BACKGROUND:In the evaluation of complex interventions, economic evaluations aim to determine the relative cost-effectiveness of interventions but generate little explanation of how or why contexts and underlying causal mechanisms impact this. Conversely, realist approaches aim to explain 'what works, for whom, in which circumstances and why' but rarely capture the economic costs and consequences of interventions. As a result, many evaluations remain partial. OBJECTIVE:To identify past attempts to integrate realist and economic evaluation approaches and summarise the recent developments in realist and economic evaluation approaches in the evaluation of complex health and social care interventions. METHODS:We conducted a series of scoping reviews using online academic databases, personal libraries and expert stakeholder workshops, to identify the theoretical, methodological, and practical challenges and developments in bringing together realist and economic evaluation approaches. FINDINGS AND RECOMMENDATIONS:Although increasing, there remain relatively few examples of evaluations that have attempted to integrate realist and economic evaluation approaches, and challenges for their integration mean that further guidance is required. The wider literature indicated challenges in the theoretical (e.g. ontology, causality), methodological (e.g. accounting for context, study design, mixing methods) and practical (e.g. terminology, scale and scope) domains, for which we have developed recommendations. CONCLUSION:To deliver services that are both effective and efficient, evaluations must synthesise relevant explanatory evidence with cost and outcome data to enable policymakers and commissioners to make informed decisions. Findings and recommendations from this review were used to inform the development of guidance for the integration of realist and economic evaluation approaches.

Background Poor oral health among older people living in long-term residential care is associated with serious health consequences and reduced quality of life. Oral health commonly deteriorates in these settings and is often attributed to care staff workload pressures and limited oral health knowledge and skills. However, practice colleagues in our established UK care home and science partnership told us that a range of factors support and hinder them with oral care provision. Objective To identify and synthesise the individual (micro), organisational (meso) and wider social and political (macro) factors that influence oral care provision for older people living in long-term residential care. Design and method A scoping review was undertaken. Search strategies were developed by information specialists and study selection involved independent screening by two reviewers using predefined eligibility criteria. Data synthesis was informed by the Capability, Opportunity, Motivation and Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Data sources Systematic searches were conducted in February 2022 and updated in March 2026. Searches included CINAHL, Web of Science Core Collection, Embase, MEDLINE, APA PsycInfo, Google Scholar and relevant grey literature sources. Findings Sixty-three studies (reported in 86 publications) were included. The most frequently reported influences on staff behaviours were in the COM-B ‘opportunity’ domain: environmental context and resources, and social influences. Staff knowledge and skills were important determinants of capability, while beliefs about consequences influenced motivation. Key enablers included training, oral health champions, supportive leadership, assessment and monitoring systems, and collaborative relationships between care staff, residents, relatives and dental professionals. Key barriers included staffing shortages, workload pressures, limited time, inadequate training, low organisational prioritisation of oral care, and restricted access to external dental services. Interpersonal relationships were central to effective oral care provision. Conclusions Oral care provision is influenced by a complex interplay of factors at the individual, organisational and policy levels and cannot be attributed solely to care staff. While workforce pressures and limited training are important, staff knowledge, skills and behaviours must be understood within a broader organisational and system context. Interventions should extend beyond technical training to address emotional labour, relational dynamics and structural constraints. The COM-B and TDF frameworks provide a robust foundation for designing multi-component, context-sensitive interventions that reflect the realities of long-term care environments. Protocol registration Open Science Framework https://doi.org/10.17605/OSF.IO/STRKW Tweetable abstract ‘Mouth minutes’ matter. Poor oral care in care homes affects older adults' health & quality of life. Our theory informed scoping review maps barriers/enablers for oral care provision in this setting. It’s about more than technical skill #OralHealth #CareHomes #NICHELeeds @IJNS

