Systematic reviews of convalescent plasma in COVID-19 continue to be poorly conducted and reported: a systematic review

OBJECTIVES

To suggest possible approaches to combatting the impact of the COVID-19 infodemic to prevent research waste in future health emergencies and in everyday research and practice.

STUDY DESIGN AND SETTING

Systematic review. The Epistemonikos database was searched in June 2021 for systematic reviews on the effectiveness of convalescent plasma for COVID-19. Two reviewers independently screened the retrieved references with disagreements resolved by discussion. Data extraction was completed by one reviewer with a proportion checked by a second. We used the Assessment of Multiple Systematic Reviews to assess the quality of conduct and reporting of included reviews.

RESULTS

Fifty one systematic reviews are included with 193 individual studies included within the systematic reviews. There was considerable duplication of effort; multiple reviews were conducted at the same time with inconsistencies in the evidence included. The reviews were of low methodological quality, poorly reported, and did not adhere to preferred reporting items for systematic reviews and meta-analysis guidance.

CONCLUSION

Researchers need to conduct, appraise, interpret, and disseminate systematic reviews better. All in the research community (researchers, peer-reviewers, journal editors, funders, decision makers, clinicians, journalists, and the public) need to work together to facilitate the conduct of robust systematic reviews that are published and communicated in a timely manner, reducing research duplication and waste, increasing transparency and accessibility of all systematic reviews.

Cross-Sectional and Longitudinal Associations between Subjective Sleep Difficulties and Self-Perceptions of Aging

BACKGROUND

Only one study has explored the associations of subjective sleep difficulties with self-perceptions of aging. It focused on a global indicator of self-perceptions of aging (subjective age) despite individuals reporting different experiences of aging in relation to different life domains. The concept of awareness of negative age-related change, capturing perceived losses across five domains (e.g., physical health, cognition), may be more appropriate when relating subjective sleep difficulties to self-perceptions of aging. We examined whether nine different indicators of subjective sleep difficulties predict levels of awareness of negative age-related change and subjective age, measured concurrently and one year later, while controlling for covariates (mood and daily function).

PARTICIPANTS/METHODS

We used data from the PROTECT cohort study; 4,482 UK residents (mean age = 66.1; SD = 6.9) completed measures of awareness of age-related change, subjective age, mood, daily function, and subjective sleep difficulties.

RESULTS

Based on linear regression analyses, poorer quality of sleep, lower alertness after awakening, satisfaction with sleep, depth of sleep, more frequent early awakening, difficulty falling asleep, more times awake during a night, fewer hours of sleep during the night and more hours of sleep during the day predicted higher awareness of negative age-related change at baseline and follow-up (p< .001). Associations were small in size. Associations between subjective sleep difficulties and subjective age were either negligible or statistically non-significant.

CONCLUSIONS

Although subjective sleep difficulties are one of the many factors associated with awareness of negative age-related change, addressing sleep difficulties, alongside negative mood, and poor daily functioning, may promote a small additional increase in positive self-perceptions of aging.

Identifying Child Anxiety Through Schools-identification to intervention (iCATS-i2i): protocol for a cluster randomised controlled trial to compare screening, feedback and intervention for child anxiety problems to usual school practice

Background

Systematically screening for child anxiety problems, and offering and delivering a brief, evidence-based intervention for children who are identified as likely to benefit would minimise common barriers that families experience in accessing treatment. We have developed a short parent-report child anxiety screening questionnaire, and procedures for administering screening questionnaires, sharing screening outcomes with families, and offering and delivering a brief parent-led online intervention (OSI: Online Support and Intervention for child anxiety) through schools. This trial aims to evaluate clinical and health economic outcomes for (1) children (aged 8–9) who screen positive for anxiety problems at baseline (target population) and (2) the wider population of all children in participating classes (total population) in schools randomly allocated to receive identification-to-intervention procedures and usual school practice (‘screening and intervention’), compared to assessment and usual school practice only (‘usual school practice’). 

Methods

The trial design is a parallel-group, superiority cluster randomised controlled trial, with schools (clusters) randomised to ‘screening and intervention’ or ‘usual school practice’ arms in a 1:1 ratio stratified according to the level of deprivation within the school. We will recruit schools and participants in two phases (a pilot phase (Phase 1) and Phase 2), with progression criteria assessed prior to progressing to Phase 2. In total, the trial will recruit 80 primary/junior schools in England, and 398 children (199 per arm) who screen positive for anxiety problems at baseline (target population). In schools allocated to ‘screening and intervention’: (1) parents/carers will complete a brief parent-report child anxiety screening questionnaire (at baseline) and receive feedback on their child’s screening outcomes (after randomisation), (2) classes will receive a lesson on managing fears and worries and staff will be provided with information about the intervention and (3) parents/carers of children who screen positive for anxiety problems (target population) will be offered OSI. OSI will also be available for any other parents/carers of children in participating classes (total population) who request it. We will collect child-, parent- and teacher-report measures for the target population and total population at baseline (before randomisation), 4 months, 12 months and 24 months post-randomisation. The primary outcome will be the proportion of children who screen positive for anxiety problems at baseline (target population) who screen negative for anxiety problems 12 months post-randomisation.

Discussion

This trial will establish if systematic screening for child anxiety problems, sharing screening outcomes with families and delivering a brief parent-led online intervention through schools is effective and cost-effective.

Trial registration

ISRCTN registry ISRCTN76119074. Prospectively registered on 4.1.2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06773-0.

