The impact of the world's first regulatory, multi-setting intervention on sedentary behaviour among children and adolescents (ENERGISE): a natural experiment evaluation

BACKGROUND

Regulatory actions are increasingly used to tackle issues such as excessive alcohol or sugar intake, but such actions to reduce sedentary behaviour remain scarce. World Health Organization (WHO) guidelines on sedentary behaviour call for system-wide policies. The Chinese government introduced the world's first nation-wide multi-setting regulation on multiple types of sedentary behaviour in children and adolescents in July 2021. This regulation restricts when (and for how long) online gaming businesses can provide access to pupils; the amount of homework teachers can assign to pupils according to their year groups; and when tutoring businesses can provide lessons to pupils. We evaluated the effect of this regulation on sedentary behaviour safeguarding pupils.

METHODS

With a natural experiment evaluation design, we used representative surveillance data from 9- to 18-year-old pupils before and after the introduction of the regulation, for longitudinal (n = 7,054, matched individuals, primary analysis) and repeated cross-sectional (n = 99,947, exploratory analysis) analyses. We analysed pre-post differences for self-reported sedentary behaviour outcomes (total sedentary behaviour time, screen viewing time, electronic device use time, homework time, and out-of-campus learning time) using multilevel models, and explored differences by sex, education stage, residency, and baseline weight status.

RESULTS

Longitudinal analyses indicated that pupils had reduced their mean total daily sedentary behaviour time by 13.8% (95% confidence interval [CI]: -15.9 to -11.7%, approximately 46 min) and were 1.20 times as likely to meet international daily screen time recommendations (95% CI: 1.01 to 1.32) one month after the introduction of the regulation compared to the reference group (before its introduction). They were on average 2.79 times as likely to meet the regulatory requirement on homework time (95% CI: 2.47 to 3.14) than the reference group and reduced their daily total screen-viewing time by 6.4% (95% CI: -9.6 to -3.3%, approximately 10 min). The positive effects were more pronounced among high-risk groups (secondary school and urban pupils who generally spend more time in sedentary behaviour) than in low-risk groups (primary school and rural pupils who generally spend less time in sedentary behaviour). The exploratory analyses showed comparable findings.

CONCLUSIONS

This regulatory intervention has been effective in reducing total and specific types of sedentary behaviour among Chinese children and adolescents, with the potential to reduce health inequalities. International researchers and policy makers may explore the feasibility and acceptability of implementing regulatory interventions on sedentary behaviour elsewhere.

Evaluation of risks of cardiovascular disease from radiation exposure linked to computed tomography scans in the UK

Epidemiological studies of patient populations have shown that high doses of radiation increase risks of cardiovascular disease (CVD). Results from a recent meta-analysis of 93 epidemiological studies covering a wide range of doses provided evidence of a causal association between radiation exposure and CVD, and indicated excess relative risk per Gy for maximum dose below 500 mGy or delivered at low dose rates. These doses cover the range of organ doses expected from multiple diagnostic computed tomography (CT) scans. Dose-effect factors for the excess absolute risk of mortality from CVD following radiation exposure were derived from the meta-analysis. The present study uses these factors to estimate excess risks of mortality for various types of CVD, including cerebrovascular disease (CeVD), from CT scans of the body and head, assuming that the meta-analytic factors were accurate and represented a causal relationship. Estimates are based on cumulative doses to the heart and brain from CT scans performed on 105 574 patients on 12 CT scanners over a period of 5½ years. The results suggest that the excess number of deaths from CeVD could be 7 or 26 per 100 000 patients depending whether threshold brain doses of 200 mGy or 50 mGy, respectively are assumed. These results could have implications for head CT scans. However, the results rely on the validity of risk factors derived in the meta-analysis informing this assessment and which include significant uncertainties. Further incidence studies should provide better information on risk factors and dose thresholds, particularly for CeVD following head CT scans.

Does a local Alcohol Health Champion programme have a measurable impact on health and crime outcomes? A natural experiment evaluation of Communities in Charge of Alcohol (CICA) based on triangulation of methods

BACKGROUND AND AIM

Drinking alcohol may cause harm to an individual's health and social relationships, while a drinking culture may harm societies as it may increase crime rates and make an area feel less safe. Local councils in Greater Manchester, UK, developed the Communities in Charge of Alcohol (CICA) intervention, in which volunteers were trained to give alcohol-related advice to the public and taught how to influence policies to restrict when, where and how alcohol is sold. As part of a larger study, the aim of the current project is to measure the impact of CICA on health and crime outcomes at the lower super output (LSOA) geographical aggregation.

DESIGN

Quantitative evaluation using four time series analytic methods (stepped-wedge design, and comparisons to local controls, national controls and synthetic controls) with findings triangulated across these methods. A cost-benefit analysis was carried out alongside the effectiveness analysis.