Background:Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions is lacking. An individual participant data meta-analysis has potential to provide more reliable estimates of the effects of therapeutic interventions than conventional meta-analyses and to explore which treatments are best suited to certain groups. Methods:A systematic review and individual participant data meta-analysis of randomised controlled trials of therapeutic interventions to reduce repeat self-harm in adolescents with a history of self-harm and who had presented to clinical services. We searched Cochrane Library, EMBASE, trial registers and other databases for randomised controlled trials published in January 2022. Eligible randomised controlled trials compared any therapeutic intervention against a control, aimed to reduce self-harm in adolescents (11-18 years old), with past self-harm presenting to clinical services, and collected outcome data on self-harm or suicide attempts. Interventions reviewed were grouped into nine categories: cognitive-behavioural therapy; dialectical behaviour therapy; family therapy; group therapy; mentalisation based, psychodynamic, cognitive analytic therapy; multisystemic therapy; problem-solving, psychoeducation, support; postcards, tokens, documents (postcards/tokens); and other single session, brief interventions. Control interventions were all either treatment as usual or enhanced treatment as usual and were not usually well described. There were no 'no treatment' controls except in the postcard/document/token studies. Primary outcome was repetition of self-harm at 12 months. Other outcomes included repetition of self-harm at other time points, overall mental health, depressive symptoms, thoughts of suicide, quality of life and death. Two-stage random-effects individual participant data meta-analyses were conducted overall and by intervention, and to examine interaction between treatment received and participant characteristics. Secondary analyses incorporated aggregate data from randomised controlled trials without individual participant data. Metaregression explored moderating study effects. Results:We identified 39 eligible studies, from 10 countries, where we sought individual participant data (18 studies with full sample eligibility, 21 with partial sample eligibility). We obtained individual participant data from 26 studies of 3448 eligible participants. We used published data from a further seven studies where individual participant data were not available for a combined individual participant data aggregate data meta-analysis (698 participants). For our primary outcome, repetition of self-harm, only six studies were rated as low risk of bias. There was no evidence that intervention/s were more or less effective than controls at preventing repeat self-harm by 12 months using individual participant data (odds ratios 1.06, 95% confidence interval 0.86 to 1.31) or individual participant data + aggregate data (odds ratios 1.02, 95% confidence interval 0.82 to 1.27) and no evidence of heterogeneity of treatment effects on study and treatment factors. We found no evidence that intervention was more or less effective than control for secondary outcomes, except general psychopathology and suicidal ideation at 12 and 6 months, respectively. Across all interventions, participants with multiple prior self-harm episodes showed evidence of improved treatment effect on self-harm repetition 6-12 months after randomisation [odds ratios 0.33 (95% confidence interval 0.12 to 0.94), studies = 9, n = 1771]. Modest evidence suggesting differential treatment effects based on participants' age, gender, self-harm method, and anxiety levels are noted. Limitations:A significant limitation was missing individual participant data where authors were unable to share data; we offset this by including published data in secondary individual participant data plus aggregate meta-analysis. A wide range of interventions were evaluated and lacked replication. There was variability in the definitions and timings of outcomes, measures used for data collection, and available moderator data, with little consistency across studies. Conclusions:More attention needs to be paid to seeking appropriate consent from study participants for data-sharing. We found no evidence that any therapeutic intervention (overall or by intervention) was more or less effective than control for reducing repeat self-harm. We are therefore unable to recommend any specific intervention to prevent repetition of self-harm in adolescents. We observed evidence and trends indicating more effective interventions within specific subgroups. Analysis was constrained due to scarcity of data concerning common baseline characteristics, outcomes, and follow-up lengths. We recommend efficient, adaptive platform trial designs to tackle research questions and ascertain the most effective interventions for different groups, covering available treatments. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/117/11.

Reviews of youth justice intervention effectiveness prioritise hierarchies of evidence that obscure how contextual features shape the 'mechanisms' of change in preventative interventions. This article critiques this current evidence-based approach to youth justice interventions and its reliance on reoffending reduction as a measure of effectiveness. Community-based prevention programmes have been central to youth justice, since the late 20th century in England and Wales. However, by concentrating primarily on effect sizes, this approach often overlooks the influence specific contexts have on the mechanisms that can facilitate behaviour or attitude change through these preventative interventions. The authors propose that a realist approach could enhance understanding by focusing on how interventions work, for whom, and why. The article begins by outlining key theories that underpin youth justice programmes, followed by an overview of the realist synthesis (RS) approach to evidence review. This approach emphasises the mechanisms behind interventions and the contextual factors influencing their success. The authors apply this perspective to two types of community-based interventions used with two distinct and different groups of children: Intensive Supervision and Surveillance and Restorative Justice Conferencing in Referral Orders. The study makes three contributions. First, it provides an original detailed account of conducting an RS in the youth justice context, demonstrating the value of realist methods in evaluating youth justice interventions. Second, it highlights that youth justice interventions are often underpinned by competing programme theories that, in practice, work both in harmony and tension - producing a more diverse set of outcomes beyond simple proclamations of interventions being effective or not. Third, it emphasises that understanding and refining these underlying theories can improve children's outcomes in youth justice programmes through practical guidance.

