Background Early cancer diagnosis is a major health-system priority, particularly for cancers presenting with vague, non-specific symptoms. Current screening programmes remain limited to selected cancers with more site-specific symptoms. Innovative diagnostic technologies may offer opportunities for earlier detection outside secondary care settings. This horizon scan aimed to identify and characterise emerging technologies for the early detection of cancers with generic symptoms for potential use in primary care, community or home-based settings. Methods A horizon scanning and evidence synthesis approach was used. Searches were conducted from 2020 in Embase, clinical trial registries, supplemented by relevant systematic reviews, then screened against predefined eligibility criteria to support early cancer detection. Data was extracted on study and/or clinical trial details, technology type, developers, sample or data source, cancer type, and technology readiness level. Findings were summarised descriptively. Results After deduplication, 5,293 records were screened, including 4,791 studies and 502 clinical trial protocols. Data extraction was completed for 196 studies, identifying 169 technologies, with 67 targeting generic cancer detection. Most technologies were biomarker-based (n=36), followed by other technologies (n=19), and AI and digital technologies (n=12). Technologies ranged from TRL-2 to TRL-7, with most technologies at TRL-4, indicating early laboratory-stage validation. Blood, plasma and serum were the most common sample types, suggesting stronger suitability for GP or community settings than home testing. A small number of technologies used saliva or urine samples, which may be more compatible with home-based testing. Research activity was concentrated around lung, colorectal, pancreatic, liver, oesophageal and multi-cancer detection. Thirty-one clinical trials for generic cancer detection were identified. Conclusions The emerging landscape for generic cancer detection is active but largely early-stage. Biomarker-based and AI-enabled technologies show potential to support earlier diagnosis outside secondary care, although evidence gaps remain around clinical validity, implementation, equity, follow-up pathways and health-system readiness.

Background:Myalgic encephalomyelitis/chronic fatigue syndrome is a chronic condition, classified by the World Health Organization as a nervous system disease, impacting around 17 million people worldwide. Presentation involves persistent fatigue and postexertional malaise (a worsening of symptoms after minimal exertion) and a wide range of other symptoms. Case definitions have historically varied; postexertional malaise is a core diagnostic criterion in current definitions. In 2022, a James Lind Alliance Priority Setting Partnership established research priorities relating to myalgic encephalomyelitis/chronic fatigue syndrome. Objective(s):We created a map of myalgic encephalomyelitis/chronic fatigue syndrome evidence (2018-23), showing the volume and key characteristics of recent research in this field. We considered diagnostic criteria and how current research maps against the James Lind Alliance Priority Setting Partnership research priorities. Methods:Using a predefined protocol, we conducted a comprehensive search of Cochrane, MEDLINE, EMBASE and Cumulative Index to Nursing and Allied Health Literature. We included all English-language research studies published between January 2018 and May 2023. Two reviewers independently applied inclusion criteria with consensus involving additional reviewers. Studies including people diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome using any criteria (including self-report), of any age and in any setting were eligible. Studies with < 10 myalgic encephalomyelitis/chronic fatigue syndrome participants were excluded. Data extraction, coding of topics (involving stakeholder consultation) and methodological quality assessment of systematic reviews (using A MeaSurement Tool to Assess systematic Reviews 2) was conducted independently by two reviewers, with disagreements resolved by a third reviewer. Studies were presented in an evidence map. Results:Of the 11,278 identified studies, 742 met the selection criteria, but only 639 provided sufficient data for inclusion in the evidence map. These reported data from approximately 610,000 people with myalgic encephalomyelitis/chronic fatigue syndrome. There were 81 systematic reviews, 72 experimental studies, 423 observational studies and 63 studies with other designs. Most studies (94%) were from high-income countries. Reporting of participant details was poor; 16% did not report gender, 74% did not report ethnicity and 81% did not report the severity of myalgic encephalomyelitis/chronic fatigue syndrome. Forty-four per cent of studies used multiple diagnostic criteria, 16% did not specify criteria, 24% used a single criterion not requiring postexertional malaise and 10% used a single criterion requiring postexertional malaise. Most (89%) systematic reviews had a low methodological quality. Five main topics (37 subtopics) were included in the evidence map. Of the 639 studies; 53% addressed the topic 'what is the cause?'; 38% 'what is the problem?'; 26% 'what can we do about it?'; 15% 'diagnosis and assessment'; and 13% other topics, including 'living with myalgic encephalomyelitis/chronic fatigue syndrome'. Discussion:Studies have been presented in an interactive evidence map according to topic, study design, diagnostic criteria and age. This evidence map should inform decisions about future myalgic encephalomyelitis/chronic fatigue syndrome research. Limitations:An evidence map does not summarise what the evidence says. Our evidence map only includes studies published in 2018 or later and in English language. Inconsistent reporting and use of diagnostic criteria limit the interpretation of evidence. We assessed the methodological quality of systematic reviews, but not of primary studies. Conclusions:We have produced an interactive evidence map, summarising myalgic encephalomyelitis/chronic fatigue syndrome research from 2018 to 2023. This evidence map can inform strategic plans for future research. We found some, often limited, evidence addressing every James Lind Alliance Priority Setting Partnership priority; high-quality systematic reviews should inform future studies. Funding:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme as award number NIHR159926.