SETTING AND PARTICIPANTS

The general public in Greater Manchester, UK, between 2010 and 2020.

MEASUREMENTS

The primary outcome of interest was alcohol-related hospital admissions. Secondary outcomes were accident and emergency (A&E) attendances, ambulance callouts, recorded crimes and anti-social behaviour incidents.

FINDINGS

Triangulation of the results did not indicate any consistent effect on area-level alcohol-related hospital admissions, A&E attendances, ambulance callouts, reported crimes or anti-social behaviour associated with the implementation of CICA. The primary stepped-wedge analysis indicated an increase in alcohol-related hospital admissions following the implementation of CICA of 13.4% (95% confidence interval -3.3%, +30.1%), which was consistent with analyses based on other methods with point estimates ranging from +3.4% to 16.4%.

CONCLUSION

There is no evidence of a measurable impact of the Communities in Charge of Alcohol (CICA) programme on area-level health and crime outcomes in Greater Manchester, UK, within 3 years of the programme start. The increase in alcohol-related hospital admissions was likely the result of other temporal trends rather than the CICA programme. Possible explanations include insufficient follow-up time, too few volunteers trained, volunteers being unwilling to get involved in licensing decisions or that the intervention has no direct impact on the selected outcomes.

Physical activity interventions in European primary schools: a scoping review to create a framework for the design of tailored interventions in European countries

Introduction

Schools provide a unique environment to facilitate physical activity for children. However, many school-based physical activity interventions have not been effective. We propose a new approach, which allows schools to tailor interventions to their specific context. This scoping review aimed to identify intervention components from previous school-based physical activity interventions to form the basis of a tailored approach in a European setting.

Methods

Joanna Briggs Institute guidelines for conducting scoping reviews were followed. European school-based intervention studies aimed at increasing physical activity in children aged 7-11 years published in English since 2015 were included. Databases searched were Ovid Medline, Embase, PsycINFO, Web of Science Social Sciences Citation Index, ERIC and British Education Index. Data was extracted on intervention components, context-related factors (geographical location, school size, child socioeconomic status and ethnicity), feasibility, acceptability and cost-effectiveness. A data-driven framework was developed to summarize the identified intervention components.

Results

79 articles were included, constituting 45 intervention studies. We identified 177 intervention components, which were synthesized into a framework of 60 intervention component types across 11 activity opportunities: six within the school day, three within the extended school day and two within the wider school environment. Interventions most frequently targeted physical education (21%), active and outdoor learning (16%), active breaks (15%), and school-level environmewnt (12%). Of the intervention components, 41% were delivered by school staff, 31% by the research team, and 24% by external organizations. Only 19% of intervention studies reported geographical location and only 10% reported school size. Participant ethnicity and socioeconomic information was reported by 15% and 25%, respectively. Intervention acceptability was reported in 51% of studies, feasibility in 49%, and cost effectiveness in 2%.

Discussion

This review offers a first step in developing a future framework to help schools to develop context-specific, tailored interventions. However, there was a lack of reporting of contextual factors within the included studies, making it difficult to understand the role of context. Future research should seek to measure and report contextual factors, and to better understand the important aspects of context within school-based physical activity.

Public health engagement in alcohol licensing in England and Scotland: the ExILEnS mixed-method, natural experiment evaluation

Background

International systematic reviews suggest an association between alcohol availability and increased alcohol-related harms. Alcohol availability is regulated through separate locally administered licensing systems in England and Scotland, in which local public health teams have a statutory role. The system in Scotland includes a public health objective for licensing. Public health teams engage to varying degrees in licensing matters but no previous study has sought to objectively characterise and measure their activity, examine their effectiveness, or compare practices between Scotland and England.

Aim

To critically assess the impact and mechanisms of impact of public health team engagement in alcohol premises licensing on alcohol-related harms in England and Scotland.

Methods

We recruited 39 diverse public health teams in England (n = 27) and Scotland (n = 12). Public health teams more active in licensing were recruited first and then matched to lower-activity public health teams. Using structured interviews (n = 66), documentation analysis, and expert consultation, we developed and applied the Public Health Engagement In Alcohol Licensing (PHIAL) measure to quantify six-monthly activity levels from 2012 to 2019. Time series of PHIAL scores, and health and crime outcomes for each area, were analysed using multivariable negative binomial mixed-effects models to assess correlations between outcome and exposure, with 18-month average PHIAL score as the primary exposure metric. In-depth interviews (n = 53) and a workshop (n = 10) explored public health team approaches and potential mechanisms of impact of alcohol availability interventions with public health team members and licensing stakeholders (local authority licensing officers, managers and lawyers/clerks, police staff with a licensing remit, local elected representatives).