Background:Social care staff shortages are having a detrimental impact across the health and care system. There are reports of care homes closing, stopping nursing services and not admitting new residents because of challenges with staff shortages. Aim:To develop an explanatory framework of strategies used to attract, recruit, and retain registered nurses and care workers working in care homes. Explain how and why strategies work, for whom, the conditions needed and the costs involved. Design and methods:A realist synthesis approach was used. In step 1, strategies were identified and initial programme theories developed using data from stakeholder consultations (n = 10), theory gleaning interviews with registered nurses and care workers (n = 13), and evidence retrieved from scoping literature searches (n = 50). Strategies (and initial programme theories) prioritised by sector stakeholders focused on staff recruitment and retention, and were taken forward for testing/refinement. Step 2 involved searching academic databases and social care websites for evidence. Step 3 involved screening and selecting records relevant to the prioritised initial programme theories. Relevant data were extracted and analysed to identify context-mechanism-outcome configurations. To assess rigour, the appropriateness of research methods, and the plausibility/transparency of grey literature were assessed. Step 4 involved testing and refining the programme theories, with programme theories sense checked/refined by sector stakeholders. Existing and established theories were used to help further explain the programme theories and develop an overarching explanatory framework. Results:During step 1, strategies used to attract, recruit, and retain registered nurses and care workers were identified and initial programme theories developed (n = 22). Ten strategies and initial programme theories were prioritised for testing/refining and were focused on recruitment and retention: staff recognition, flexible working, career development, salary package, early investment, induction, continuous feedback, caring community, effective interviewing and listening to all staff. From the focused literature searches, 153 papers were included and data from these were used to test and refine the prioritised strategies and initial programme theories, and throughout the process collated into five final theories: effective interviewing, career development, reward and recognition, promoting work-life balance and caring conversations. These strategies do not operate independently; they interact and work together. Effective interviewing sets accurate expectations, and loyalty starts to develop through setting an accurate 'psychological contract' which is fulfilled over time. Opportunities for career development, rewarding and recognising staff, providing flexible working options and supporting staff with caring conversations help staff to feel listened to, respected and valued, which in turn, develops job satisfaction. Supportive leaders and a sense of inclusion and fairness are needed for these strategies to work. These strategies provide staff with positive experiences, and these are reciprocated through employee commitment and loyalty. Supporting staff through providing caring conversations and opportunities for career development also help staff feel empowered. Conclusions:This is the first realist synthesis in this field. The findings provide practical strategies for improving staff recruitment and retention. Limitations:Stakeholder consultations did not include the views of staff who had left care work. Future work:Understanding how to attract new staff to the social care workforce remains an important research gap. Study registration:This study is registered as PROSPERO CRD42021261112. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131016) and is published in full in Health and Social Care Delivery Research; Vol. 14, No. 21. See the NIHR Funding and Awards website for further award information.

Poor oral health is common among older people living in long-term residential care environments, or care homes. For decades, various strategies have been proposed to enhance and sustain oral health within this setting. However, implementation of these strategies and interventions has been variable, with limited positive impacts on long term oral health outcomes. The aim of this overview of reviews was to identify, appraise and synthesise systematic reviews of interventions or strategies provided by care home staff to support residents with their oral health. Protocol registration: PROSPERO (International Prospective Register of Systematic Reviews) registration ID: CRD42021293159. The search for systematic reviews was conducted in March 2025 in the following databases: Medline, Embase, CINAHL, PsycINFO and Epistemonikos. An analysis of overlapping primary studies within SRs was undertaken. Quality of reviews was assessed using AMSTAR2. Results were tabulated and a narrative synthesis was conducted. A total of 14 SRs were included. Most studies focused on training care staff to improve oral health knowledge and skills and just under half of included studies involved oral health care interventions testing protocols, such as regular mouth cleaning and structured regimens tailored to residents’ needs, some studies focused on resident care with dementia or cognitive impairments. Barriers to delivering oral health care were reported including time constraints, insufficient training, staff turnover, and resistance from residents. Suggestions to overcome such barriers were hands-on training to enhance staff confidence, tailored care plans for residents with impairments, managerial support for resource allocation, and fostering collaboration between care staff, family, and dental professionals. Evidence suggests that interventions are available to improve the oral health and care for this population, particularly around training of staff. However, the detail of the intervention was poorly documented. High-quality research is needed to determine which interventions benefit oral care for older people living in care homes.