Background:Polyvascular disease (atherosclerosis across two or more vascular beds) is becoming increasingly common, yet systematic reviews of interventions such as exercise are traditionally targeted at people with a single disease. We aimed to determine the effect of exercise in the secondary prevention of major adverse cardiovascular events and health-related quality of life (HRQoL) in people with an existing vascular disease and to assess the impact of polyvascular disease. Methods:For this systematic review and meta-analysis, we searched databases (Cochrane Register of Studies Online, MEDLINE, Embase Ovid, CINAHL EBSCO, WHO-ICTRP and ClinicalTrials.gov) in January 2025 for randomised controlled trials (RCTs) of exercise in people with coronary artery disease, heart failure, stroke (including transient ischaemic attack (TIA)) and peripheral arterial disease (PAD). We excluded studies where exercise was delivered for <6 weeks. Two reviewers independently assessed articles for eligibility and extracted data. Disagreements were resolved through discussion. Critical outcomes were mortality (all-cause and cardiovascular-specific), vascular events (myocardial infarction, stroke, amputation, acute limb ischaemia (ALI)), vascular hospitalisations, and HRQoL (EQ-5D and SF-36). We extracted data at end of intervention, medium term (6-30 months follow-up), and long term (>30 months follow-up). We performed random-effects meta-analyses. Risk of bias was assessed using Cochrane's Risk of Bias 1 tool. The certainty of the evidence was assessed using GRADE. PROSPERO registration: CRD42024517019. Findings:We included 280 RCTs involving 23,419 participants. 114 (40·71%) studies did not report whether their populations had more than one vascular disease. Exercise may result in little to no difference in all-cause mortality compared to no exercise at end of intervention (risk ratio (RR) 0·92, 95% confidence interval (CI) 0·80-1·07; P = 0·30; 143 studies, 12,811 participants; low-certainty evidence). Similar effects were found at medium and long term. Exercise may result in little to no difference in cardiovascular mortality compared to no exercise at end of intervention (RR 0·92, 95% CI 0·75-1·12; P = 0·41; 77 studies, 7319 participants; low-certainty evidence). A similar effect was found at medium term. At long term there may be a difference favouring exercise on cardiovascular mortality (RR 0·81, 95% CI 0·64-1·01; P = 0·06; 10 studies, 3935 participants). Exercise probably reduces vascular hospitalisations compared to no exercise at end of intervention (RR 0·73, 95% CI 0·56-0·95; P = 0·02; 64 studies, 7101 participants; moderate-certainty evidence) and medium term (RR 0·83, 95% CI 0·70-0·99; P = 0·04; 49 studies, 7514 participants; low-certainty evidence), with little or no difference at long term. Exercise probably increases HRQoL as assessed by EQ-5D compared to no exercise at end of intervention (mean difference (MD), 6·20, 95% CI 2·21-10·20; P = 0·002; 8 studies, 805 participants; moderate-certainty evidence), with little or no difference at medium term (MD 2·23, 95% CI -3·19 to 7·66; P = 0·42; 7 studies, 707 participants; moderate-certainty evidence) and long term (MD 6·00, 95% CI -2·05 to 14·05; P = 0·14; 1 study, 73 participants). Exercise probably increases HRQoL as assessed by SF-36 compared to no exercise at end of intervention (MD 6·83, 95% CI 5·22-8·44; P < 0·0001; 50 studies, 3231 participants; moderate-certainty evidence) and medium term (MD 6·44, 95% CI 3·71-9·18; P < 0·0001; 15 studies, 1522 participants; moderate-certainty evidence). No studies reported SF-36 at long term. Data on vascular events were mixed and of low certainty. Evidence was limited, and therefore uncertain, for amputation and ALI. Limiting issues were poor descriptions of exercise, and poor, inconsistently reported study inclusion and exclusion criteria, therefore limiting our ability to categorise included populations as polyvascular/single. Interpretation:We believe this systematic review and meta-analysis to be the first to combine RCTs with vascular diseases and examine the effects of exercise in people with single conditions and polyvascular disease. We found consistent evidence that exercise improves HRQoL and reduces hospitalisations across vascular disease but does not appear to impact mortality. However, the vast majority of trials were designed to target people with a single vascular condition and did not report the presence of additional vascular diseases. Therefore, it was not possible to formally assess the impact of the addition of polyvascular disease on exercise outcomes or determine the applicability of our findings to a population with polyvascular disease. More trials are needed that include participants with polyvascular conditions to strengthen the evidence on safety of this intervention, in order to inform clinical guidelines. Funding:This study was funded by the NIHR Evidence Synthesis Programme (NIHR162044).