Findings

Nineteen public health team activity types were assessed in six categories: (1) staffing; (2) reviewing and (3) responding to licence applications; (4) data usage; (5) influencing licensing stakeholders/policy; and (6) public involvement. Usage and intensity of activities and overall approaches varied within and between areas over time, including between Scotland and England. The latter variation could be explained by legal, structural and philosophical differences, including Scotland's public health objective. This objective was felt to legitimise public health considerations and the use of public health data within licensing. Quantitative analysis showed no clear evidence of association between level of public health team activity and the health or crime outcomes examined, using the primary exposure or other metrics (neither change in, nor cumulative, PHIAL scores). Qualitative data suggested that public health team input was valued by many licensing stakeholders, and that alcohol availability may lead to harms by affecting the accessibility, visibility and norms of alcohol consumption, but that the licensing systems have limited power to act in the interests of public health.

Conclusions

This study provides no evidence that public health team engagement in local licensing matters was associated with measurable downstream reductions in crime or health harms, in the short term, or over a 7-year follow-up period. The extensive qualitative data suggest that public health team engagement is valued and appears to be slowly reorienting the licensing system to better address health (and other) harms, especially in Scotland, but this will take time. A rise in home drinking, alcohol deliveries, and the inherent inability of the licensing system to reduce - or in the case of online sales, to contain - availability, may explain the null findings and will continue to limit the potential of these licensing systems to address alcohol-related harms.

Future work

Further analysis could consider the relative success of different public health team approaches in terms of changing alcohol availability and retailing. A key gap relates to the nature and impact of online availability on alcohol consumption, harms and inequalities, alongside development and study of relevant policy options. A national approach to licensing data and oversight would greatly facilitate future studies and public health input to licensing.

Limitations

Our interview data and therefore PHIAL scores may be limited by recall bias where documentary evidence of public health activity was not available, and by possible variability in grading of such activity, though steps were taken to minimise both. The analyses would have benefited from additional data on licensing policies and environmental changes that might have affected availability or harms in the study areas.

Study registration

The study was registered with the Research Registry (researchregistry6162) on 26 October 2020. The study protocol was published in BMC Medical Research Methodology on 6 November 2018.

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/129/11.

Association Between Household Online Grocery Delivery Service Use and Food and Drink Purchase Behavior in England: Cross-Sectional Analysis

BACKGROUND

Online grocery delivery services (OGDSs) are a popular way of acquiring food. However, it is unclear whether OGDS use is associated with the healthiness of purchases and whether there are sociodemographic differences in OGDS use. If so, the increased prevalence of OGDS use may have implications for population diet, and differential OGDS use could contribute to diet inequalities.

OBJECTIVE

This study aimed to examine whether OGDS use varies by sociodemographic characteristics and is associated with the amount and types of groceries purchased.

METHODS

Item-level take-home food and drink purchase data (n=3,233,920 items) from households in London and the North of England were available from the 2019 UK Kantar fast-moving consumer goods panel (N=1911). Purchases were categorized as being bought online or in-store. We used logistic regression to estimate the likelihood of an above-median frequency of OGDS use by sociodemographic characteristics. We used Poisson regression to estimate the differences in energy and nutrients purchased by households that had above- and below-median OGDS use and the proportion of energy purchased from products high in fat, salt, and sugar (HFSS) online versus in-store among households that used both shopping methods (n=665).

RESULTS

In total, 668 (35%) households used OGDSs at least once in 2019. Of the households that used OGDSs, the median use was 5 occasions in 2019. Households were more likely to have above-median use in London versus in the North of England (odds ratio 1.29, 95% CI 1.01-1.65) and if they had a higher annual household income (odds ratio 1.56, 95% CI 1.02-2.38 for ≥£50,000 [US $64,000] vs <£20,000 [$25,600]). Households with above-median OGDS use had a higher weekly mean purchase of energy by 1461 (95% CI 1448-1474) kcal per person compared with households with below-median OGDS use. For households that used a combination of in-store and online shopping, HFSS products made up a lower proportion (-10.1%, 95% CI -12% to -8.1%) of energy purchased online compared to in-store.

CONCLUSIONS

Differences in grocery purchases between households with above- and below-median OGDS use could have positive or negative consequences. The extra energy purchased among households with above-median OGDS use could lead to overconsumption or food waste, which has negative consequences for population and environmental health. Alternatively, this extra energy may be replacing out-of-home purchasing, which tends to be less healthy, and may be beneficial for the population diet. Households made fewer HFSS purchases when shopping online compared to in-store, which may be due to differences in the shopping environment or experience, such as fewer promotions and advertisements when shopping online or not having to transport and carry purchases home. As higher-income households used OGDS more frequently, the implications of this sociodemographic pattern on dietary inequalities must be explored.