Ethnic inequalities in routes to diagnosis of cancer: a population-based UK cohort study

BACKGROUND

UK Asian and Black ethnic groups have poorer outcomes for some cancers and are less likely to report a positive care experience than their White counterparts. This study investigated ethnic differences in the route to diagnosis (RTD) to identify areas in patients' cancer journeys where inequalities lie, and targeted intervention might have optimum impact.

METHODS

We analysed data of 243,825 patients with 10 cancers (2006-2016) from the RTD project linked to primary care data. Crude and adjusted proportions of patients diagnosed via six routes (emergency, elective GP referral, two-week wait (2WW), screen-detected, hospital, and Other routes) were calculated by ethnicity. Adjusted odds ratios (including two-way interactions between cancer and age, sex, IMD, and ethnicity) determined cancer-specific differences in RTD by ethnicity.

RESULTS

Across the 10 cancers studied, most patients were diagnosed via 2WW (36.4%), elective GP referral (23.2%), emergency (18.2%), hospital routes (10.3%), and screening (8.61%). Patients of Other ethnic group had the highest proportion of diagnosis via the emergency route, followed by White patients. Asian and Black group were more likely to be GP-referred, with the Black and Mixed groups also more likely to follow the 2WW route. However, there were notable cancer-specific differences in the RTD by ethnicity.

CONCLUSION

Our findings suggest that, where inequalities exist, the adverse cancer outcomes among Asian and Black patients are unlikely to be arising solely from a poorer diagnostic process.

Identifying Child Anxiety Through Schools-identification to intervention (iCATS-i2i): protocol for single-arm feasibility trial

Background

Anxiety disorders are common among primary-school aged children, but few affected children receive evidence-based treatment. Identifying and supporting children who experience anxiety problems through schools would address substantial treatment access barriers that families and school staff often face. We have worked with families and school staff to co-design procedures that incorporate screening, feedback for parents, and the offer of a brief intervention in primary schools. This study sets out to assess the feasibility of a subsequent school-based cluster randomised controlled trial to evaluate these procedures. Our objectives are to ensure our procedures for identifying and supporting children with anxiety difficulties through primary schools are acceptable and there are no negative impacts, to estimate recruitment and retention rates, and to identify any changes needed to study procedures or measures.

Methods

We will recruit six primary/junior schools in England (2 classes per school), and invite all children (aged 8–9) (n = 360) and their parent/carer and class teacher in participating classes to take part. Children, parents and class teachers will complete questionnaires at baseline and 12-week follow-up. Children who ‘screen positive’ on a 2-item parent-report child anxiety screen at baseline will be the target population (expected n = 43). Parents receive feedback on screening questionnaire responses, and where the child screens positive the family is offered support (OSI: Online Support and Intervention for child anxiety). OSI is a brief, parent-led online intervention, supported by short telephone sessions with a Children’s Wellbeing Practitioner. Participants’ experiences of study procedures will be assessed through qualitative interviews/discussion groups.

Discussion

Evidence-based procedures for identifying and supporting children with anxiety difficulties through primary schools would improve children’s access to timely, effective intervention for anxiety difficulties.

Trial registration

ISRCTN registry: ISRCTN30032471. Retrospectively registered on 18 May 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01140-x.

Attitudes toward own aging and cognition among individuals living with and without dementia: findings from the IDEAL programme and the PROTECT study

Background

It is unclear whether people with dementia (PwD) have more negative attitudes toward own aging (ATOA) than people without dementia and what factors influence ATOA among PwD. We investigated whether PwD have more negative ATOA than individuals without dementia and whether cognition and dementia subtype are associated with ATOA in PwD.

Methods

Data from the IDEAL and PROTECT studies were used to compare ATOA between 1502 PwD (mean (SD) age = 76.3 (8.5)) and 6377 individuals without dementia (mean (SD) age = 66.1 (7.1)). Linear regressions and ANOVA were used.

Results

PwD reported slightly more negative ATOA than people without dementia; this relationship disappeared after controlling for depression and self-rated health. In PwD more positive ATOA showed negligible associations with better general cognition, memory performance, verbal fluency, and visuospatial ability. However, after adjusting for covariates only better visuospatial ability predicted more positive ATOA. Additional analyses showed that before and after controlling for covariates, individuals with poorer self-reported visual acuity have more negative ATOA. Amongst dementia subtypes, people with Parkinson’s disease dementia and dementia with Lewy bodies reported most negative ATOA.

Conclusions

ATOA between PwD and people without dementia do not differ. ATOA in PwD appear to be affected not by cognitive impairment but by other characteristics that vary across dementia subtypes. Among PwD, those with Parkinson’s disease dementia and dementia with Lewy bodies may have higher risk of experiencing negative ATOA due to the motor and visual impairments that they experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03336-5.

Universal Mindfulness Training in Schools for Adolescents: a Scoping Review and Conceptual Model of Moderators, Mediators, and Implementation Factors

There is evidence that universal school-based mindfulness training (SBMT) can have positive effects for young people. However, it is unknown who benefits most from such training, how training exerts effects, and how implementation impacts effects. This study aimed to provide an overview of the evidence on the mediators, moderators, and implementation factors of SBMT, and propose a conceptual model that can be used both to summarize the evidence and provide a framework for future research. A scoping review was performed, and six databases and grey literature were searched. Inclusion and exclusion criteria were applied to select relevant material. Quantitative and qualitative information was extracted from eligible articles and reported in accordance with PRISMA-ScR guidelines. The search produced 5479 articles, of which 31 were eligible and included in the review. Eleven studies assessed moderators of SBMT on pupil outcomes, with mixed findings for all variables tested. Five studies examined the mediating effect of specific variables on pupil outcomes, with evidence that increases in mindfulness skills and decreases in cognitive reactivity and self-criticism post-intervention are related to better pupil outcomes at follow-up. Twenty-five studies assessed implementation factors. We discuss key methodological shortcomings of included studies and integrate our findings with existing implementation frameworks to propose a conceptual model. Widespread interest in universal SBMT has led to increased research over recent years, exploring who SBMT works for and how it might work, but the current evidence is limited. We make recommendations for future research and provide a conceptual model to guide theory-led developments.

