost-effectiveness of different formats for delivery of cognitive–behavioural therapy for depression We developed a decision model to evaluate the cost-effectiveness of F2F CBT, multimedia CBT and hybrid CBT, given in addition to TAU, in comparison with TAU alone. F2F and hybrid CBTs were modelled by treatment intensity defined by combinations of number and length of CBT sessions. The model covered an average treatment period of 4 months with a 5-year follow-up period to extrapolate long-term cost-effectiveness. The model inputs were derived from our NMA and the literature. The primary outcome was quality-adjusted life-years (QALYs). All CBT modes given in addition to TAU were more cost-effective than TAU alone. Probabilistic sensitivity analyses found that F2F CBT with intensities of six 30-minute sessions and sixteen 60-minute sessions had the highest probability of being cost-effective. However, neither option reached 50% probability of being most cost-effective (32.5% and 31.1%, respectively). There was substantial uncertainty around estimates. Development of the online therapy platform This comprised: (1) an iterative design stage, (2) a pilot study and (3) final refinement. In phase 1, we held individual interviews, prototype testing sessions, platform walkthroughs and workshops with stakeholders aimed at understanding the design requirements for the platform. Feedback informed the intervention design. Three requirements were identified for integrated CBT therapy platforms: (1) features to overcome depression-related barriers; (2) features that support engagement; and (3) that reinforce learning and support the acquisition and learning of new skills. Therapists highlighted the importance of collaborative working, and the impact of technology on therapists’ workflow and workload, and its potential in supporting clients’ engagement. In phase 2, we conducted a pilot study to evaluate usability and user experience of the intervention. Patients with depression were recruited from primary care and offered a course of integrated therapy using the newly developed platform. Qualitative interviews were conducted with patients, including those who completed and withdrew from therapy. Eighteen patients with depression were recruited from primary care. Of these, 10 completed therapy. Initial interviews were conducted with 13 patients (after 3–6 therapy sessions), and 9 ‘end of therapy’ interviews were completed. Patients appreciated the first session being F2F so they could meet their therapist and build rapport. Typing limited the amount discussed during online sessions, but some patients noted it aided focus and promoted reflection. Patients said that the integrated approach made therapy more accessible, but not all patients engaged with between-session tasks. Some found the worksheets too complex. Usage data showed that patients reviewed transcripts of the instant messaging therapy sessions and commented that these were a useful learning aid. Some technical issues were experienced that sometimes led to lower engagement. Phase 3 involved final refinement of the platform following feedback from patients, therapists and wider stakeholders, and input from the multidisciplinary study team. Platform security was assessed. Development of cognitive–behavioural therapy materials for the online platform We conducted a survey of 3665 accredited UK CBT therapists asking about their use and views of resources commonly described in CBT manuals. Overall, 994 individuals (27%) responded and a further 33 completed the questionnaire online. Over 85% of respondents used symptom measures, lists of problems/goals, activity schedules, behavioural activation diaries/plans, and case formulation worksheets ‘frequently’ or ‘very frequently’. Selection of platform materials was based on: therapist survey findings; the competency framework for CBT for depression; Delphi findings; and systematic review and NMA findings. Most worksheets were selected from resources already available and familiar to therapists. Development of a training package for therapists Training for the therapists employed for WP1.3 – phase 2 was developed and delivered with CBT experts in the research team and supported by the therapists’ supervisor. Online training for the RCT included lectures covering the trial background, therapy protocol, managing risk, and role play. Work package 2: randomised controlled trial We conducted a pragmatic RCT of 451 patients with depression from 67 general practices in 3 UK sites. Patients aged ≥ 18 years, scoring ≥ 14 on the Beck Depression Inventory, version 2 (BDI-II) and who met International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) criteria for depression were eligible. Patients were individually randomised to either integrated CBT [in addition to usual care (UC)] or to continue with usual general practitioner care (UC). The primary outcome was BDI-II score at 6 months post randomisation. Secondary outcomes included response and remission (based on BDI-II), other measures of depression and anxiety [Patient Health Questionnaire-9 items (PHQ-9)/Generalised Anxiety Disorder-7 (GAD-7)], function [Work and Social Adjustment Scale (WSAS)], EuroQol-5 Dimensions, five-level version, and costs of interventions and wider services at 6 and 12 months. The primary analyses were of 334 patients (171 integrated CBT; 163 UC). Those in the intervention group had a BDI-II score that was, on average, 4.4 points lower (less depressed) than those in the UC group at 6 months {difference in means: −4.4 [95% confidence interval (CI) −7.0 to −1.9]; p = 0.001}. In repeated-measures analyses using data from 6 and 12 months, the intervention group had a BDI-II score that was, on average, 3.8 points lower than the UC group (95% CI −6.1 to −1.5, p = 0.001). The intervention group had a twofold increased odds of response (≥ 50% improvement in symptoms) and remission (BDI-II score < 10), fewer symptoms of depression (PHQ-9) and anxiety (GAD-7), and less functional impairment (WSAS). Work package 3: economic evaluation We assessed cost-effectiveness from three perspectives: NHS and Personal Social Services (PSS); participants and their informal carers; and societal. Costs were collected accordingly. The primary analysis was an incremental cost–utility analysis of integrated CBT over and above UC, over 12 months from an NHS and PSS perspective. The incremental cost-effectiveness ratio (ICER) was calculated by dividing incremental costs by incremental QALYs. The mean costs of integrated CBT were £987 [standard error (SE) £14] per participant. The mean costs of UC were estimated at £382 (SE £57) in the UC group and £193 (SE £42) in the intervention group. In the primary analysis, costs from the NHS/PSS perspective were £753 (SE £77) per participant in the UC group and £1754 (SE £127) in the intervention group, with adjusted incremental costs of £1009 (95% CI £737 to £1286). The mean QALYs were 0.554 (SE 0.017) in the UC group and 0.597 (SE 0.017) in the intervention group, with adjusted incremental QALYs at 0.033 (95% CI −0.002 to 0.059). The ICER was £30,576 per QALY gain (probability of cost-effectiveness from £20,000 to £30,000: 13%–39%). Complete-case analysis (CCA) from NHS/PSS perspective showed a slightly more favourable picture with ICER at £22, 421 (probability of cost-effectiveness: 37%–66%). Work package 4: qualitative evaluation A qualitative study was nested within the main trial. We interviewed 30 patients (20 who received the intervention and 10 from UC), 9 therapists and 3 therapist supervisors. Data were analysed using thematic analysis. The combination of one-to-one sessions with a therapist and having access to integrated online CBT resources enabled patients to better manage their depression. Benefits included the opportunity to review transcripts to clarify homework tasks and track progress in managing their depression. Those who completed therapy valued talking to a therapist and accessing CBT resources within a single platform. Those who did not complete therapy found it difficult to express themselves through typing and found the CBT approach too demanding. As typing limited what could be covered in a single session, therapists restricted the session agenda and asked more focused questions. Conclusions Developing an integrated approach to delivering cognitive–behavioural therapy Based on the systematic review and NMA of trials of CBT interventions, we found no evidence of specific effects of any content components or combinations of components of CBT interventions to inform the platform development. Our decision model showed that there was uncertainty around estimates of cost-effectiveness for different treatment modalities and intensities limiting the extent to which this work could inform the intervention design. Through our survey of CBT therapists, we identified the most frequently used resources. The Delphi study provided insight into the generic therapeutic competences that CBT experts agreed on. In the absence of evidence on the effective or cost-effective components of CBT from the earlier systematic review, NMA and decision model, the findings from the survey and Delphi study were used to map and identify the CBT resources required within our online platform that aligned with the CBT competences framework. Iterative development of the online therapy platform resulted in a prototype platform that was acceptable to patients and therapists. Integrated CBT was provided to a small sample of depressed patients recruited from primary care. Effectiveness, cost-effectiveness and acceptability of an integrated approach to delivering cognitive–behavioural therapy Integrated CBT was effective in reducing depressive symptoms in primary care patients with depression. Benefits were also seen for the outcomes of response and remission in depressive symptoms, and symptoms of anxiety. Improvements were maintained over 12 months. The intervention was not cost-effective based on the current thresholds used by NICE. However, the intervention cost included training costs that would be unlikely to be maintained at the same level if the intervention was rolled out in NHS services. Further, once trained, therapists could treat more patients (beyond the study sample) which would reduce the per-patient training cost and may make the longer-term cost–benefit more favourable. The intervention was acceptable to patients and therapists. The qualitative study highlighted the importance of establishing patient and therapist goals and expectations about what can be achieved in CBT mediated by typing. Some patients are comfortable communicating via typing and are motivated to utilise online resources between sessions. Exploring the benefits and challenges of integrated CBT with patients will enable them to make an informed choice about referral for this novel therapy. Implications for health care The COVID-19 pandemic resulted in many services moving to remote delivery of therapy. There has also been a proliferation of mental health apps in recent years, but with little empirical evidence to support their use. The integrated approach that we have developed is of proven effectiveness. While the intervention was just above the upper limit in terms of accepted thresholds of value for money, the costs of training may be over-estimated compared to those incurred if this intervention was implemented within the NHS. Importantly, the approach was acceptable to patients and therapists and as such offers the potential to increase access for those who find it difficult to attend therapy appointments in person. Recommendations for research Future research needs to examine The longer-term clinical and cost-effectiveness of integrated cognitive–behavioural therapy Studies of in-person CBT have found that CBT is a clinically and cost-effective intervention over four years. Evidence is thus needed to quantify and substantiate the long-term gain for this integrated CBT approach. Which aspects of the platform led to improvements in depression This may enable refinement of the intervention to increase benefits. Study registration This study is registered as ISRCTN14850613 (phase 2 pilot study) and ISRCTN13112900 (RCT). 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-0514-20012) and is published in full in Programme Grants for Applied Research; Vol. 14, No. 13. See the NIHR Funding and Awards website for further award information.