BACKGROUND:Mental health disorders amongst children and young people pose a significant burden, with a growing emphasis on early intervention. A notable gap exists between the prevalence of these disorders and sufficiently early treatment, emphasising the need for effective preventive measures. AIMS:This review aims to comprehensively assess and narratively synthesise both quantitative and qualitative literature on secondary preventative (indicated and selective) school-based mental health interventions in the UK. METHOD:All empirical studies published since 2010, which reported on UK secondary preventative school-based interventions were eligible. Eligible studies were identified by searching the following electronic databases: PsycINFO (Ovid), MEDLINE (Ovid), Scopus (Elsevier), EMBASE (Elsevier), ERIC (EBSCO), and Web of Science (Clarivate). Database searches yielded 3269 results, with 26 articles meeting inclusion criteria. These articles covered 22 unique studies encompassing various study designs. The Mixed Method Appraisal Tool (MMAT) was used to assess study quality, and study findings were synthesised using a single narrative synthesis ('storytelling') approach. RESULTS:Three central themes emerged: (1) Outcomes for children and young people; (2) acceptability and preferences; and (3) practical considerations. The majority of included studies demonstrated high quality. Studies revealed diverse perspectives on the strengths, limitations, barriers, and facilitators of school-based interventions. CONCLUSIONS:School-based interventions hold promise in promoting positive mental health amongst young people, emphasising the pivotal role of educational settings in addressing these challenges. Despite encouraging outcomes, this review highlights the need for further research to better understand intervention effectiveness, implementation barriers, and cost-effectiveness; to facilitate the development of tailored and impactful strategies for supporting young people's mental health. PRISMA/PROSPERO STATEMENT:This systematic review was conducted following Cochrane methodology PRISMA guidelines. The review was registered with PROSPERO in June 2023 (CRD42023431966).