Effectiveness of universal school-based mindfulness training compared with normal school provision on teacher mental health and school climate: results of the MYRIAD cluster randomised controlled trial

BACKGROUND

Education is broader than academic teaching. It includes teaching students social-emotional skills both directly and indirectly through a positive school climate.

OBJECTIVE

To evaluate if a universal school-based mindfulness training (SBMT) enhances teacher mental health and school climate.

METHODS

The My Resilience in Adolescence parallel group, cluster randomised controlled trial (registration: ISRCTN86619085; funding: Wellcome Trust (WT104908/Z/14/Z, WT107496/Z/15/Z)) recruited 85 schools (679 teachers) delivering social and emotional teaching across the UK. Schools (clusters) were randomised 1:1 to either continue this provision (teaching as usual (TAU)) or include universal SBMT. Data on teacher mental health and school climate were collected at prerandomisation, postpersonal mindfulness and SBMT teacher training, after delivering SBMT to students, and at 1-year follow-up.

FINDING

Schools were recruited in academic years 2016/2017 and 2017/2018. Primary analysis (SBMT: 43 schools/362 teachers; TAU: 41 schools/310 teachers) showed that after delivering SBMT to students, SBMT versus TAU enhanced teachers' mental health (burnout) and school climate. Adjusted standardised mean differences (SBMT minus TAU) were: exhaustion (-0.22; 95% CI -0.38 to -0.05); personal accomplishment (-0.21; -0.41, -0.02); school leadership (0.24; 0.04, 0.44); and respectful climate (0.26; 0.06, 0.47). Effects on burnout were not significant at 1-year follow-up. Effects on school climate were maintained only for respectful climate. No SBMT-related serious adverse events were reported.

CONCLUSIONS

SBMT supports short-term changes in teacher burnout and school climate. Further work is required to explore how best to sustain improvements.

CLINICAL IMPLICATIONS

SBMT has limited effects on teachers' mental and school climate. Innovative approaches to support and preserve teachers' mental health and school climate are needed.

The impact of mindfulness training in early adolescence on affective executive control, and on later mental health during the COVID-19 pandemic: a randomised controlled trial

BACKGROUND

Previous research suggests that mindfulness training (MT) appears effective at improving mental health in young people. MT is proposed to work through improving executive control in affectively laden contexts. However, it is unclear whether MT improves such control in young people. MT appears to mitigate mental health difficulties during periods of stress, but any mitigating effects against COVID-related difficulties remain unexamined.

OBJECTIVE

To evaluate whether MT (intervention) versus psychoeducation (Psy-Ed; control), implemented in after-school classes: (1) Improves affective executive control; and/or (2) Mitigates negative mental health impacts from the COVID-19 pandemic.

METHODS

A parallel randomised controlled trial (RCT) was conducted (Registration: https://osf.io/d6y9q/; Funding: Wellcome (WT104908/Z/14/Z, WT107496/Z/15/Z)). 460 students aged 11-16 years were recruited and randomised 1:1 to either MT (N=235) or Psy-Ed (N=225) and assessed preintervention and postintervention on experimental tasks and self-report inventories of affective executive control. The RCT was then extended to evaluate protective functions of MT on mental health assessed after the first UK COVID-19 lockdown.

FINDINGS

Results provided no evidence that the version of MT used here improved affective executive control after training or mitigated negative consequences on mental health of the COVID-19 pandemic relative to Psy-Ed. No adverse events were reported.

CONCLUSIONS

There is no evidence that MT improves affective control or downstream mental health of young people during stressful periods.

CLINICAL IMPLICATIONS

We need to identify interventions that can enhance affective control and thereby young people's mental health.

School-based mindfulness training in early adolescence: what works, for whom and how in the MYRIAD trial?

BACKGROUND

Preventing mental health problems in early adolescence is a priority. School-based mindfulness training (SBMT) is an approach with mixed evidence.

OBJECTIVES

To explore for whom SBMT does/does not work and what influences outcomes.

METHODS

The My Resilience in Adolescence was a parallel-group, cluster randomised controlled trial (K=84 secondary schools; n=8376 students, age: 11-13) recruiting schools that provided standard social-emotional learning. Schools were randomised 1:1 to continue this provision (control/teaching as usual (TAU)), and/or to offer SBMT ('.b' (intervention)). Risk of depression, social-emotional-behavioural functioning and well-being were measured at baseline, preintervention, post intervention and 1 year follow-up. Hypothesised moderators, implementation factors and mediators were analysed using mixed effects linear regressions, instrumental variable methods and path analysis.

FINDINGS

SBMT versus TAU resulted in worse scores on risk of depression and well-being in students at risk of mental health problems both at post intervention and 1-year follow-up, but differences were small and not clinically relevant. Higher dose and reach were associated with worse social-emotional-behavioural functioning at postintervention. No implementation factors were associated with outcomes at 1-year follow-up. Pregains-postgains in mindfulness skills and executive function predicted better outcomes at 1-year follow-up, but the SBMT was unsuccessful to teach these skills with clinical relevance.SBMT as delivered in this trial is not indicated as a universal intervention. Moreover, it may be contraindicated for students with existing/emerging mental health symptoms.