OBJECTIVE:Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions that stop repetition is lacking. This individual participant data (IPD) meta-analysis of randomized controlled trials (RCTs) aimed to provide robust estimates of therapeutic intervention effects and explore which treatments are best suited to different subgroups. METHOD:Databases and trial registers to January 2022 were searched. RCTs compared therapeutic intervention to control, targeted adolescents ages 11 to 18 with a history of self-harm and receiving clinical care, and reported on outcomes related to self-harm or suicide attempt. Primary outcome was repetition of self-harm 12 months after randomization. Two-stage random-effects IPD meta-analyses were conducted overall and by intervention. Secondary analyses incorporated aggregate data from RCTs without IPD. RESULTS:The search identified 39 eligible studies; 26 provided IPD (3,448 participants), and 7 provided aggregate data (698 participants). There was no evidence that interventions were more or less effective than controls at preventing repeat self-harm by 12 months in IPD (odds ratio 1.06 [95% CI 0.86, 1.31], 20 studies, 2,949 participants) or IPD and aggregate data (odds ratio 1.02 [95% CI 0.82, 1.27], 22 studies, 3,117 participants) meta-analyses and no evidence of heterogeneity of treatment effects on study and treatment factors. Across all interventions, participants with multiple prior self-harm episodes showed evidence of improved treatment effect on self-harm repetition 6 to 12 months after randomization (odds ratio 0.33 [95% CI 0.12, 0.94], 9 studies, 1,771 participants). CONCLUSION:This large-scale meta-analysis of RCTs provided no evidence that therapeutic intervention was more, or less, effective than control for reducing repeat self-harm. Evidence indicating more effective interventions in youth with 2 or more self-harm incidents was observed. Funders and researchers need to agree on a core set of outcome measures to include in subsequent studies. PLAIN LANGUAGE SUMMARY:Self-harm is common in adolescents and linked to higher risks of repeated self-harm and suicide. This meta-analysis of 33 randomized controlled trials involving 4,146 adolescents found that therapeutic interventions were no more effective than standard care at preventing repeat self-harm at 12 months. However, interventions were more effective in youth with 2 or more self-harm incidents. The authors discuss limitations posed by the lack of uniform outcome measures for self-harm. CLINICAL GUIDANCE:STUDY PREREGISTRATION INFORMATION: Reducing Self-harm in Adolescents: An Individual Participant Data Meta-analysis; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=152119.

BACKGROUND:Excessive midwifery workload is a growing concern that may affect safety and quality of care, with potential consequences for mothers and babies. AIMS:To assess how midwife workload affects delivery of care, and maternal and neonatal outcomes; and whether maternal, neonatal, and staffing factors modify these relationships. METHODS:This systematic review updated a prior review (January 1998 to June 2014) with revisions to search strategies. We searched for new evidence (June 2014 to October 2023) across 11 academic databases (Cochrane Database of Systematic Reviews (Wiley); Cochrane Central Register of Controlled Trials (Wiley); CINAHL (EBSCOhost); EconLit (EBSCOhost; Embase (Ovid); Epistemonikos; Health Management Information Consortium (Ovid); International HTA Database (INAHTA); Maternity & Infant Care Database (Ovid); Ovid MEDLINE(R); CEA Registry) and 10 grey literature websites. Screening involved multiple reviewers, with 10% of records independently double-screened. Inclusion criteria were intrapartum births in maternity wards in OECD countries, a measure of midwifery workload, and outcomes related to provision of care, mode of birth, and maternal or neonatal morbidity and mortality. A single reviewer conducted data extraction, bias assessments, and a narrative synthesis. RESULTS:We included 23 studies (15 new, 8 from the original review) from the UK, USA, Italy, France, and Germany, covering 2,943,120 births. Only three studies were rated as high quality. Many outcomes showed no significant effects, or inconsistent effects across studies. High workload was significantly linked to care delays, increased instrumental and caesarean births, and some maternal outcomes (e.g., perineal trauma). Associations were modified by maternal characteristics, including clinical risk, parity, and civil status. No significant associations were found between workload and neonatal outcomes, except for one low-quality study reporting increased neonatal ward admissions. CONCLUSIONS:High midwifery workload may alter care provision, potentially affecting mother and baby outcomes. Further robust research is needed to address limitations in current evidence.