Background:Stroke often affects recognition and interpretation of information from our senses, resulting in perceptual disorders. Evidence to inform treatment is unclear. Objective:To determine the breadth and effectiveness of interventions for stroke-related perceptual disorders and identify priority research questions. Methods:We undertook a scoping review and then Cochrane systematic review. Definitions, outcome prioritisation, data interpretation and research prioritisation were coproduced with people who had perceptual disorders post stroke and healthcare professionals. We systematically searched electronic databases (including MEDLINE, EMBASE, inception to August 2021) and grey literature. We included studies (any design) of interventions for people with hearing, smell, somatosensation, taste, touch or visual perception disorders following stroke. Abstracts and full texts were independently dual reviewed. Data were tabulated, synthesised narratively and mapped by availability, sense and interventions. Research quality was not evaluated. Our Cochrane review synthesised the randomised controlled trial data, evaluated risk of bias (including randomisation, blinding, reporting) and meta-analysed intervention comparisons (vs. controls or no treatment) using RevMan 5.4. We judged certainty of evidence using grading of recommendations, assessment, development and evaluation. Activities of daily living after treatment was our primary outcome. Extended activities of daily living, quality of life, mental health and psychological well-being perceptual functional and adverse event data were also extracted. Results:We included 80 studies (n = 893): case studies (36/80) and randomised controlled trials (22/80). No stroke survivor or family stakeholder involvement was reported. Studies addressed visual (42.5%, 34/80), somatosensation (35%, 28/80), auditory (8.7%, 7/80) and tactile (7.5%, 6/80) perceptual disorders; some studies focused on 'mixed perceptual disorders' (6.2%, 5/80 such as taste-smell disorders). We identified 93 pharmacological, non-invasive brain stimulation or rehabilitation (restitution, substitution, compensation or mixed) interventions. Details were limited. Studies commonly measured perceptual (75%, 60/80), motor-sensorimotor (40%, 32/80) activities of daily living (22.5%, 18/80) or sensory function (15%, 12/80) outcomes. Cochrane systematic review:We included 18 randomised controlled trials (n = 541) addressing tactile (3 randomised controlled trials; n = 70), somatosensory (7 randomised controlled trials; n = 196), visual (7 randomised controlled trials; n = 225) and mixed tactile-somatosensory (1 randomised controlled trial; n = 50) disorders. None addressed hearing, taste or smell disorders. One non-invasive brain stimulation, one compensation, 25 restitution and 4 mixed interventions were described. Risk of bias was low for random sequence generation (13/18), attrition (14/18) and outcome reporting (16/18). Perception was the most commonly measured outcome (11 randomised controlled trials); only 7 randomised controlled trials measured activities of daily living. Limited data provided insufficient evidence to determine the effectiveness of any intervention. Confidence in the evidence was low-very low. Our clinical (n = 4) and lived experience (n = 5) experts contributed throughout the project, coproducing a list of clinical implications and research priorities. Top research priorities included exploring the impact of, assessment of, and interventions for post-stroke perceptual disorders. Limitations:Results are limited by the small number of studies identified and the small sample sizes, with a high proportion of single-participant studies. There was limited description of the perceptual disorders and intervention(s) evaluated. Few studies measured outcomes relating to functional impacts. There was limited investigation of hearing, smell, taste and touch perception disorders. Conclusion:Evidence informing interventions for perceptual disorders after stroke is limited for all senses. Future work:Further research, including high-quality randomised controlled trials, to inform clinical practice are required. Study registration:This study is registered as PROSPERO CRD42019160270. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128829) and is published in full in Health Technology Assessment; Vol. 28, No. 69. See the NIHR Funding and Awards Website for further award information.

Lower-intensity interventions delivered in primary and community care contacts could provide more equitable and scalable weight management support for postnatal women. This mixed-methods systematic review aimed to explore the effectiveness, implementation, and experiences of lower-intensity weight management support delivered by the non-specialist workforce. We included quantitative and qualitative studies of any design that evaluated a lower-intensity weight management intervention delivered by non-specialist workforce in women up to 5 years post-natal, and where intervention effectiveness (weight-related and/or behavioural outcomes), implementation and/or acceptability were reported. PRISMA guidelines were followed, and the review was prospectively registered on PROSPERO (CRD42022371828). Nine electronic databases were searched to identify literature published between database inception to January 2023. This was supplemented with grey literature searches and citation chaining for all included studies and related reviews (completed June 2023). Screening, data extraction and risk of bias assessments were performed in duplicate. Risk of bias was assessed using the Joanna Briggs Institute appraisal tools. Narrative methods were used to synthesise outcomes. Seven unique studies described in 11 reports were included from the Netherlands (n = 2), and the United Kingdom, Germany, Taiwan, Finland, and the United States (n = 1 each). All studies reported weight-related outcomes; four reported diet; four reported physical activity; four reported intervention implementation and process outcomes; and two reported intervention acceptability and experiences. The longest follow-up was 13-months postnatal. Interventions had mixed effects on weight-related outcomes: three studies reported greater weight reduction and/or lower postnatal weight retention in the intervention group, whereas four found no difference or mixed effects. Most studies reporting physical activity or diet outcomes showed no intervention effect, or mixed effects. Interventions were generally perceived as acceptable by women and care providers, although providers had concerns about translation into routine practice. The main limitations of the review were the limited volume of evidence available, and significant heterogeneity in interventions and outcome reporting which limited meaningful comparisons across studies. There is a need for more intervention studies, including process evaluations, with longer follow-up in the postnatal period to understand the role of primary and community care in supporting women’s weight management. Public Health Wales was the primary funder of this review.