CLINICAL IMPLICATIONS

Universal SBMT is not recommended in this format in early adolescence. Future research should explore social-emotional learning programmes adapted to the unique needs of young people.

Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial

BACKGROUND

Systematic reviews suggest school-based mindfulness training (SBMT) shows promise in promoting student mental health.

OBJECTIVE

The My Resilience in Adolescence (MYRIAD) Trial evaluated the effectiveness and cost-effectiveness of SBMT compared with teaching-as-usual (TAU).

METHODS

MYRIAD was a parallel group, cluster-randomised controlled trial. Eighty-five eligible schools consented and were randomised 1:1 to TAU (43 schools, 4232 students) or SBMT (42 schools, 4144 students), stratified by school size, quality, type, deprivation and region. Schools and students (mean (SD); age range=12.2 (0.6); 11-14 years) were broadly UK population-representative. Forty-three schools (n=3678 pupils; 86.9%) delivering SBMT, and 41 schools (n=3572; 86.2%) delivering TAU, provided primary end-point data. SBMT comprised 10 lessons of psychoeducation and mindfulness practices. TAU comprised standard social-emotional teaching. Participant-level risk for depression, social-emotional-behavioural functioning and well-being at 1 year follow-up were the co-primary outcomes. Secondary and economic outcomes were included.

FINDINGS

Analysis of 84 schools (n=8376 participants) found no evidence that SBMT was superior to TAU at 1 year. Standardised mean differences (intervention minus control) were: 0.005 (95% CI -0.05 to 0.06) for risk for depression; 0.02 (-0.02 to 0.07) for social-emotional-behavioural functioning; and 0.02 (-0.03 to 0.07) for well-being. SBMT had a high probability of cost-effectiveness (83%) at a willingness-to-pay threshold of £20 000 per quality-adjusted life year. No intervention-related adverse events were observed.

CONCLUSIONS

Findings do not support the superiority of SBMT over TAU in promoting mental health in adolescence.

CLINICAL IMPLICATIONS

There is need to ask what works, for whom and how, as well as considering key contextual and implementation factors.

TRIAL REGISTRATION

Current controlled trials ISRCTN86619085. This research was funded by the Wellcome Trust (WT104908/Z/14/Z and WT107496/Z/15/Z).

Systematic review of the characteristics of school-based feasibility cluster randomised trials of interventions for improving the health of pupils in the UK

Background

The last 20 years have seen a marked increase in the use of cluster randomised trials (CRTs) in schools to evaluate interventions for improving pupil health outcomes. Schools have limited resources and participating in full-scale trials can be challenging and costly, given their main purpose is education. Feasibility studies can be used to identify challenges with implementing interventions and delivering trials. This systematic review summarises methodological characteristics and objectives of school-based cluster randomised feasibility studies in the United Kingdom (UK).

Methods

We systematically searched MEDLINE from inception to 31 December 2020. Eligible papers were school-based feasibility CRTs that included health outcomes measured on pupils.

Results

Of 3285 articles identified, 24 were included. School-based feasibility CRTs have been increasingly used in the UK since the first publication in 2008. Five (21%) studies provided justification for the use of the CRT design. Three (13%) studies provided details of a formal sample size calculation, with only one of these allowing for clustering. The median (IQR; range) recruited sample size was 7.5 (4.5 to 9; 2 to 37) schools and 274 (179 to 557; 29 to 1567) pupils. The most common feasibility objectives were to estimate the potential effectiveness of the intervention (n = 17; 71%), assess acceptability of the intervention (n = 16; 67%), and estimate the recruitment/retention rates (n = 15; 63%). Only one study was used to assess whether cluster randomisation was appropriate, and none of the studies that randomised clusters before recruiting pupils assessed the possibility of recruitment bias. Besides potential effectiveness, cost-effectiveness, and the intra-cluster correlation coefficient, no studies quantified the precision of the feasibility parameter estimates.

Conclusions

Feasibility CRTs are increasingly used in schools prior to definitive trials of interventions for improving health in pupils. The average sample size of studies included in this review would be large enough to estimate pupil-level feasibility parameters (e.g., percentage followed up) with reasonable precision. The review highlights the need for clearer sample size justification and better reporting of the precision with which feasibility parameters are estimated. Better use could be made of feasibility CRTs to assess challenges that are specific to the cluster design.

Trial registration

PROSPERO: CRD42020218993.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01098-w.

Assessing Ethnic Inequalities in Diagnostic Interval of Common Cancers: A Population-Based UK Cohort Study

BACKGROUND

This study investigated ethnic differences in diagnostic interval (DI)-the period between initial primary care presentation and diagnosis.

METHODS

We analysed the primary care-linked data of patients who reported features of seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, and ovarian) one year before diagnosis. Accelerated failure time (AFT) models investigated the association between DI and ethnicity, adjusting for age, sex, deprivation, and morbidity.

RESULTS

Of 126,627 eligible participants, 92.1% were White, 1.99% Black, 1.71% Asian, 1.83% Mixed, and 2.36% were of Other ethnic backgrounds. Considering all cancer sites combined, the median (interquartile range) DI was 55 (20-175) days, longest in lung [127, (42-265) days], and shortest in breast cancer [13 (13, 8-18) days]. DI for the Black and Asian groups was 10% (AFT ratio, 95%CI 1.10, 1.05-1.14) and 16% (1.16, 1.10-1.22), respectively, longer than for the White group. Site-specific analyses revealed evidence of longer DI in Asian and Black patients with prostate, colorectal, and oesophagogastric cancer, plus Black patients with breast cancer and myeloma, and the Mixed group with lung cancer compared with White patients. DI was shorter for the Other group with lung, prostate, myeloma, and oesophagogastric cancer than the White group.