BACKGROUND:Integrating therapist-led sessions and cognitive behavioural therapy (CBT) materials within one online platform may be effective for people with depression. A trial evaluating this mode of delivering CBT is being conducted. To maximise future trial recruitment and understand patients' views of health interventions, it is important to explore reasons for declining to participate. AIM:To explore patients' reasons for declining to participate in a trial of integrated online CBT for depression. DESIGN & SETTING:A mixed-methods study collecting data from patients via questionnaires and telephone interviews at three UK trial sites. METHOD:Individuals completed a short questionnaire about their reasons for not taking part in the trial. Telephone interviews further explored these reasons with a subgroup. Quantitative data were summarised using descriptive statistics. Qualitative interviews were analysed thematically. RESULTS:Of 1799 patients who responded to an invitation to participate in the trial, 40.3% declined contact. The most common reasons were not wanting: to take part in research (n = 387); therapy provided online (n = 284); to receive CBT (n = 262). Qualitative interviews with 15 'decliners' highlighted that decisions related to perceptions of eligibility, previous experiences of CBT, and uncertainty about receiving CBT online. Personal circumstances, depressive symptoms, or other mental health issues were also barriers to participation. CONCLUSION:Reasons given by primary care patients for not taking part in a trial of integrated online CBT suggest that, at the point of recruitment, it is important to discuss the patient's perceptions of their eligibility and whether they would accept the intervention being evaluated.