Background Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear. Objective To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented. Methods Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0–18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains. Results Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps. Scoping review 651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations. Effectiveness systematic reviews studies explored service delivery models ( n = 15); interventions delivered by families/carers ( n = 32), wider children’s workforce ( n = 21), continence teams ( n = 31) and specialist consultant-led teams ( n = 42); complementary therapies ( n = 15); and psychosocial interventions ( n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators. Conclusions Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children. Study registration This study is registered as PROSPERO CRD42019159008. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment ; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

BackgroundUp to 50% of people in low- and middle-income countries do not receive the rehabilitation they require. Telerehabilitation has the potential to improve access to neurorehabilitation services especially in low- and middle-income countries. Although there are reports of the barriers and facilitators to telerehabilitation in such settings, almost all are anecdotal. Furthermore, family or carers have a significant influence on the adoption and success of telerehabilitation, but their views have not been reported. ObjectiveThis study aimed to investigate the views of service users, their family or carers, and health care professionals (HCPs) on telerehabilitation for people with neurological conditions in Ghana. MethodsTwo focus groups were held at Komfo Anokye Hospital in Kumasi, Ghana: one in person for service users (n=11) and their family or carers (n=9), conducted in the Ghanaian language of Twi, and one hybrid for HCPs (n=18) conducted in English. The mean (SD) age of the service users was 59.8 (8.6) years; 5 users had a stroke and 6 had Parkinson disease. The HCP group consisted of 7 speech and language therapists, 3 physiotherapists, 3 occupational therapists, 3 medical staff, 1 nurse, and 1 industry representative. Focus groups were semi-structured and explored previous experiences of telerehabilitation, perceived benefits and challenges, and solutions to overcome these challenges. Focus groups were audio transcribed, and the service user transcript was translated into English. The resulting transcripts were analyzed using thematic analysis. ResultsOverall, participants were positive about the role of telerehabilitation but recommended hybrid delivery, with in-person rehabilitation in the early stages and telerehabilitation in the later stages. In relation to telerehabilitation in Ghana, there were 3 main themes: benefits, challenges or barriers, and implementation. Benefits included the convenience and lower cost for service users, the higher dose of therapy possible, and increased access for people in remote areas. However, challenges included lack of a stable internet connection, cost of phones and data packages, and low levels of literacy. Implementation issues included cultural relevance, information governance, and the platform used to deliver telerehabilitation, with most participants being familiar with WhatsApp. ConclusionsTelerehabilitation has the potential to be a useful method of delivering rehabilitation to people with neurological conditions in Ghana, especially in a hybrid rehabilitation model with telerehabilitation augmenting in-person sessions. However, many people were unaware of telerehabilitation, and challenges such as a reliable internet connection, cultural relevance, and costs need to be addressed. Clinical trials of low-cost telerehabilitation interventions contextualized to the specific user group are required.

Gambling messaging is one potential component of a public health approach towards reducing gambling-related harm (GRH). This systematic review examined the effectiveness of existing public health gambling messaging interventions. Four databases were searched from inception to June 2023. Twenty-one papers met inclusion criteria. Studies were conducted in diverse settings, employed various designs, and evaluated messaging interventions that differed in their aims and reported outcomes. Interventions were categorised into three groups: general population-level messaging, gambling harm reduction messages, and product risk warnings. The evidence—currently limited—suggests that existing gambling messaging interventions are ineffective in changing behaviours but can raise awareness of GRH. Our findings underpinned recommendations for how the format and presentation of currently used ‘safer’ gambling messages and product warning labels may be improved. Research is required to develop and test messages that can help prevent and reduce GRH both for the general population and people who gamble.