CONCLUSION

We found limited and inconsistent evidence of ethnic differences in DI among patients who reported cancer features in primary care before diagnosis. Our findings suggest that inequalities in diagnostic intervals, where present, are unlikely to be the sole explanation for ethnic variations in cancer outcomes.

Locating and testing the healthy context paradox: examples from the INCLUSIVE trial

Background

The healthy context paradox, originally described with respect to school-level bullying interventions, refers to the generation of differences in mental wellbeing amongst those who continue to experience bullying even after interventions successfully reduce victimisation. Using data from the INCLUSIVE trial of restorative practice in schools, we relate this paradox to the need to theorise potential harms when developing interventions; formulate the healthy context paradox in a more general form defined by mediational relationships and cluster-level interventions; and propose two statistical models for testing the healthy context paradox informed by multilevel mediation methods, with relevance to structural and individual explanations for this paradox.

Methods

We estimated two multilevel mediation models with bullying victimisation as the mediator and mental wellbeing as the outcome: one with a school-level interaction between intervention assignment and the mediator; and one with a random slope component for the student-level mediator-outcome relationship predicted by school-level assignment. We relate each of these models to contextual or individual-level explanations for the healthy context paradox.

Results

Neither model suggested that the INCLUSIVE trial represented an example of the healthy context paradox. However, each model has different interpretations which relate to a multilevel understanding of the healthy context paradox.

Conclusions

Greater exploration of intervention harms, especially when those accrue to population subgroups, is an essential step in better understanding how interventions work and for whom. Our proposed tests for the presence of a healthy context paradox provide the analytic tools to better understand how to support development and implementation of interventions that work for all groups in a population.

Trial registration

Current Controlled Trials, ISRCTN10751359.

Minimising young children's anxiety through schools (MY-CATS): protocol for a cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of an online parent-led intervention compared with usual school practice for young children identified as at risk for anxiety disorders

BACKGROUND

Identifying and supporting young children who are at risk of developing anxiety disorders would benefit children, families, and wider society. Elevated anxiety symptoms, inhibited temperament, and high parental anxiety are established risk factors for later anxiety disorders, but it remains unclear who is most likely to benefit from prevention and early intervention programmes. Delivering an online intervention through schools to parents of young children who have one or more of these risks could maximise reach. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of delivering an online parent-led intervention, compared with usual school provision only, for children (aged 4-7) identified as at risk for anxiety disorders on the basis of at least one risk factor. We also aim to identify the characteristics of children who do and do not benefit from intervention and mechanisms of change from the intervention.

METHODS

The design will be a parallel group, superiority cluster randomised controlled trial, with schools (clusters) randomised to intervention or usual school practice arms in a 1:1 ratio stratified according to level of deprivation within the school. The study will recruit and randomise at least 60 primary/infant schools in England, and on the basis of recruiting 60 schools, we will recruit 1080 trial participants (540 per arm). Parents of all children (aged 4-7) in sampled Reception, Year 1, and Year 2 classes will be invited to complete screening questionnaires. Children who screen positive on the basis of anxiety symptoms, and/or behavioural inhibition, and/or parent anxiety symptoms will be eligible for the trial. Parents/carers of children in schools allocated to the intervention arm will be offered a brief online intervention; schools in both arms will continue to provide any usual support for children and parents throughout the trial. Assessments will be completed at screening, baseline (before randomisation), 6 weeks, 12 weeks, and 12 months post-randomisation. The primary outcome will be the absence/presence of an anxiety disorder diagnosis at 12 months.

DISCUSSION

The trial will determine if delivering an online intervention for parents of young children at risk of anxiety disorders identified through screening in schools is effective and cost-effective.

TRIAL REGISTRATION

ISRCTN 82398107 . Prospectively registered on Jan. 14, 2021.

Mental health and school absenteeism in children with long-term physical conditions: A secondary analysis of the British Child and Adolescent Mental Health Surveys 2004 and 2007

BACKGROUND

Children and young people (CYP) with long-term physical conditions (LTCs) are more likely to have poorer mental health and more school absenteeism compared with CYP with no LTCs. However, there is limited longitudinal research, and the extent to which these difficulties persist in CYP with LTCs is unknown. Furthermore, little is known about the relative impact of different types of LTC on mental health and absenteeism.

METHODS

We investigated cross-sectional and longitudinal associations of different LTCs with mental health and school absenteeism in a large (N = 7977) nationally representative survey of CYP in Great Britain and its 3-year follow-up. Psychopathology was assessed using the parent-reported Strengths and Difficulties Questionnaire (SDQ), and diagnosis of any psychiatric disorder using the Development and Wellbeing Assessment (DAWBA). Days absent and persistent absence (missing 10% or more of school days) were reported by parents.

RESULTS

Compared with those with no LTCs, CYP with any LTC had higher SDQ total difficulties scores at baseline (adjusted mean difference 1.4, 1.1-1.6) and follow-up (1.1, 0.8-1.4) and were more likely to have a psychiatric disorder at baseline (adjusted odds ratio [aOR] 1.59, 1.34-1.89) and follow-up (1.75, 1.44-2.12). Children with any LTC also missed more days of school at baseline (adjusted incidence rate ratio 1.47, 1.31-1.64) and follow-up (1.17, 1.00-1.36) and were more likely to be persistently absent (aOR baseline 1.78, 1.48-2.14; follow-up 1.27, 1.00-1.61). Neurodevelopmental disorders, migraines and atopic conditions were particularly strongly associated with both mental health and absenteeism.