Objectives Hip fractures are common injuries in older age with high mortality requiring multidisciplinary clinical care. Despite guidance, there is considerable variation in hip fracture services and patient outcomes; furthermore, little is known about how successful multidisciplinary working can be enabled. This study aimed to characterise professionals’ views about the core components of multidisciplinary teamwork in hip fracture care.Design The study comprised qualitative interviews with healthcare professionals delivering hip fracture care. Interviews were audio recorded, transcribed and analysed abductively: material was coded inductively and grouped into higher level concepts informed by theories and frameworks relating to teamwork.Setting Four hospitals in England.Participants Participants were 40 healthcare professionals including orthopaedic surgeons, orthogeriatricians, physiotherapists and service managers.Results Results identified four components of successful multidisciplinary teamwork: (1) defined roles and responsibilities, (2) information transfer processes, (3) shared goals and (4) collaborative leadership. These were underpinned by a single concept: shared responsibility. Defined roles and responsibilities were promoted through formal care pathways, reinforced through induction and training with clear job plans outlining tasks. Information transfer processes facilitated timely information exchange to appropriate individuals. Well-defined common purpose was hindered by complex interdisciplinary professional relationships, particularly between orthogeriatric and orthopaedic staff, and encouraged through multidisciplinary team meetings and training. Clinical service leads were integral to bridging interdisciplinary boundaries. Mutual trust and respect were based on recognition of the value of different professional groups. Teamwork depended on formal clinical leads with facilitative and motivational roles, and on hospital leadership that created an environment supporting collaboration. Shared responsibility for patients was encouraged by joint orthopaedic and orthogeriatric care models. Staff shared responsibility by assisting colleagues when needed.Conclusions Shared responsibility across the multidisciplinary team is fundamental to delivery of hip fracture care. Findings will inform development of clinical practice recommendations and training to build teamworking competencies.

BACKGROUND:CBT is an effective treatment for depression, but access varies across the United Kingdom. Online CBT increases access. The INTERACT platform was designed to support patient engagement in CBT, enabling therapists to deliver high-intensity CBT via typed instant messaging and allowing patients and therapists access to an integrated online library of resources during and between sessions. METHODS:The INTERACT trial aimed to evaluate this integrated approach to delivering CBT for primary care patients with depression. A nested qualitative study was conducted within the trial. Interviews were conducted with 20 patients who received the intervention, 9 therapists who delivered it and 3 therapist supervisors. Data were analysed using thematic analysis. RESULTS:The combination of receiving support from a therapist and having access to integrated online CBT resources enabled patients to better manage their depression. Platform benefits included the opportunity to review transcripts to clarify how to complete homework tasks and track progress in managing their depression. The typing process allowed reflection and a focused discussion. However, less could be covered than during an in-person session, which reduced therapists' expectations around goal setting. Patients who did not complete therapy struggled with the typing and found the CBT approach too demanding. CONCLUSION:Findings highlight the importance of establishing patient and therapist goals and expectations about what can be achieved in CBT mediated by typing. Some patients are comfortable communicating via typing and are motivated to utilise online resources in between sessions. Exploring the benefits and challenges of typed CBT with patients will enable them to make an informed choice about referral for this novel approach to therapy. PATIENT OR PUBLIC CONTRIBUTION:Patients, service users and members of the public were involved in the study design and management. Substantial pilot work gathered stakeholder feedback and informed the design of the intervention, before undertaking the RCT. Coauthor P.L. is a service user representative co-applicant and member of the management group responsible for developing the intervention and the trial. Two PPI members sit on the Independent Steering Committee. PPI members provided valuable feedback on the study resources and documents.

