Abstract Background Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme. Methods Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018–2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach. Results Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system. Conclusions Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients’ expectations and needs, as strategies for increasing cataract surgery uptake.

AbstractBackgroundEvidence indicates that school-based vision screening by trained teachers is an effective way of identifying and addressing potential vision problems in schoolchildren. However, inconsistencies have been reported in both the testing methods and accuracy of the screeners. This study assessed the prevalence of refractive errors and accuracy of screening by teachers in Grand Kru County, Liberia.MethodsWe conducted a retrospective analysis of data from four schools where, in February 2019, children were screened for refractive errors by trained teachers and then re-examined by ophthalmic technicians. One row of five optotypes of the Snellen 6/9 (0.2 logMar) scale (tumbling E chart) was used at a distance of 3 m. The prevalence of visual impairment and associations with sex, age and school were explored. Sensitivity, specificity and predictive values were calculated.ResultsData were available for 823 of 1095 eligible children with a mean age of 13.7 y (range 5–18) and male:female ratio of 1:0.8. Poor vision was identified in 24 (2.9%) children with no differences by either sex or age but small differences by school. Screening by teachers had a sensitivity of 0.25 (95% confidence interval [CI] 0.077 to 0.423) and a specificity of 0.996 (95% CI 0.992 to 1.000). Positive and negative predictive values were 0.667 (95% CI 0.359 to 0.975) and 0.978 (95% CI 0.968 to 0.988), respectively. The results were influenced by a high number of misclassifications in one of the four schools.ConclusionsTeachers can be trained to conduct vision screening tests on schoolchildren to an acceptable level of accuracy, but strong monitoring and quality assurance systems should be built into screening programmes from the onset. In settings like Liberia, where many children do not attend school regularly, screening programmes should extend to community platforms to reach children out of school.

Background Preventing visual impairment due to avoidable causes has been a long-standing global priority. Of all blindness in Sierra Leone, 91.5% is estimated to be avoidable and 58.2% treatable, however there are only 6 ophthalmologists for the whole country. Task-shifting has been suggested as a strategy to address this issue and a training intervention was developed to create a cadre of community-based staff known as Ophthalmic Community Health Officers (OCHOs). This qualitative study aimed to explore the experiences of OCHOs, their relationship with other eye health workers, and how they interact with the wider health system, in order to provide recommendations for the design and delivery of future task shifting strategies. Methods Between April and May 2018, we conducted semi-structured interviews with 42 participants including: OCHOs (n = 13), traditional ophthalmic staff (n = 17) and other stakeholders from the districts (n = 6), training institution staff (n = 4) and MOH headquarters (n = 2). We identified participants using purposive sampling. Interviews were audio-recorded, transcribed, and thematically analysed. We draw largely on in-depth interviews but complement the analysis with evidence from a document review. Results In Sierra Leone, the roll-out of the OCHO programme presented a mixed picture. OCHOs participating in the study expressed a strong commitment to their new role. However, policy changes proposed to clearly demarcate roles and responsibilities and institutionalise the cadre in the civil service were not implemented, resulting in the posting of some staff at an inappropriate level, dissatisfaction with the OCHO certification, and lack of opportunities for advancement and training. These challenges reflect structural weaknesses in the health system that undermine a cohesive implementation of eye health initiatives at the primary health care level in Sierra Leone. Conclusions Task-shifting has the potential to improve provision in under-resourced specialities such as eye health. However, the success of this approach will be contingent upon the development of a robust and supportive health policy environment.

Aim To examine assumptions about public-private partnership (PPP) activities and their role in improving public procurement of primary healthcare surgeries.BACKGROUND:PPPs were developed to improve the quality of care and patient satisfaction. However, evidence of their effectiveness in delivering health benefits is limited.METHODS:A qualitative study design was employed. A total of 25 interviews with public sector staff (n=23) and private sector managers (n=2) were conducted to understand their interpretations of assumptions in the activities of private investors and service contractors participating in Local Improvement Finance Trust (LIFT) partnerships. Realist evaluation principles were applied in the data analysis to interpret the findings.RESULTS:Six thematic areas of assumed health benefits were identified: (i) quality improvement; (ii) improved risk management; (iii) reduced procurement costs; (iv) increased efficiency; (v) community involvement; and (vi) sustainable investment. Primary Care Trusts that chose to procure their surgeries through LIFT were expected to support its implementation by providing an environment conducive for the private participants to achieve these benefits. Private participant activities were found to be based on a range of explicit and tacit assumptions perceived helpful in achieving government objectives for LIFT.CONCLUSION:The success of PPPs depended upon private participants' (i) capacity to assess how PPP assumptions added value to their activities, (ii) effectiveness in interpreting assumptions in their expected activities, and (iii) preparedness to align their business principles to government objectives for PPPs. They risked missing some of the expected benefits because of some factors constraining realization of the assumptions. The ways in which private participants preferred to carry out their activities also influenced the extent to which expected benefits were achieved. Giving more discretion to public than private participants over critical decisions may help in ensuring that assumptions in PPP activities result in outcomes that match the anticipated health benefits.