CONCLUSIONS

Children with LTCs had poorer mental health and more school absence than those with no LTCs. Clinicians should routinely enquire about mental health and school attendance in CYP with LTCs and should collaborate with families and schools to ensure these children are provided with sufficient mental health and educational support.

The Role of Schools in Early Adolescents' Mental Health: Findings From the MYRIAD Study

OBJECTIVE

Recent studies suggest mental health in youths is deteriorating. The current policy in the United Kingdom emphasizes the role of schools for mental health promotion and prevention, but little data exist on what aspects of schools influence mental health in pupils. This study explored school-level influences on the mental health of young people in a large school-based sample from the United Kingdom.

METHOD

Baseline data from a large cluster randomized controlled trial collected between 2016 and 2018 from mainstream secondary schools selected to be representative in relation to their quality rating, size, deprivation, mixed or single-sex pupil population, and country were analyzed. Participants were pupils in their first or second year of secondary school. The study assessed whether school-level factors were associated with pupil mental health.

RESULTS

The study included 26,885 pupils (response rate = 90%; age range, 11‒14 years; 55% female) attending 85 schools in the United Kingdom. Schools accounted for 2.4% (95% CI: 2.0%‒2.8%; p < .0001) of the variation in psychopathology, 1.6% (95% CI: 1.2%‒2.1%; p < .0001) of depression, and 1.4% (95% CI: 1.0%‒1.7%; p < .0001) of well-being. Schools in urban locations, with a higher percentage of free school meals and of White British, were associated with poorer pupil mental health. A more positive school climate was associated with better mental health.

CONCLUSION

School-level variables, primarily related to contextual factors, characteristics of pupil population, and school climate, explain a small but significant amount of variability in mental health of young people. This information might be used to identify schools that are in need of more resources to support mental health of young people.

CLINICAL TRIAL REGISTRATION INFORMATION

MYRIAD: My Resilience in Adolescence, a Study Examining the Effectiveness and Cost-Effectiveness of a Mindfulness Training Programme in Schools Compared With Normal School Provision; https://www.isrctn.com/; 86619085.

When should matching be used in the design of cluster randomized trials?

For cluster randomized trials (CRTs) with a small number of clusters, the matched-pair (MP) design, where clusters are paired before randomizing one to each trial arm, is often recommended to minimize imbalance on known prognostic factors, add face-validity to the study, and increase efficiency, provided the analysis recognizes the matching. Little evidence exists to guide decisions on when to use matching. We used simulation to compare the efficiency of the MP design with the stratified and simple designs, based on the mean confidence interval width of the estimated intervention effect. Matched and unmatched analyses were used for the MP design; a stratified analysis was used for the stratified design; and analyses without and with post-stratification adjustment for factors that would otherwise have been used for restricted allocation were used for the simple design. Results showed the MP design was generally the most efficient for CRTs with 10 or more pairs when the correlation between cluster-level outcomes within pairs (matching correlation) was moderate to strong (0.3-0.5). There was little gain in efficiency for the MP or stratified designs compared to simple randomization when the matching correlation was weak (0.05-0.1). For trials with four pairs of clusters, the simple and stratified designs were more efficient than the MP design because greater degrees of freedom were available for the analysis, although an unmatched analysis of the MP design recovered precision for weak matching correlations. Practical guidance on choosing between the MP, stratified, and simple designs is provided.

Visual Impairment, Eye Diseases, and Dementia Risk: A Systematic Review and Meta-Analysis

BACKGROUND

Visual impairment and eye diseases have been associated with dementia, though with mixed findings and often in cross-sectional studies.

OBJECTIVE

To identify prospective studies investigating associations between visual impairment or common eye diseases and risk of all-cause dementia or key dementia subtypes.

METHODS

We searched Medline, PsycINFO, and Embase from inception to January 2020. We also conducted backward and forward citation searches of included studies and set up alerts to identify studies published after the search date. Random-effects meta-analysis was used to combine adjusted estimates across studies.

RESULTS

Thirty studies met our eligibility criteria. For visual impairment, pooled estimates indicated an increased risk of all-cause dementia (37,705 participants, 3,415 cases, risk ratio [RR] = 1.38, 95%confidence interval [CI]: 1.19-1.59, I2 = 28.6%). Pooled estimates also suggested an increased dementia risk associated with cataract (6,659 participants, 1,312 cases, hazard ratio [HR] = 1.17, 95%CI 1.00-1.38, I2 = 0.0%) and diabetic retinopathy (43,658 participants, 7,060 cases, HR = 1.34, 95%CI 1.11-1.61, I2 = 63.9%), respectively. There was no evidence of an association between glaucoma (175,357 participants, 44,144 cases, HR = 0.97, 95%CI 0.90-1.04, I2 = 51.5%) or age-related macular degeneration (7,800,692 participants, >  2,559 cases, HR = 1.15, 95%CI 0.88-1.50, I2 = 91.0%) and risk of dementia, respectively.

CONCLUSION

As visual impairment, cataract, and diabetic retinopathy are associated with an increased likelihood of developing dementia, early diagnosis may help identify those at risk of dementia. Given most causes of visual impairment are treatable or preventable, the potential for dementia prevention warrants further investigation.