INTRODUCTION:In England, increasing numbers of young people seek help from emergency healthcare services, such as ambulances and emergency departments, after they self-harm. One contributing factor is a lack of meaningful and available community-based alternative sources of support for self-harm. It is not clear what helps young people in this context, how or why. This research aims to understand which resources are available in the emergency setting for young people (aged ≤25 years) who self-harm in England, and how and why they produce their intended and unintended effects. METHODS AND ANALYSIS:A realist review is a theory-driven interpretive approach to evidence synthesis. It provides realist logic of inquiry to produce an explanatory analysis of how and why resources work, for whom and in what circumstances. This review has two key components; one will identify the resources available in England for young people who self-harm in the emergency setting, the other will identify initial programme theories from the international literature. The review will closely follow Pawson's five iterative stages: (1) clarifying scope, (2) evidence search, (3) article selection, (4) data extraction and organisation, and (5) evidence synthesis. Published and grey literature will be reviewed and included. Three key stakeholder groups will be involved throughout the review process, namely two patient and public involvement (PPI) groups (one for young people, one for parents and carers) and an interdisciplinary group of healthcare professionals. ETHICS AND DISSEMINATION:Ethical approval is not required for this review. Results will be reported according to Realist And Meta-narrative Evidence Synthesis: Evolving Standards publication and quality standards. Findings will be disseminated via a peer-reviewed publication in a scientific journal, conference presentations, a study website, an animated video shared via social media and other avenues identified by our PPI groups. PROSPERO REGISTRATION NUMBER:CRD42025638539.

IntroductionThe burden of multimorbidity is recognised increasingly in low- and middle-income countries (LMICs), creating a strong emphasis on the need for effective evidence-based interventions. Core outcome sets (COS) appropriate for the study of multimorbidity in LMICs do not presently exist. These are required to standardise reporting and contribute to a consistent and cohesive evidence-base to inform policy and practice. We describe the development of two COS for intervention trials aimed at preventing and treating multimorbidity in adults in LMICs.MethodsTo generate a comprehensive list of relevant prevention and treatment outcomes, we conducted a systematic review and qualitative interviews with people with multimorbidity and their caregivers living in LMICs. We then used a modified two-round Delphi process to identify outcomes most important to four stakeholder groups (people with multimorbidity/caregivers, multimorbidity researchers, healthcare professionals and policymakers) with representation from 33 countries. Consensus meetings were used to reach agreement on the two final COS. Registration:https://www.comet-initiative.org/Studies/Details/1580.ResultsThe systematic review and qualitative interviews identified 24 outcomes for prevention and 49 for treatment of multimorbidity. An additional 12 prevention and 6 treatment outcomes were added from Delphi round 1. Delphi round 2 surveys were completed by 95 of 132 round 1 participants (72.0%) for prevention and 95 of 133 (71.4%) participants for treatment outcomes. Consensus meetings agreed four outcomes for the prevention COS: (1) adverse events, (2) development of new comorbidity, (3) health risk behaviour and (4) quality of life; and four for the treatment COS: (1) adherence to treatment, (2) adverse events, (3) out-of-pocket expenditure and (4) quality of life.ConclusionFollowing established guidelines, we developed two COS for trials of interventions for multimorbidity prevention and treatment, specific to adults in LMIC contexts. We recommend their inclusion in future trials to meaningfully advance the field of multimorbidity research in LMICs.PROSPERO registration numberCRD42020197293.