Aim: To compare the characteristics of mental health and physical health participants attending an exercise referral scheme (ERS) and investigate associations with their adherence to exercise. Background: While people referred to an ERS with a mental health diagnosis have similar initial rates of uptake as physical health participants, they are more likely to drop out. Comparisons of the groups to understand their differences and how these might impact on their adherence have been limited by the typically low numbers of mental health referrals in many schemes. Methods: Retrospective analysis of a participant cohort. Data were extracted on all participants enrolled over a 12-month period (n = 701) and included measurements at baseline, mid-point (13 weeks) and end of programme (20-26weeks). Differences were explored between the mental health (n = 141) and physical health (n = 560) subcohorts, and between adherers and non-adherers in each group. Binomial logistic regression estimated the effect of group-level factors associated with adherence. Findings: Mental health referrals were more likely to be younger, White and unemployed, and had a lower mean body mass index and lower proportion of participants with high blood pressure. They were also more likely to drop out. While occupation was associated with exercise adherence among the physical health group, no predictive factors were identified in the mental health group. Conclusion: Participants referred for mental health disorders are more likely to drop out of exercise referral schemes than those with physical health problems. While no factors were found to be predictive of their exercise adherence, an understanding of their distinguishing characteristics and attendance behaviour can guide in making better referral decisions concerning them and planning more appropriately tailored support.

Multiple individual and neighbourhood characteristics are theorised to influence adult sedentary behaviour. The aim of this study was to examine associations between individual and neighbourhood-level characteristics in 40 deprived neighbourhoods in London, UK. A cross-sectional design was utilised with baseline data from the Well London Cluster Randomised Controlled Trial in 40 deprived neighbourhoods in London. Multilevel linear regression was used to examine associations between individual characteristics (measured by household survey), neighbourhood characteristics (neighbourhood audit, GIS and routinely available datasets) and sedentary behaviour (sitting time). Individual-level positive mental well-being and health behaviours were associated with sedentary time. Individual-level social networks were associated with decreased sedentary time in men and increased sedentary time in women. Neighbourhood-level measures of social networks and perceived neighbourhood quality were associated with reduced sedentary time. Fifteen per cent of the variance in sedentary time was attributable to differences at the neighbourhood level (intra-class correlation coefficient=0.15). These findings suggest that social networks at the individual and neighbourhood levels, collective perceptions of neighbourhood quality, individual-level positive mental well-being and other health behaviours may be important components of interventions developed to reduce sedentary time in deprived populations.

This article discusses the methods and findings of a study to estimate the unit costs of a programme to promote health and wellbeing in deprived neighbourhoods of London. In view of the policy emphasis on primary prevention of ill health and promotion of wellbeing, it is as important to understand the costs and outcomes of public health initiatives as those of health and social care services. Investigating the costs of public health initiatives, however, can present challenges.

Background We report the main results, among adults, of a cluster-randomised-trial of Well London, a community-engagement programme promoting healthy eating, physical activity and mental well-being in deprived neighbourhoods. The hypothesis was that benefits would be neighbourhood-wide, and not restricted to intervention participants. The trial was part of a multicomponent process/outcome evaluation which included non-experimental components (self-reported behaviour change amongst participants, case studies and evaluations of individual projects) which suggested health, well-being and social benefits to participants.Methods Twenty matched pairs of neighbourhoods in London were randomised to intervention/control condition. Primary outcomes (five portions fruit/vegetables/day; 5x30 m of moderate intensity physical activity/week, abnormal General Health Questionnaire (GHQ)-12 score and Warwick-Edinburgh Mental Well-being Scale (WEMWBS) score) were measured by postintervention questionnaire survey, among 3986 adults in a random sample of households across neighbourhoods.Results There was no evidence of impact on primary outcomes: healthy eating (relative risk [RR] 1.04, 95% CI 0.93 to 1.17); physical activity (RR: 1.01, 95% CI 0.88 to 1.16); abnormal GHQ12 (RR: 1.15, 95% CI 0.84 to 1.61); WEMWBS (mean difference [MD]: -1.52, 95% CI -3.93 to 0.88). There was evidence of impact on some secondary outcomes: reducing unhealthy eating-score (MD: -0.14, 95% CI -0.02 to 0.27) and increased perception that people in the neighbourhood pulled together (RR: 1.92, 95% CI 1.12 to 3.29).Conclusions The trial findings do not provide evidence supporting the conclusion of non-experimental components of the evaluation that intervention improved health behaviours, well-being and social outcomes. Low participation rates and population churn likely compromised any impact of the intervention. Imprecise estimation of outcomes and sampling bias may also have influenced findings. There is a need for greater investment in refining such programmes before implementation; new methods to understand, longitudinally different pathways residents take through such interventions and their outcomes, and new theories of change that apply to each pathway.