Abstract Background Cognitive behavioural therapy (CBT) is an effective treatment for depression. Self-directed online CBT interventions have made CBT more accessible at a lower cost. However, adherence is often poor and, in the absence of therapist support, effects are modest and short-term. Delivering CBT online using instant messaging is clinically and cost-effective; however, most existing platforms are limited to instant messaging sessions, without the support of between-session “homework” activities. The INTERACT intervention integrates online CBT materials and ‘high-intensity’ therapist-led CBT, delivered remotely in real-time. The INTERACT trial will evaluate this novel integration in terms of clinical and cost-effectiveness, and acceptability to therapists and clients. Methods Pragmatic, two parallel-group multi-centre individually randomised controlled trial, with 434 patients recruited from primary care practices in Bristol, London and York. Participants with depression will be identified via General Practitioner record searches and direct referrals. Inclusion criteria: aged ≥ 18 years; score ≥ 14 on Beck Depression Inventory (BDI-II); meeting International Classification of Diseases (ICD-10) criteria for depression. Exclusion criteria: alcohol or substance dependency in the past year; bipolar disorder; schizophrenia; psychosis; dementia; currently under psychiatric care for depression (including those referred but not yet seen); cannot complete questionnaires unaided or requires an interpreter; currently receiving CBT/other psychotherapy; received high-intensity CBT in the past four years; participating in another intervention trial; unwilling/unable to receive CBT via computer/laptop/smartphone. Eligible participants will be randomised to integrated CBT or usual care. Integrated CBT utilises the standard Beckian intervention for depression and comprises nine live therapist-led sessions, with (up to) a further three if clinically appropriate. The first session is 60–90 min via videocall, with subsequent 50-min sessions delivered online, using instant messaging. Participants allocated integrated CBT can access integrated online CBT resources (worksheets/information sheets/videos) within and between sessions. Outcome assessments at 3-, 6-, 9- and 12-month post-randomisation. The primary outcome is the Beck Depression Inventory (BDI-II) score at 6 months (as a continuous variable). A nested qualitative study and health economic evaluation will be conducted. Discussion If clinically and cost-effective, this model of integrated CBT could be introduced into existing psychological services, increasing access to, and equity of, CBT provision. Trial registration ISRCTN, ISRCTN13112900. Registered on 11/11/2020. Currently recruiting participants. Trial registration data are presented in Table 1.

Background: Good Grief Festival was originally planned as a face-to-face festival about grief and bereavement. Due to COVID-19, it was held online over 3 days in October 2020. Objective: To evaluate the festival’s reach and impact. Design: Pre/post evaluation Methods: Pre-festival online surveys assessed reasons for attending and attitudes to bereavement across four items (fear of saying the wrong thing, avoiding talking to someone bereaved, knowing what to do if someone bereaved was struggling, knowing how to help). Post-festival online surveys evaluated audience experiences and the four attitude items. Free-text responses, analysed using thematic analysis, generated suggestions for improvement and general comments. Results: Between 5003 and 6438 people attended, with most attending two to five events. Pre-festival survey participants ( n = 3785) were mostly women (91%) and White (91%). About 9% were from Black or minoritised ethnic communities. About 14% were age ⩾65 years, 16% age ⩽34 years. Around 75% were members of the public, teachers, students or ‘other’; 25% academics, clinicians or bereavement counsellors. A third had been bereaved in the last year; 6% had never been bereaved. People attended to learn about grief/bereavement (77%), be inspired (52%) and feel part of a community (49%). Post-festival participants ( n = 685) reported feeling part of a community (68%), learning about grief/bereavement (68%) and being inspired (66%). 89% rated the festival as excellent/very good and 75% agreed that they felt more confident talking about grief after attending. Higher ratings and confidence were associated with attending more events. Post-festival attitudes were improved across all four items ( p < 0.001). Attendees appreciated the festival, particularly valuing the online format, opportunities for connection during lockdown and the diversity and quality of speakers. Suggestions included improving registration, more interactive events and less content. Conclusion: Good Grief Festival successfully reached a large public audience, with benefit in engagement, confidence and community-building. Evaluation was critical in shaping future events. Findings suggest festivals of this nature can play a central role in increasing death- and grief-literacy within a public health approach.

Background Hip fractures are devastating injuries, with high health and social care costs. Despite national standards and guidelines, substantial variation persists in hospital delivery of hip fracture care and patient outcomes. This qualitative study aimed to identify organisational processes that can be targeted to reduce variation in service provision and improve patient care. Methods Interviews were conducted with 40 staff delivering hip fracture care in four UK hospitals. Twenty-three anonymised British Orthopaedic Association reports addressing under-performing hip fracture services were analysed. Following Thematic Analysis of both data sources, themes were transposed onto domains both along and across the hip fracture care pathway. Results Effective pre-operative care required early alert of patient admission and the availability of staff in emergency departments to undertake assessments, investigations and administer analgesia. Coordinated decision-making between medical and surgical teams regarding surgery was key, with strategies to ensure flexible but efficient trauma lists. Orthogeriatric services were central to effective service delivery, with collaborative working and supervision of junior doctors, specialist nurses and therapists. Information sharing via multidisciplinary meetings was facilitated by joined up information and technology systems. Service provision was improved by embedding hip fracture pathway documents in induction and training and ensuring their consistent use by the whole team. Hospital executive leadership was important in prioritising hip fracture care and advocating service improvement. Nominated specialty leads, who jointly owned the pathway and met regularly, actively steered services and regularly monitored performance, investigating lapses and consistently feeding back to the multidisciplinary team. Conclusion Findings highlight the importance of representation from all teams and departments involved in the multidisciplinary care pathway, to deliver integrated hip fracture care. Complex, potentially modifiable, barriers and facilitators to care delivery were identified, informing recommendations to improve effective hip fracture care delivery, and assist hospital services when re-designing and implementing service improvements.