Context: Advance care planning (ACP) is a comprehensive procedure aimed at helping individuals understand and articulate their values, life goals, and preferences concerning future medical treatment. Despite extensive research on ACP in populations with terminal illnesses, dementia, and those in long-term care, there is a lack of focus on its impact among older adults without life-limiting conditions. Objectives: To investigate the effectiveness, acceptability, and feasibility of ACP for older adults without life-limiting conditions. Methods: We searched 11 electronic databases, spanning from inception to November 2023, complemented by extensive grey literature and reference searches. Rigorous quality assessments were conducted using the Mixed Methods Appraisal Tool (MMAT). Our approach adopted a dynamic convergent mixed-methods design, incorporating thematic and narrative synthesis. Findings: From over 12,600 citations, a total of 16 studies, comprising four randomised controlled trials (RCTs), nine qualitative studies, and three mixed methods studies met the inclusion criteria. Limited findings indicate that ACP interventions are generally effective in improving document completion rates and reducing hospital readmissions. Acceptability and feasibility of these interventions were high, although significantly influenced by cultural and religious factors. Limitations: Evidence supporting the effectiveness, acceptability, and feasibility of ACP in reducing unplanned hospital admissions in older adults without life-limiting conditions was limited. We excluded observations based on unwell older people, though some material with unclear distinctions may have been included. Quality assessments revealed that one of four RCTs had a high risk of bias, three had unclear risks; all nine qualitative studies had low risk; and one of three mixed methods studies had low risk while two had unclear risks. Implications: Further targeted research is necessary to assess the intervention’s value for this population. Rigorous real-world evidence studies involving older adults without life-limiting conditions and their proxies is crucial to enabling providers to tailor ACPs to diverse populations, whilst respecting individuals’ religious and cultural beliefs.

The effectiveness of immunization is widely accepted: it can successfully improve health outcomes by reducing the morbidity and mortality associated with vaccine-preventable diseases. In the era of pandemics, there is a pressing need to identify and understand the factors associated with vaccine uptake amongst different socioeconomic groups. The knowledge generated from research in this area can be used to inform effective interventions aimed at increasing uptake. This umbrella systematic review aims to determine whether there is an association between socioeconomic inequalities and rate of vaccine uptake globally. Specifically, the study aims to determine whether an individual’s socioeconomic status, level of education, occupation, (un)-employment, or place of residence affects the uptake rate of routine vaccines. The following databases will be searched from 2011 to the present day: Medline (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane CENTRAL, Science Citation Index (Web of Science), DARE, SCOPUS (Elsevier), and ASSIA (ProQuest). Systematic reviews will be either included or excluded based on a priori established eligibility criteria. The relevant data will then be extracted, quality appraised, and narratively synthesised. The synthesis will be guided by the theoretical framework developed for this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Equity extension (PRISMA-E) guidance will be followed. This protocol has been registered on PROSPERO, ID: CRD42022334223.

Introduction Cardiovascular disease (CVD) has shown significant health inequalities for people with low socioeconomic status associated with more risk factors. This review was to synthesize interventions that targeted CVD risks and outcomes among socioeconomically disadvantaged populations and to understand the impact associated with these interventions.Sources of data Cochrane CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL were searched for records published in the last decade using a systematic search strategy, complemented by screening the reference lists and citation indexes. Nineteen studies were included and a narrative synthesis with the effect direction plot was undertaken in which studies, interventions, participants and outcomes were examined according to the intervention type focusing on behaviours, lifestyle, education, medication and monitoring.Areas of agreement No universal definition of disadvantaged socioeconomic status was used with common factors relating to racial/ethnic minorities, low income and low or no health insurance. Mixed effects of interventions were reported on clinical outcomes including weight, body mass index, blood pressure, glycated haemoglobin and cholesterol.Areas of controversy Inconsistent effect was reported due to a large variety of settings, participants and intervention components although they are considered necessary to address the complex health needs of socioeconomically disadvantaged populations.Growing points There is inadequate evidence to determine whether any of the intervention types are effective in optimising lipids management for socioeconomically disadvantaged populations.Areas timely for developing research Research is needed with mixed evidence using real world evaluation and lived experience combined with health economic evaluation, on both mental and physical health outcomes.