In this paper, we describe the measures of intervention exposure used in the cluster randomised trial of the Well London programme, a public health intervention using community engagement and community-based projects to increase physical activity, healthy eating and mental health and well-being in 20 of the most deprived neighbourhoods in London.10 No earmarked resources to support the development of these measures and associated data collection were provided to either the research team or to those delivering the interventions on the ground. Instead, these were derived from contractually specified performance management information reported quarterly by partners and by inclusion of questions seeking information about participation in the follow-up questionnaires used to measure the main trial outcomes. The exposure measures are consequently considerably less sophisticated than those used in the US studies, where earmarked funding was available.

Background Traditionally health and social needs assessments have been developed from a deficit approach, focusing on community problems and needs. There is growing interest in working in new ways, using community assets to inform commissioning and service delivery. The Institute for Health and Human Development was commissioned by a London borough to support their transition to an asset based Joint Strategic Needs Assessment (JSNA), …

Objectives To examine the extent to which individual and ecological-level cognitive and structural social capital are associated with common mental disorder (CMD), the role played by physical characteristics of the neighbourhood in moderating this association, and the longitudinal change of the association between ecological level cognitive and structural social capital and CMD. Design Cross-sectional and longitudinal study of 40 disadvantaged London neighbourhoods. We used a contextual measure of the physical characteristics of each neighbourhood to examine how the neighbourhood moderates the association between types of social capital and mental disorder. We analysed the association between ecological-level measures of social capital and CMD longitudinally. Participants 4,214 adults aged 16-97 (44.4% men) were randomly selected from 40 disadvantaged London neighbourhoods. Main Outcome Measures General Health Questionnaire (GHQ-12). Results Structural rather than cognitive social capital was significantly associated with CMD after controlling for socio-demographic variables. However, the two measures of structural social capital used, social networks and civic participation, were negatively and positively associated with CMD respectively. ‘Social networks’ was negatively associated with CMD at both the individual and ecological levels. This result was maintained when contextual aspects of the physical environment (neighbourhood incivilities) were introduced into the model, suggesting that ‘social networks’ was independent from characteristics of the physical environment. When ecological-level longitudinal analysis was conducted, ‘social networks’ was not statistically significant after controlling for individual-level social capital at follow up. Conclusions If we conceptually distinguish between cognitive and structural components as the quality and quantity of social capital respectively, the conclusion of this study is that the quantity rather than quality of social capital is important in relation to CMD at both the individual and ecological levels in disadvantaged urban areas. Thus, policy should support interventions that create and sustain social networks. One of these is explored in this article. Trial Registration Controlled-Trials.com ISRCTN68175121 http://www.controlled-trials.com/ISRCTN68175121

The objectives of this study were to examine relationships between neighbourhood-level and individual-level characteristics and physical activity in deprived London neighbourhoods.In 40 of the most deprived neighbourhoods in London (ranked in top 11% in London by Index of Multiple Deprivation) a cross-sectional survey (n = 4107 adults aged > = 16 years), neighbourhood audit tool, GIS measures and routine data measured neighbourhood and individual-level characteristics. The binary outcome was meeting the minimum recommended (CMO, UK) 5 × 30 mins moderate physical activity per week. Multilevel modelling was used to examine associations between physical activity and individual and neighbourhood-level characteristics.Respondents living more than 300 m away from accessible greenspace had lower odds of achieving recommended physical activity levels than those who lived within 300 m; from 301-600 m (OR = 0.7; 95% CI 0.5-0.9) and from 601-900 m (OR = 0.6; 95% CI 0.4-0.8). There was substantial residual between-neighbourhood variance in physical activity (median odds ratio = 1.7). Other objectively measured neighbourhood-level characteristics were not associated with physical activity levels.Distance to nearest greenspace is associated with meeting recommended physical activity levels in deprived London neighbourhoods. Despite residual variance in physical activity levels between neighbourhoods, we found little evidence for the influence of other measured neighbourhood-level characteristics.