Abstract Introduction Hip fractures are devastating injuries which incur high healthcare costs. Despite national standards and guidelines, there is substantial variation in hospital delivery of hip fracture care and in patient outcomes. This study aimed to understand organisational processes that facilitate successful delivery of hip fracture services. Method Forty qualitative interviews were conducted with healthcare professionals involved in delivering hip fracture care at four English hospitals. Interview data were supplemented with documentary analysis of 23 anonymised British Orthopaedic Association hospital-initiated peer-review reports of services. Data were analysed thematically, with themes transposed onto key components of the care pathway. Results We identified multiple aspects of service organisation that facilitated good care delivery. At admission, standardisation of training in nerve block administration impacted care delivery. During hospital stays, service delivery was improved by integrated, shared-care between orthopaedics and orthogeriatrics, and by strategies to improve trauma list efficiency. Adequately staffed orthogeriatric services and the ‘right’ skills and seniority mix were important to holistic care provision. Placing patients on designated hip fracture wards concentrated staff expertise. Collaborative working was achieved through multi-disciplinary team (MDT) meetings between key staff, protocols and care pathways that defined roles and responsibilities, MDT documentation, ‘joined-up’ IT systems within hospitals and with primary care, and shared working spaces such as shared offices and onwards. Trauma and hip fracture coordinators organised care processes and provided a valuable central point of contact within teams. Nominated leads, representing diverse specialties, worked together in MDT planning meetings to develop joint protocols, establish audit priorities, and agree shared goals. Routine, comprehensive monitoring and evaluation of service delivery, with findings shared throughout the MDT, was beneficial. Conclusion Our study has characterised potentially modifiable elements of successful hip fracture service delivery. Findings are intended to help services overcome organisational barriers towards delivery of high-quality hip fracture services.

Background Good Grief Festival was planned as a face-to-face festival to engage the public in multi-disciplinary research about grief and bereavement. Due to COVID-19, the festival was held online over 3 days in October 2020. Aim To evaluate the festival's reach and impact. Methods A pre/post evaluation was conducted via online surveys. Pre-festival surveys assessed reasons for attending and attitudes to bereavement across 4 items (being scared of saying the wrong thing, avoiding talking to someone bereaved, knowing what to do if someone bereaved was having trouble, knowing what kind of help/support to offer). Post-festival surveys evaluated audience experiences and the 4 attitude items. Results 8500+ people attended, with most attending 2–5 events. Pre-festival survey participants (n=3785) were majority women (91%) and White (91%). 9% were from Black or minoritized ethnic communities. 14% were age ≥65 years, 16% age ≤34 years. 44% were members of the public. A third had been bereaved in the last year; 6% had never been bereaved. People attended to learn about grief/bereavement (77%), be inspired (52%) and feel part of a community (49%). Post-festival participants (n=685) reported feeling part of a community (68%), learning about grief/bereavement (68%) and being inspired (66%). 89% rated the festival as excellent/very good, with a higher rating associated with attending a greater number of events. 75% agreed that through attending they felt more confident talking about grief. Post-festival attitudes were significantly higher across all 4 items (P<0.001). Free-text data showed appreciation e.g. for the online format, connection in the context of lockdown and ethnic diversity in speakers. Suggestions included improving registration, more interactive/arts-based events and reducing the volume of content. Conclusion Good Grief Festival was successful at reaching a large public audience, with data indicating benefit in terms of engagement and confidence. The evaluation was critical in shaping future events.