Background:Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions is lacking. An individual patient data meta-analysis has the potential to provide more reliable estimates of the effects of therapeutic interventions for self-harm than conventional meta-analyses, to explore which treatments are best suited to certain groups. Method:A systematic review and individual patient data meta-analysis of randomised controlled trials of therapeutic interventions to reduce repeat self-harm in adolescents who had a history of self-harm and presented to clinical services. Primary outcome was repetition of self-harm. The methods employed for searches, study screening and selection, and risk of bias assessment are described, with an overview of the outputs of the searching, selection and quality assessment processes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance is followed. Results:We identified a total 39 eligible studies, from 10 countries, where we sought Individual Patient Data (IPD), of which the full sample of participants were eligible in 18 studies and a partial sample of participants were eligible in 21 studies. We obtained IPD from 26 studies of 3448 eligible participants. For our primary outcome, repetition of self-harm, only 6 studies were rated as low risk of bias with 10 rated as high risk (although 2 of these were for secondary outcomes only). Conclusions:Obtaining individual patient data for meta-analyses is possible but very time-consuming, despite clear guidance from funding bodies that researchers should share their data appropriately. More attention needs to be paid to seeking appropriate consent from study participants for (pseudo) anonymised data-sharing and institutions need to collaborate on agreeing template data-sharing agreements. Researchers and funders need to consider issues of research design more carefully. Our next step is to analyse all the data we have collected to see if it will tell us more about how we might prevent repetition of self-harm in young people. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/117/11.

Background:Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable. Aim:To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England. Design:Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60). Setting:Three Trusts, one orthopaedic and one older person ward in each. Results:Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling. Limitations:Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted. Conclusions:(1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling. Future work:(1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English. Study registration:This study is registered as PROSPERO CRD42020184458. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

BACKGROUND:People with severe mental illness (SMI), such as schizophrenia, have higher rates of type 2 diabetes and worse outcomes, compared to those without SMI and it is not known whether diabetes self-management interventions are effective for people who have both conditions. Research in this area has been impeded by a lack of consensus on which outcomes to prioritise in people with co-existing SMI and diabetes. AIMS:To develop a core outcome set (COS) for use in effectiveness trials of diabetes self-management interventions in adults with both type 2 diabetes and SMI. METHODS:The COS was developed in three stages: (i) identification of outcomes from systematic literature review of intervention studies, followed by multi-stakeholder and service user workshops; (ii) rating of outcomes in a two-round online Delphi survey; (iii) agreement of final 'core' outcomes through a stakeholder consensus workshop. RESULTS:Seven outcomes were selected: glucose control, blood pressure, body composition (body weight, BMI, body fat), health-related quality of life, diabetes self-management, diabetes-related distress and medication adherence. CONCLUSIONS:This COS is recommended for future trials of effectiveness of diabetes self-management interventions for people with SMI and type 2 diabetes. Its use will ensure trials capture important outcomes and reduce heterogeneity so findings can be readily synthesised to inform practice and policy.

Unprofessional behaviours (UBs) between healthcare staff are widespread and have negative impacts on patient safety, staff well-being and organisational efficiency. However, knowledge of how to address UBs is lacking. Our recent realist review analysed 148 sources including 42 reports of interventions drawing on different behaviour change strategies and found that interventions insufficiently explain their rationale for using particular strategies. We also explored the drivers of UBs and how these may interact. In our analysis, we elucidated both common mechanisms underlying both how drivers increase UB and how strategies address UB, enabling the mapping of strategies against drivers they address. For example, social norm-setting strategies work by fostering a more professional social norm, which can help tackle the driver 'reduced social cohesion'. Our novel programme theory, presented here, provides an increased understanding of what strategies might be effective to adddress specific drivers of UB. This can inform logic model design for those seeking to develop interventions addressing UB in healthcare settings.