The cross-sectional relationship between pain and awareness of age-related changes

BACKGROUND

Awareness of positive and negative age-related changes (AARC gains and losses) captures the perceived changes that older individuals experience in several domains of their lives including physical, cognitive and social functioning; interpersonal relationships; and lifestyle. Exploring antecedents of AARC is important to identify those individuals that could benefit the most from interventions promoting positive experiences of ageing and/or adaptation to age-related changes. This study investigates the experience of pain as a predictor of lower AARC gains and higher AARC losses.

METHODS

Analyses are based on cross-sectional data from the PROTECT cohort (2019); 1013 UK residents (mean (SD; range) age: 65.3 (7.1; 51.4-92) years, 84.4% women) completed measures of AARC and pain and provided demographic information. Linear regression models were fitted to examine pain as a predictor of AARC gains and AARC losses.

RESULTS

Higher levels of pain predicted more AARC losses both before (regression coefficient, B = 0.36; 95% confidence interval (CI): 0.29 to 0.42, p-value < 0.001; R 2 = 0.11) and after adjusting for demographic covariates (B = 0.34; 95% CI: 0.27 to 0.40; p-value < 0.001; Partial R 2 = 0.11). Pain was not significantly associated with AARC gains (unadjusted B = 0.05; 95% CI: -0.03 to 0.12, p-value = 0.21; Partial R 2 = 0.01).

CONCLUSION

Individuals experiencing pain may perceive more AARC losses. Interventions aiming to decrease levels of pain could include a component targeting self-perceptions of ageing and/or promoting acceptance of the negative changes that can happen with ageing.

STATEMENT OF SIGNIFICANCE

The predictive role of greater levels of pain for more negative perceptions of age-related changes extends the literature on the negative psychological outcomes of pain and on predictors of perceived awareness of age-related changes (AARC). As individuals experiencing pain may be more at risk of perceiving their own ageing in a more negative way, they may benefit from interventions that combine strategies to reduce levels of pain and the interference that pain exerts on their daily activities with an educational component enhancing positive self-perceptions of ageing and promoting acceptance of negative age-related changes.

Characteristics and practices of school-based cluster randomised controlled trials for improving health outcomes in pupils in the United Kingdom: a methodological systematic review

Background

Cluster randomised trials (CRTs) are increasingly used to evaluate non-pharmacological interventions for improving child health. Although methodological challenges of CRTs are well documented, the characteristics of school-based CRTs with pupil health outcomes have not been systematically described. Our objective was to describe methodological characteristics of these studies in the United Kingdom (UK).

Methods

MEDLINE was systematically searched from inception to 30^th June 2020. Included studies used the CRT design in schools and measured primary outcomes on pupils. Study characteristics were described using descriptive statistics.

Results

Of 3138 articles identified, 64 were included. CRTs with pupil health outcomes have been increasingly used in the UK school setting since the earliest included paper was published in 1993; 37 (58%) studies were published after 2010. Of the 44 studies that reported information, 93% included state-funded schools. Thirty six (56%) were exclusively in primary schools and 24 (38%) exclusively in secondary schools. Schools were randomised in 56 studies, classrooms in 6 studies, and year groups in 2 studies. Eighty percent of studies used restricted randomisation to balance cluster-level characteristics between trial arms, but few provided justification for their choice of balancing factors. Interventions covered 11 different health areas; 53 (83%) included components that were necessarily administered to entire clusters. The median (interquartile range) number of clusters and pupils recruited was 31.5 (21 to 50) and 1308 (604 to 3201), respectively. In half the studies, at least one cluster dropped out. Only 26 (41%) studies reported the intra-cluster correlation coefficient (ICC) of the primary outcome from the analysis; this was often markedly different to the assumed ICC in the sample size calculation. The median (range) ICC for school clusters was 0.028 (0.0005 to 0.21).

Conclusions

The increasing pool of school-based CRTs examining pupil health outcomes provides methodological knowledge and highlights design challenges. Data from these studies should be used to identify the best school-level characteristics for balancing the randomisation. Better information on the ICC of pupil health outcomes is required to aid the planning of future CRTs. Improved reporting of the recruitment process will help to identify barriers to obtaining representative samples of schools.

Healthy Parent Carers: feasibility randomised controlled trial of a peer-led group-based health promotion intervention for parent carers of disabled children

Background

Parent carers of children with special educational needs or disability are at higher risk of poor mental and physical health. The need for a tailored, peer-led group programme was raised by parent carers, who co-developed the Healthy Parent Carers programme with researchers. This study aimed to test the feasibility of programme delivery in community settings, and the feasibility and acceptability of a randomised controlled trial design.

Methods

Participants were individually randomised with concealed allocation to a structured group programme and access to online resources (intervention), or access to the online resources only (control). Measures of wellbeing and secondary and economic outcomes were collected before randomisation, immediately post-intervention, and 6 months post-intervention. Descriptive statistics on recruitment and attrition, demographics, attendance, and fidelity of intervention delivery were analysed with feedback on the acceptability of the trial design.

Results

One hundred and ninety-three parent carers expressed an interest in taking part. Ninety-two participants recruited from across six sites were randomised (47 intervention, 45 control). Lead and assistant facilitators were trained and delivered the group sessions. Sixteen (34%) participants in the intervention arm did not attend any sessions, and attendance varied across sites and sessions. One participant withdrew post-randomisation, and 83 (90%) participants completed outcome measures at the six-month follow-up.