Background Surgery for established cataract is highly cost-effective and uncontroversial, yet uncertainty remains for individuals about when to proceed and when to delay surgery during the earlier stages of cataract. Objective We aimed to improve decision-making for cataract surgery through the development of evidence-based clinical tools that provide general information and personalised risk/benefit information. Design We used a mixed methodology consisting of four work packages. Work package 1 involved the development and psychometric validation of a brief, patient self-reported measure of visual difficulty from cataract and its relief from surgery, named Cataract Patient-Reported Outcome Measure, five items (Cat-PROM5). Work package 2 involved the review and refinement of risk models for adverse surgical events (posterior capsule rupture and visual acuity loss related to cataract surgery). Work package 3 involved the development of prediction models for the Cat-PROM5-based self-reported outcomes from a cohort study of 1500 patients; assessment of the validity of preference-based health economic indices for cataract surgery and the calibration of these to Cat-PROM5; assessment of patients’ and health-care professionals’ views on risk–benefit presentation formats, the perceived usefulness of Cat-PROM5, the value of personalised risk–benefit information, high-value information items and shared decision-making; development of cataract decision aid frequently asked questions, incorporation of personalised estimates of risks and benefits; and development of a cataract decision quality measure to assess the quality of decision-making. Work package 4 involved a mixed-methods feasibility study for a fully powered randomised controlled trial of the use of the cataract decision aid and a qualitative study of discordant or mismatching perceptions of outcome between patients and health-care professionals. Setting Four English NHS recruitment centres were involved: Bristol (lead centre), Brighton, Gloucestershire and Torbay. Multicentre NHS cataract surgery data were obtained from the National Ophthalmology Database. Participants Work package 1 – participants ( n = 822) were from all four centres. Work package 2 – electronic medical record data were taken from the National Ophthalmology Database (final set > 1M operations). Work package 3 – cohort study participants were from Bristol ( n = 1200) and Gloucestershire ( n = 300); qualitative and development work was undertaken with patients and health-care professionals from all four centres. Work package 4 – Bristol, Brighton and Torbay participated in the recruitment of patients ( n = 42) for the feasibility trial and recruitment of health-care professionals for the qualitative elements. Interventions For the feasibility trial, the intervention was the use of the cataract decision aid, incorporating frequently asked questions and personalised estimations of both adverse outcomes and self-reported benefit. Main outcome measures There was a range of quantitative and qualitative outcome measures: questionnaire psychometric performance metrics, risk indicators of adverse surgical events and visual outcome, predictors of self-reported outcome following cataract surgery, patient and health-care practitioner views, health economic calibration measures and randomised controlled trial feasibility measures. Data sources The data sources were patient self-reported questionnaire responses, study clinical data collection forms, recorded interviews with patients and health-care professionals, and anonymised National Ophthalmology Database data. Results Work package 1 – Cat-PROM5 was developed and validated with excellent to good psychometric properties (Rasch reliability 0.9, intraclass correlation repeatability 0.9, unidimensionality with residual eigenvalues ≤ 1.5) and excellent responsiveness to surgical intervention (Cohen delta –1.45). Work package 2 – earlier risk models for posterior capsule rupture and visual acuity loss were broadly affirmed ( C -statistic for posterior capsule rupture 0.64; visual acuity loss 0.71). Work package 3 – the Cat-PROM5-based self-reported outcome regression models were derived based on 1181 participants with complete data ( R 2 ≈ 30% for each). Of the four preference-based health economic indices assessed, two demonstrated reasonable performance. Cat-PROM5 was successfully calibrated to health economic indices; adjusted limited dependent variable mixture models offered good to excellent fit (root-mean-square error 0.10–0.16). The personalised quantitative risk information was generally perceived as beneficial. A cataract decision aid and cataract decision quality measure were successfully developed based on the views of patients and health-care professionals. Work package 4 – data completeness was good for the feasibility study primary and secondary variables both before and after intervention/surgery (data completeness range 100–88%). Considering ability to recruit, the sample size required, instrumentation and availability of necessary health economic data, a fully powered randomised controlled trial (patients, n = 800, effect size 0.2 standard deviations, power 80%; p = 0.05) of the cataract decision aid would be feasible following psychometric refinement of the primary outcome (the cataract decision quality measure). The cataract decision aid was generally well-received by patients and health-care professionals, with cautions raised regarding perceived time and workload barriers. Discordant outcomes mostly related to patient dissatisfaction, with no clinical problem found. Limitations The National Ophthalmology Database data are expected to include some errors (mitigated by large multicentre data aggregations). The feasibility randomised controlled trial primary outcome (the cataract decision quality measure) displayed psychometric imperfections requiring refinement. The clinical occurrence of discordant outcomes is uncommon and the study team experienced difficulty identifying patients in this situation. Future work Future work could include regular review of the risk models for adverse outcomes to ensure currency, and the technical precision of complex-numbers analysis of refractive outcome to invite opportunities to improve post-operative spectacle-free vision. In addition, a fully powered randomised controlled trial of the cataract decision aid would be feasible, following psychometric refinement of the primary outcome (the cataract decision quality measure); this would clarify its potential role in routine service delivery. Conclusions In this research programme, evidence-based clinical tools have been successfully developed to improve pre-operative decision-making in cataract surgery. These include a psychometrically robust, patient-reported outcome measure (Cat-PROM5); prediction models for patient self-reported outcomes using Cat-PROM5; prediction models for clinically adverse surgical events and adverse visual acuity outcomes; and a cataract decision aid with relevant general information and personalised risk/benefit predictions. In addition, the successful mapping of Cat-PROM5 to existing health economic indices was achieved and the performances of indices were assessed in patients undergoing cataract surgery. A future full-powered randomised controlled trial of the cataract decision aid would be feasible (patients, n = 800, effect size 0.2 standard deviations, power 80%; p = 0.05). Trial registration This trial is registered as ISRCTN11309852. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research ; Vol. 10, No. 9. See the NIHR Journals Library website for further project information.

Background Hip fractures are a devastating injury with high healthcare costs. Despite national standards and guidelines, there is substantial variation in hospital delivery of hip fracture care and in patient outcomes. This study aimed to understand organisational processes that help or hinder the implementation of hip fracture services, using extended Normalization Process Theory (eNPT), which specifies four constructs that impact on successful implementation: capacity, potential, capability and contribution. Methods Thirty semi-structured interviews were conducted with healthcare professionals involved in delivering hip fracture care at four hospitals across England. Staff were purposively sampled from across the care pathway, and comprised emergency department staff, orthogeriatricians, orthopaedic surgeons, physiotherapists and discharge coordinators. Data were analysed thematically and themes transposed onto constructs from eNPT. Results The capacity of healthcare professionals to co-operate and co-ordinate their practice was achieved using formal mechanisms including shared information systems, multi-disciplinary team (MDT) meetings and integrated MDT documentation and protocols. Trauma coordinators organised important processes of care and facilitated MDT co-working. Transfer of patient information was compromised when these systems were not effectively implemented. Shared working spaces promoted frequent and spontaneous communication. Individual potential and commitment to operationalise services occurred through multiple processes. Training, mentoring and support for junior staff, particularly rotating doctors, helped their engagement in patient care. Shared commitment was undermined by complex dynamics between different professional groups, particularly medical and surgical staff. Clinical leads bridged these professional boundaries and promoted shared patient goals. Capability to deliver care was compromised by under-staffed and under-resourced services, including lack of geriatric and therapist input, particularly out-of-hours and at weekends, and lack of bed capacity. Staff identified strategies to mobilise existing resources including ‘upskilling’ of staff, effective prioritisation of patients and systems to track outlying patients on other wards. Bringing patients together on specialist wards enhanced workability by concentrating staff knowledge and expertise.Healthcare professionals made contribution by driving change and developing services through MDT meetings and consistent monitoring and auditing. Clinical leads were integral to service development by disseminating audit data, engendering enthusiasm and engaging staff from individual directorates. Ongoing development was shaped by executive support. Benchmarking services based on key performance indicators and linking clinical activity to funding mechanisms helped leverage executive support. Conclusion Findings identify elements needed to implement hip fracture services successfully. Information will assist services in overcoming organisational barriers when implementing sustainable high-quality services to improve patient care.