Introduction COVID-19 catalysed a rapid move to provide care away from the hospital using online communication platforms. Technology enabled care (TEC) continues to be an important driver in progressing future healthcare services. Due to the complex and chronic nature of conditions seen within paediatric rheumatology, TEC may lead to better outcomes. Despite some growth in published literature into the adoption of TEC in paediatric rheumatology, there is limited synthesis. The aim of this review is to provide a comprehensive understanding and evaluation of the adoption of TEC by patients in paediatric rheumatology services, to establish best practices.Methods and analysis This proposed mixed-methods systematic review will be conducted by searching a wide variety of healthcare databases, grey literature resources and associated charities and societies, for articles reported in English language. Data extraction will include population demographics, technology intervention, factors affecting adoption of intervention and consequent study outcomes. A parallel-results convergent synthesis design is planned, with independent syntheses of quantitative and qualitative data, followed by comparison of the findings of each synthesis using a narrative approach. Normalisation process theory will be used to identify, characterise and explain implementation factors. The quality of included articles will be assessed using the Mixed Methods Appraisal Tool for research papers and the Authority, Accuracy, Coverage, Objectivity, Date, Significance checklist for grey literature. Overall confidence in quality and strength of evidence will be assessed using the Confidence in the Evidence from Reviews of Qualitative Research tool.Ethics and dissemination Ethical approval is not required due to the nature of this mixed-methods systematic review. The findings will be disseminated via a peer-reviewed journal, relevant conferences and any other methods (eg, via NHS Trust or NIHR YouTube channels) as advised by paediatric rheumatology patients.PROSPERO registration number CRD42023443058.

Mental disorders are increasing in South Asia (SA), but their epidemiological burden is under-researched. We carried out a systematic umbrella review to estimate the prevalence of mental disorders and intentional self-harm in the region. Multiple databases were searched and systematic reviews reporting the prevalence of at least one mental disorder from countries in SA were included. Review data were narratively synthesised; primary studies of common mental disorders (CMDs) among adults were identified from a selected subset of reviews and pooled. We included 124 reviews. The majority (n = 65) reported on mood disorders, followed by anxiety disorders (n = 45). High prevalence of mental disorders and intentional self-harm was found in general adult and vulnerable populations. Two reviews met our pre-defined criteria for identifying primary studies of CMDs. Meta-analysis of 25 primary studies showed a pooled prevalence of 16.0% (95% CI = 11.0-22.0%, I (2) = 99.9%) for depression, 12.0% (5.0-21.0%, I (2) = 99.9%) for anxiety, and 14.0% (10.0-19.0, I (2) = 99.9%) for both among the general adult population; pooled estimates varied by country and assessment tool used. Overall, reviews suggest high prevalence for mental disorders in SA, but evidence is limited on conditions other than CMDs.

Background Falls are the most common safety incident reported by acute hospitals. In England national guidance recommends delivery of a multifactorial falls risk assessment (MFRA) and interventions tailored to address individual falls risk factors. However, there is variation in how these practices are implemented. This study aimed to explore the variation by examining what supports or constrains delivery of MFRAs and tailored interventions in acute hospitals. Methods A realist review of literature was conducted with searches completed in three stages: (1) to construct hypotheses in the form of Context, Mechanism, Outcome configurations (CMOc) about how MFRAs and interventions are delivered, (2) to scope the breadth and depth of evidence available in Embase to test the CMOcs, and (3) following prioritisation of CMOcs, to refine search strategies for use in multiple databases. Citations were managed in EndNote; titles, abstracts, and full texts were screened, with 10% independently screened by two reviewers. Results Two CMOcs were prioritised for testing labelled: Facilitation via MFRA tools, and Patient Participation in interventions. Analysis indicated that MFRA tools can prompt action, but the number and type of falls risk factors included in tools differ across organisations leading to variation in practice. Furthermore, the extent to which tools work as prompts is influenced by complex ward conditions such as changes in patient condition, bed swaps, and availability of falls prevention interventions. Patient participation in falls prevention interventions is more likely where patient directed messaging takes individual circumstances into account, e.g., not wanting to disturb nurses by using the call bell. However, interactions that elicit individual circumstances can be resource intensive and patients with cognitive impairment may not be able to participate despite appropriately directed messaging. Conclusions Organisations should consider how tools can be developed in ways that better support consistent and comprehensive identification of patients’ individual falls risk factors and the complex ward conditions that can disrupt how tools work as facilitators. Ward staff should be supported to deliver patient directed messaging that is informed by their individual circumstances to encourage participation in falls prevention interventions, where appropriate. Trial registration PROSPERO: CRD42020184458.