There is ample evidence that area-based approaches to tackling health inequalities, as part of a wider policy of community regeneration, are effective. Nevertheless, embedding this evidence in the routine practice of health professionals has not followed automatically. One of the barriers to the uptake of research is the process by which evidence is generated and its usability, or “stickiness”. This paper draws on the concept of stickiness to explore the role of deprivation monitoring data in creating an evidence base for neighbourhood health policies and intervention. The study was undertaken as part of a Knowledge Exchange Programme aimed at sharing learning to improve the participation and health of disadvantaged people in deprived neighbourhoods in Rotterdam and London. The two cities are similar in that they both have highly diverse populations and government health and social policies that employ area-based approaches to tackle deprivation. Documentary analysis and in-depth interviews with health professionals and policymakers in the two cities have explored the construction of health policy, the congruence between data on deprivation and the contextual experience of practitioners, and the factors that influenced the usability of the data.

Background Few public health interventions combining modification of the social and built environment with individual-level health promotion have been robustly evaluated in the UK. Well London is an assets-based community development programme designed to improve physical activity, healthy eating and mental wellbeing in highly deprived inner-city communities. The programme, delivered between 2007 and 2011, comprised a mix of projects delivering traditional health promotion, community development and changes to the physical neighbourhood environment. The objectives of the study are to: (i) determine the effectiveness of Well London for improving healthy eating, physical activity and mental wellbeing in deprived inner-city communities; (ii) examine the effects in population subgroups linked to health inequalities in the UK. Methods We used a pair-matched, cluster-randomised trial with 20 control neighbourhoods matched within London boroughs to 20 programme delivery neighbourhoods. The trial outcomes in adult residents (aged ≥16 years) were collected using a structured electronic household survey, administered by fieldworkers to 100 randomly sampled residents in each intervention and control neighbourhood. The main outcome measures were: physical activity: meeting UK Chief Medical Officer-recommended five sessions of 30 minutes moderate intensity activity per week (self-report International Physical Activity Questionnaire); healthy eating: eating at least five portions of fruit/vegetables per day (food frequency questionnaire from the Health Survey for England); and mental wellbeing: abnormal score on 12-item General Health Questionnaire; Warwick Edinburgh Mental Wellbeing Scale score. Results The baseline survey in 2008 showed that the intervention and control populations are comparable on socio-demographic/economic characteristics and primary trial outcomes. At baseline, 37% of adults met the five-a-day (healthy eating), 60% met the five-a-week (physical activity), and 18% reported experiencing anxiety or depression. Results from the follow-up survey will be available in April 2012. We will present the effects of Well London on the primary outcomes and subgroup analyses by gender, age, ethnicity and level of education. Conclusion In a health system where less than 1% of the research budget is spent on primary preventive interventions for non-communicable diseases, robust evidence about the effectiveness and cost-effectiveness of upstream interventions is essential for action on health inequalities and reductions in healthcare spending recommended by the Marmot Review (2010) and the Wanless report (2004).

Background: Exercise referral schemes are one of the most popular forms of physical activity intervention in primary care in the UK and present an opportunity to better understand the factors related to exercise adherence. But standard schemes tend to be delivered over a short period and so provide information about the factors associated with short-term adherence. This retrospective register-based study of a longer-duration scheme allowed investigation of longer-term adherence.Methods: Social, physiological and anthropometric data were extracted from records of a cohort of ERS participants who had enrolled between 01 January and 31 December 2007 (n = 701). Characteristics of adherers and non-adherers were compared and potential predictors of longer-term adherence examined using binomial logistic regression.Results: Significant adjusted odds ratios predicting longer-term adherence were found for age and medical condition. For every 10 year increase in age, the odds of people continuing exercise increased by 21.8% (OR = 1.02; CI = 1.00 to 1.04; p = 0.03). Participants referred with orthopaedic (OR = 0.25; CI = 0.07-0.94; p = 0.04), cardiovascular (OR = 0.18; CI = 0.05-0.70; p = 0.01) and other (OR = 0.20; CI = 0.04-0.93; p = 0.04) problems had significantly lower odds of adhering than those with metabolic conditions.Conclusion: Improved understanding of the factors that influence adherence to exercise referral schemes will enable providers develop better referral guidance and tailor schemes to better meet participants' needs. Longer-term schemes offer the opportunity to understand participants' likelihood of maintaining adherence to exercise.