Objectives Older people living with frailty (OPLWF) are often unable to leave hospital even if they no longer need acute care. The aim of this study was to elicit the views of health care professionals in England on the barriers to effective discharge of OPLWF. Methods We conducted semi-structured interviews with hospital-based doctors and nurses with responsibility for discharging OPLWF from one large urban acute care hospital in England. The data were analysed using the constant comparative method. Results We conducted interviews with 17 doctors (12 senior doctors or consultants and 5 doctors in training) and six senior nurses. Some of our findings reflect well-known barriers to hospital discharge including service fragmentation, requiring skilled coordination that was often not available due to high volumes of work, and poor communication between staff from different organizations. Participants’ accounts also referred to less frequently documented factors that affect decision making and the organization of patient discharges. These raised uncomfortable emotions and tensions that were often ignored or avoided. One participant referred to ‘conversations not had’, or failures in communication, because difficult topics about resuscitation, escalation of treatment and end-of-life care for OPLWF were not addressed. Conclusions The consequences of not initiating important conversations about decisions relating to the end of life are potentially far reaching not only regarding reduced efficiency due to delayed discharges but also for patients’ quality of life and care. As the population of older people is rising, this becomes a key priority for all practitioners in health and social care. Evidence to support practitioners, OPLWF and their families is needed to ensure that these vital conversations take place so that care at the end of life is humane and compassionate.

Background Patients often have very different ideas from clinicians about what they want treatments to achieve. Their views on what outcomes are important are not always reflected in trials. Aims To elicit the views of people who self-harm on the most commonly used outcome measures and to identify the outcomes that matter to them. Method We conducted in-depth interviews with 18 people with histories of self-harm, recruited from hospital and community settings. We conducted thematic analysis using a framework approach and used visual mapping to arrive at our final analysis and interpretation. Results Participants' accounts contained a number of challenges to the validity and meaningfulness of current trial outcome measures. Five broad issues emerged: (a) relationship between frequency and severity of self-harm; (b) behavioural substitution; (b) self-management skills; (d) the role of self-harm as survival tool and affect regulator, and (e) strategic self-presentation. We show how these affect the visibility and measurability of commonly used outcomes. The outcomes that mattered to participants focused on positive achievements in three domains: (a) general functioning and activities of everyday living; (b) social participation, and (c) engagement with services. Participants conceptualised these as both measures and means of sustained improvement. Conclusions Our findings suggest that current self-harm trial science rests on flawed assumptions about the relationship between mental states and behaviours and about our ability to measure both. Greater understanding of the outcomes that matter to people who self-harm is needed to inform both intervention development and trial design.

Background Co-production is predicated on equal power-sharing and responsibility in research partnerships. However, relatively few accounts exist that explore the subjective experience of how co-researchers achieve such equality, from the perspectives of public contributors and researchers. Aim This paper aims to provide a unique insight into the process of co-production, by weaving personal reflections with principles to evaluate the impact arising from co-produced knowledge. It is based upon participatory research that was initiated by a 'lay' person, on behalf of a community organization, seeking support for Somali families who are affected by autism. The paper explores the evolving partnerships that began with community theatre and qualitative research and leading to extensive dissemination and impact, all of which has been jointly owned and negotiated by the co-researchers and community organizations. Discussion Initially, this paper reflects on the process, drawing on principles defined for co-production in health research and combining it with the co-researcher's personal reflections of their experiences as insiders and outsiders, stepping in and out of each other's worlds. The value of reciprocity, flexibility and continuous reflection is illustrated. The latter part of the paper explores the impact of this co-produced knowledge using a theoretical framework, to assess the specific impacts and its broader transformative potential. It demonstrates how (1) opportunities for all partners to be equitably involved to the maximum degree possible throughout the research process can affect social change and (2) co-produced research can become a catalyst that is dynamic and complex, achieving multi-layered impact.

Background Alcohol Screening and Brief Intervention (ASBI) helps reduce risky drinking in adults, but less is known about its effectiveness with young people. This article explores implementation of DrinkThink, an ASBI co-produced with young people, by health, youth and social care professionals trained in its delivery. Methods A qualitative evaluation was conducted using focus groups with 33 staff trained to deliver DrinkThink, and eight interviews with trained participants and service managers. These were recorded, transcribed and a thematic analysis undertaken. Results DrinkThink was not delivered fully by health, youth or social care agencies. The reasons for this varied by setting but included: the training staff received, a working culture that was ill-suited to the intervention, staff attitudes towards alcohol which prioritized other health problems presented by young people, over alcohol use. Conclusions Implementation was limited because staff had not been involved in the design and planning of DrinkThink. Staffs' perceptions of alcohol problems in young people and the diverse cultures in which they work were subsequently not accounted for in the design. Co-producing youth focused ASBIs with the professionals expected to deliver them, and the young people whom they target, may ensure greater success in integrating them into working practice.