BACKGROUND:Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them. OBJECTIVES:1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services? SEARCH METHODS:Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022. SELECTION CRITERIA:To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families. DATA COLLECTION AND ANALYSIS:We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain. MAIN RESULTS:We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work. AUTHORS' CONCLUSIONS:We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

Abstract Non-uniform-based staff dress codes are beginning to emerge in UK long-term care facilities for older people. However, there is little research evidence on the impact of staff clothing on resident, staff and visitor experiences, wellbeing or quality of life. Uniforms may be reassuring and facilitate identification of staff; a non-uniform approach may create a home-like, relaxed environment. This study aimed to synthesise existing international evidence and explore staff views about work clothing in three not-for-profit long-term care facilities in the UK. Five bibliometric databases were searched from inception. A narrative synthesis of included papers was conducted due to heterogeneity of study designs and outcome reporting. 77 (49%) of 158 staff responded to the survey. 68 staff (88%) did not currently wear a uniform at work. Views about the importance and impact of uniform were mixed: 25 (32%) believed that their role needed a uniform; 60 (78%) thought staff clothing made no difference in resident care quality but 45 (58%) agreed the environment felt more home-like when staff did not wear a uniform. 36 staff (47%) would choose to wear a uniform and 17 staff (22%) reported finding it difficult to afford clothes for work. In the context of limited research evidence, staff clothing is perceived to have little impact on care quality but considerable impact on long-term care facility atmosphere and staff working experiences. There is a need to research the impact of staff clothing to support evidence-based decisions about staff clothing policies in long-term care settings.

Background: Up to 50% of people in low-and middle-income countries do not receive the rehabilitation they require.Telerehabilitation has the potential to improve access to neurorehabilitation services especially in low-and middle-income countries.Although there are reports of the barriers and facilitators to telerehabilitation in such settings, almost all are anecdotal.Furthermore, family or carers have a significant influence on the adoption and success of telerehabilitation, but their views have not been reported.Objective: This study aimed to investigate the views of service users, their family or carers, and health care professionals (HCPs) on telerehabilitation for people with neurological conditions in Ghana.Methods: Two focus groups were held at Komfo Anokye Hospital in Kumasi, Ghana: one in person for service users (n=11) and their family or carers (n=9), conducted in the Ghanaian language of Twi, and one hybrid for HCPs (n=18) conducted in English.The mean (SD) age of the service users was 59.8 (8.6) years; 5 users had a stroke and 6 had Parkinson disease.The HCP group consisted of 7 speech and language therapists, 3 physiotherapists, 3 occupational therapists, 3 medical staff, 1 nurse, and 1 industry representative.Focus groups were semi-structured and explored previous experiences of telerehabilitation, perceived benefits and challenges, and solutions to overcome these challenges.Focus groups were audio transcribed, and the service user transcript was translated into English.The resulting transcripts were analyzed using thematic analysis.Results: Overall, participants were positive about the role of telerehabilitation but recommended hybrid delivery, with in-person rehabilitation in the early stages and telerehabilitation in the later stages.In relation to telerehabilitation in Ghana, there were 3 main themes: benefits, challenges or barriers, and implementation.Benefits included the convenience and lower cost for service users, the higher dose of therapy possible, and increased access for people in remote areas.However, challenges included lack of a stable internet connection, cost of phones and data packages, and low levels of literacy.Implementation issues included cultural relevance, information governance, and the platform used to deliver telerehabilitation, with most participants being familiar with WhatsApp.Conclusions: Telerehabilitation has the potential to be a useful method of delivering rehabilitation to people with neurological conditions in Ghana, especially in a hybrid rehabilitation model with telerehabilitation augmenting in-person sessions.However, many people were unaware of telerehabilitation, and challenges such as a reliable internet connection, cultural relevance, and costs need to be addressed.Clinical trials of low-cost telerehabilitation interventions contextualized to the specific user group are required.