Conclusions

The study demonstrated that it was feasible to deliver the programme in community settings. The number of parent carers who expressed interest signifies the need for such a programme and the feasibility of recruiting to a definitive trial. Loss to follow-up was low. Further research is needed to explore ways to reduce barriers to participation in person and assess the feasibility and acceptability of programme content and delivery for more ethnically diverse groups, and potentially using interpreters. Given the Covid-19 pandemic and delivery format feedback, there is also a need to investigate remote or blended delivery strategies. Although the results indicate that a definitive trial is feasible, programme impact would be strengthened through exploration of these uncertainties.

Trial registration

ISRCTN, ISRCTN15144652, registered on 25 October 2018, ClinicalTrials.gov, NCT03705221, registered on 15 October 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00881-5.

The longitudinal relationship between child emotional disorder and parental mental health in the British Child and Adolescent Mental Health surveys 1999 and 2004

BACKGROUND

Research suggests parental psychopathology has an adverse effect on child mental health. However, due to the interactional nature of parent-child relationships and with a high rate of emotional disorders reported in school-age children, it is important to know whether the effect is reciprocal.

METHODS

We explored the longitudinal relationship between child and parent mental health in the British Child and Adolescent Mental Health Surveys (N=7,100 child-parent dyads) and their three-year follow-ups. The Development and Well-Being Assessment with DSM-IV diagnostic criteria was used to measure child psychiatric diagnoses, while parental mental health was assessed using the General Health Questionnaire. Multivariable logistic regression was used to explore the longitudinal association between child emotional disorder and parent mental health.

RESULTS

Parents of children who had an emotional disorder at baseline were more likely to have poor mental health three years later compared with parents whose children had no psychiatric diagnosis (33.3% versus 16.7%; crude odds ratio=2.52; adjusted odds ratio=2.19, 95% CI=1.58 to 3.05, p<0.001). Children of parents with poor mental health at baseline were more likely to develop an emotional disorder three years later compared with children whose parents had good mental health (5.2% versus 2.5%; crude odds ratio=2.08; adjusted odds ratio=1.63, 95% CI=1.18 to 2.25, p=0.003).

LIMITATIONS

The findings of this research are limited by the survey data collected, the measures used and survey dropout.

CONCLUSIONS

We detected a bi-directional relationship between child and parent mental health, suggesting that effective intervention for one individual may benefit other family members.

Associations of subjective cognitive and memory decline with depression, anxiety, and two-year change in objectively-assessed global cognition and memory

Research studies exploring the association of cognitive complaints with objectively assessed cognitive decline report inconsistent results. However, many of these have methodological limitations. We investigated whether 1) more severe subjective cognitive decline (SCD) and subjective memory decline (SMD) predict change in objectively assessed global cognition, remote memory, recent memory, learning; 2) the predictive value of more severe SMD over change in objectively assessed remote memory, recent memory, and learning is stronger for individuals that report an SMD that started within the past five years than for those that report an SMD that started five or more years previously and/or stronger for those that experienced SMD within the past two years than for those who had not; and 3) greater depression and anxiety are associated with more severe SCD and SMD. We used two-year longitudinal data from the CFAS-Wales study (N = 1,531; mean (SD) age = 73.0 (6.0) years). We fitted linear regression models. More severe SCD and SMD did not predict change in objectively assessed global cognition, remote memory, and recent memory but predicted lower scores in learning. The prediction of SMD over change in learning was not stronger when individuals reported an SMD that started within the past five years compared to when they reported an SMD that started five or more years previously nor when individuals reported an SMD that started within the past two years than those who did not. Greater depression and anxiety were associated with more severe SCD and SMD. More severe SMD may be useful for predicting lower learning ability and for identifying individuals experiencing depression and anxiety.

Update to the effectiveness and cost-effectiveness of a mindfulness training programme in schools compared with normal school provision (MYRIAD): study protocol for a randomised controlled trial

BACKGROUND

MYRIAD (My Resilience in Adolescence) is a superiority, parallel group, cluster randomised controlled trial designed to examine the effectiveness and cost-effectiveness of a mindfulness training (MT) programme, compared with normal social and emotional learning (SEL) school provision to enhance mental health, social-emotional-behavioural functioning and well-being in adolescence. The original trial protocol was published in Trials (accessible at https://doi.org/10.1186/s13063-017-1917-4 ). This included recruitment in two cohorts, enabling the learning from the smaller first cohort to be incorporated in the second cohort. Here we describe final amendments to the study protocol and discuss their underlying rationale.

METHODS

Four major changes were introduced into the study protocol: (1) there were changes in eligibility criteria, including a clearer operational definition to assess the degree of SEL implementation in schools, and also new criteria to avoid experimental contamination; (2) the number of schools and pupils that had to be recruited was increased based on what we learned in the first cohort; (3) some changes were made to the secondary outcome measures to improve their validity and ability to measure constructs of interest and to reduce the burden on school staff; and (4) the current Coronavirus Disease 2019 (SARS-CoV-2 or COVID-19) pandemic both influences and makes it difficult to interpret the 2-year follow-up primary endpoint results, so we changed our primary endpoint to 1-year follow-up.

DISCUSSION

These changes to the study protocol were approved by the Trial Management Group, Trial Steering Committee and Data and Ethics Monitoring Committees and improved the enrolment of participants and quality of measures. Furthermore, the change in the primary endpoint will give a more reliable answer to our primary question because it was collected prior to the COVID-19 pandemic in both cohort 1 and cohort 2. Nevertheless, the longer 2-year follow-up data will still be acquired, although this time-point will be now framed as a second major investigation to answer some new important questions presented by the combination of the pandemic and our study design.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials ISRCTN86619085 . Registered on 3 June 2016.