BACKGROUND:There is increasing interest in the use of artificial intelligence (AI) in pathology to increase accuracy and efficiency. To date, studies of clinicians' perceptions of AI have found only moderate acceptability, suggesting the need for further research regarding how to integrate it into clinical practice.OBJECTIVE:The aim of the study was to determine contextual factors that may support or constrain the uptake of AI in pathology.METHODS:To go beyond a simple listing of barriers and facilitators, we drew on the approach of realist evaluation and undertook a review of the literature to elicit stakeholders' theories of how, for whom, and in what circumstances AI can provide benefit in pathology. Searches were designed by an information specialist and peer-reviewed by a second information specialist. Searches were run on the arXiv.org repository, MEDLINE, and the Health Management Information Consortium, with additional searches undertaken on a range of websites to identify gray literature. In line with a realist approach, we also made use of relevant theory. Included documents were indexed in NVivo 12, using codes to capture different contexts, mechanisms, and outcomes that could affect the introduction of AI in pathology. Coded data were used to produce narrative summaries of each of the identified contexts, mechanisms, and outcomes, which were then translated into theories in the form of context-mechanism-outcome configurations.RESULTS:A total of 101 relevant documents were identified. Our analysis indicates that the benefits that can be achieved will vary according to the size and nature of the pathology department's workload and the extent to which pathologists work collaboratively; the major perceived benefit for specialist centers is in reducing workload. For uptake of AI, pathologists' trust is essential. Existing theories suggest that if pathologists are able to "make sense" of AI, engage in the adoption process, receive support in adapting their work processes, and can identify potential benefits to its introduction, it is more likely to be accepted.CONCLUSIONS:For uptake of AI in pathology, for all but the most simple quantitative tasks, measures will be required that either increase confidence in the system or provide users with an understanding of the performance of the system. For specialist centers, efforts should focus on reducing workload rather than increasing accuracy. Designers also need to give careful thought to usability and how AI is integrated into pathologists' workflow.

We evaluate the effectiveness of psychological interventions for depression in people with NCDs in South Asia and explore the individual, organizational, and policy-level barriers and facilitators for the implementation and scaling up of these interventions. Eight databases (and local web pages) were searched in May 2022. We conducted random effects models to evaluate the pooled effect of psychological interventions on depression in people with NCDs. We extracted the individual, organizational, and policy level barriers and facilitators. We found five randomized control trials, nine qualitative studies, and 35 policy documents that fitted the inclusion criteria. The pooled standardized mean difference in depression comparing psychological interventions with usual care was -2.31 (95% CI, -4.16 to -0.45; p = .015, I-2 = 96.0%). We found barriers and facilitators to intervention delivery, mental health appears in the policy agenda in Bangladesh and Pakistan. However, there is a lack of policies relating to training in mental health for NCD health providers and a lack of integration of mental health care with NCD care. All of the psychological interventions reported to be effective in treating depression in this population. There are important delivery and policy barriers to the implementation and scaling up of psychological interventions for people with NCDs.

Aims: To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty. Methods: A programme of work was conducted, including: a systematic review of the clinical and cost-effectiveness literature; analysis of routine national datasets to identify pre-, peri-, and postoperative predictors of mid-to-late term revision; prospective data analyses from 560 patients to understand how patients present for revision surgery; qualitative interviews with NHS managers and orthopaedic surgeons; and health economic modelling. Finally, a consensus meeting considered all the work and agreed the final recommendations and research areas. Results: The UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE) recommendations apply to post-primary hip and knee arthroplasty follow-up. The ten-year time point is based on a lack of robust evidence beyond ten years. The term 'complex cases' refers to individual patient and surgical factors that may increase the risk for arthroplasty failure. For Orthopaedic Data Evaluation Panel (ODEP) 10A* minimum implants, it is safe to disinvest in routine follow-up from one to years post-non-complex hip and knee arthroplasty provided there is rapid access to orthopaedic review. For ODEP 10A* minimum implants in complex cases, or non-ODEP 10A* minimum implants, periodic follow-up post-hip and knee arthroplasty may be required from one to ten years. At ten years post-hip and knee arthroplasty, clinical and radiological evaluation is recommended. After ten years post-hip and knee arthroplasty, frequency of further follow-up should be based on the ten-year assessment; ongoing rapid access to orthopaedic review is still required. Conclusion: Complex cases, implants not meeting the ODEP 10A* criteria, and follow-up after revision surgery are not covered by this recommendation. Cite this article: Bone Jt Open 2023;4(2):72–78.