Improving staff engagement has become a priority for NHS leaders, although efforts in this area vary between organisations. University Hospital Bristol NHS Foundation Trust (UH Bristol) is a tertiary teaching hospital where concerns about staff satisfaction and communication were reflected in the 2014 staff survey. To improve staff engagement, a real-time feedback mechanism to capture staff experience and to facilitate feedback from local leaders, was developed and piloted using the Model for Improvement. Initially piloted in two areas in January 2015, the Staff Participation Engagement and Communication application (SPEaC-app) was gradually rolled out to 23 areas within the trust by November 2016. The 2015 staff survey revealed significant improvements in staff motivation, satisfaction with level of responsibility and involvement, and perceived support from managers. These improvements cannot be attributed to this new mechanism in their entirety, but local surveys indicated satisfaction with SPEaC-app, the majority reporting that giving feedback about their shift was valuable while fewer staff had noticed changes in their work area as a result of the comments made via SPEaC-app. Between March 2015 and November 2016, 9259 entries were recorded, with an average of 15 entries per day across all areas. Of the entries, 45.7% were positive and nearly 40% were negative, and 'team working' was the most frequent theme. The project has identified the key factors associated with usability of the SPEaC-app, including, access, location, reliability and perceived privacy of the SPEaC-app. The SPEaC-app is valued and used most by staff in areas where feedback from local leaders is regular, rapid and comprehensive, and where staff comments are acted upon, leading to tangible change. This suggests that strong, consistent local management is required in order to embed it in new areas. SPEaC-app has the potential to support local engagement between managers and their service delivery teams, stimulate tangible improvements in service delivery and support the process of change. Longer term data are needed to determine whether SPEaC-app can influence other factors including staff turnover, recruitment and retention.

Objectives: Social stigma is commonly experienced by parents of children with autism. Our aim was to understand the nature of stigma experienced by Somali parents of children with autism in the United Kingdom (UK), and to consider how they coped with or resisted such stigma. Design: We used a community-based participatory research approach, collaborating with a community organisation of Somali parents. In-depth interviews with simultaneous translation were conducted with 15 Somali parents of children with autism living in Bristol, UK, in 2015. Parents were sampled purposively to capture diversity in children's age, severity of autism and time since diagnosis. Directed thematic analysis used Link and Phelan's model of stigma. Results: Of the 15 participants, 12 were mothers (mean age 36). The 17 children with autism they cared for were 4-13 years' old, and five were girls. Two main themes with sub-themes were identified: the nature of stigma (labelling and stereotyping; separation; emotional reactions, discrimination and power), and coping and resistance (the power of language; faith as a resource; learning, peer support and community relationships). Children with autism were labelled and stereotyped (e.g. as 'sick', 'naughty', 'different') and parents blamed for not controlling them, leading to social rejection and isolation. Stigma was associated with a poor understanding of autism, a lack of vocabulary related to autism in the Somali community, and prejudice against mental illness and disability. There was evidence of enacted and felt stigma and examples of discrimination. Finding their own language to describe their child's condition and drawing on faith, learning and peer support were important resources in resisting stigma. Conclusions: Findings inform support for this community, highlighting the need to raise awareness of autism, enable parents to speak openly, and ensure appropriate professional services and interventions are available.

BACKGROUND:It is known that many trainee doctors around the world experience work satisfaction but also considerable work stress in the training period. Such stress seems to be linked to multiple factors including workload, level of support and growing cultural inculcation into unwillingness to show any personal or professional weakness. In the United Kingdom, junior doctors are qualified medical practitioners who have gained a degree in Medicine and are now working while training to become a specialist (consultant) or a general practitioner. The period of medical training can be particularly stressful for some UK junior doctors, in common with their counterparts in other countries. UK Postgraduate Medical Deaneries provide support for those who need it via Professional Support Units (PSUs); however little is known about the perceptions and experiences of the doctors who access and utilise this support. This study aimed to generate qualitative insight into how the (PSU) provided by one UK Deanery is experienced by the trainees who accessed it. We aimed to investigate whether such experience intersects with the progressive socialisation of trainee doctors into the notion that doctors do not get ill.METHODS:Through in-depth telephone interviews with eight female junior doctors, we explored the benefits and problems associated with using a PSU with reference to the formation of trainee doctors' professional identities, and conducted a thematic analysis.RESULTS:Themes identified illustrate the process of accepting, accessing and benefiting from PSU support. These are: Medical identity intact (it will never happen to me); Denial of disrupted medical identity; Being on the edge: accepting help; Role of PSU in 'recovery' process; Repaired identity / coming back from the edge; Different ways to be a doctor. The gendered sample occurred simply as it was females who responded to study invitations. Whilst we present some related aspects (such as "manning up" as part of keeping going), analyses of this small sample showed that medical identity as a doctor in training was more salient than a gendered experience of help seeking in this study.CONCLUSIONS:This study highlights the initial reluctance of female junior doctors to seek help from the PSU, as acknowledging their own difficulties spoiled their identity as a competent doctor. However, once engaged with the PSU, the findings exemplify its role in repairing medical identity, by offering different and acceptable ways to be a doctor. We interpret these findings within Goffman's theoretical framework of stigma conferring a spoiled identity on recipients, and how this may then be repaired. Reducing the stigma attached to initial help-seeking among junior doctors is crucial to increase ease of access to the PSU and to improve the experiences of doctors who encounter challenges during their training.