Characterizing restrictions on commercial advertising and sponsorship of harmful commodities in local government policies: a nationwide study in England

BACKGROUND

Commercial advertising and sponsorship drive the consumption of harmful commodities. Local authorities (LAs) have considerable powers to reduce such exposures. This study aimed to characterize local commercial policies across all English LAs.

METHODS

We conducted a census of all English LAs (n = 333) to identify local commercial policies concerning advertising and sponsorship of tobacco, alcohol, less healthy foods and gambling, through online searches and Freedom of Information requests. We explored policy presence, commodity frequency and type, and associations with LA characteristics (region, urban/rural and deprivation).

RESULTS

Only a third (106) of LAs in England had a relevant policy (32%). These included restrictions on tobacco (91%), gambling (79%), alcohol (74%) and/or less healthy foods (24%). Policy prevalence was lowest in the East of England (22%), North East (25%) and North West (27%), higher in urban areas (36%) than rural areas (28%) and lower in the least (27%) compared with the most (38%) deprived areas. Definitions in policies varied, particularly for alcohol and less healthy foods.

CONCLUSIONS

English LAs currently underutilize their levers to reduce the negative impacts of harmful commodity industry marketing, particularly concerning less healthy foods. Standardized guidance, including clarity on definitions and application, could inform local policy development.

Comparison of children's physical activity profiles before and after COVID-19 lockdowns: A latent profile analysis

Physical activity is important for children's health, but moderate to vigorous physical activity (MVPA) declines with age. COVID-19 lockdowns resulted in reduced MVPA and increased sedentary time among children. Characterising children's activity patterns may help identify groups who are most likely to be inactive post-lockdown. Data were combined from a pre-COVID-19 cohort study on children aged 5-6 years (Year1: n = 1299), 8-9 years (Year4: n = 1223) and 10-11 years (Year6: n = 1296) and cross-sectional post-lockdown data from a natural experiment on 10-11-year-olds in 2021 (Year6-W1: n = 393) and 2022 (Year6-W2: n = 436). The proportions of time spent in MVPA, light physical activity (LPA) and sedentary time on weekdays and weekends were derived from accelerometer data. Latent class analysis was used to identify activity profiles pre and post-lockdown, and estimate pre-COVID-19 transitions between Year4 and Year6. We identified six pre-COVID-19 activity profiles in Year6, including a new profile characterised by very low MVPA and high sedentary time (19% of children). There was substantial movement between profiles at Year4 and Year6, with 45% moving to a profile with lower MVPA. Likelihood ratio tests suggested differences in Year6 activity profiles pre and post-lockdown, with a new post-lockdown profile emerging characterised by higher LPA. The percentage of children in the least active profiles (where under 20% meet UK physical activity guidelines), rose post-lockdown, from 34% pre-COVID-19 to 50% in 2021 and 40% in 2022. We also saw gender and socioeconomic gaps widen, and increased separation between high and low physical activity levels. Children's physical activity has changed post-COVID-19, in terms of who is being active and how. The impact varies by activity profile, which is influenced by gender and socio-economic position. A greater understanding of these differences and targeting of low active groups is needed to increase both individual and population levels of physical activity.

The status of active after-school clubs among primary school children in England (UK) after the COVD-19 lockdowns: implications for policy and practice

BACKGROUND

Children's physical activity in England is more dependent on active clubs after the COVID-19 pandemic. However, it is unclear how the COVID-19 pandemic and related cost-of-living crisis have impacted on active club participation, costs and provision. This mixed-methods natural experiment explored school-based and community-based active clubs after lockdowns, using a unique combination of data sources to highlight implications for policy and practice post-COVID-19.

METHODS

Cross-sectional questionnaire data on school and community active clubs were collected from 10-11-year-old children pre-COVID-19 in 2017-18 (N = 1,296; 50 schools), in 2021 (N = 393; 23 schools), and 2022 (N = 463; 27 schools). Club participation and attendance frequency were modelled using logistic and Poisson mixed effects models, adjusted for child age, gender and household education. In 2021 and 2022, parents reported expenditure on community-based clubs and schools provided data on school-based club provision, with data summarised descriptively. Qualitative data were collected in 2021 and 2022, with one-to-one interviews with school staff (N = 18) and parents (N = 43), and twelve child focus groups (N = 92), and analysed using the framework method.

RESULTS

School-based active club participation was higher in 2022 compared to pre-pandemic (50% /43%), while community-based club participation was lower (74%/80%). Children attended 0.3 fewer clubs per week. Those from lower education households were less likely to participate in both types of active clubs, and girls less likely to attend community clubs. In 2022, the median cost of community and school club sessions were £6.67 and £3.88 respectively, with 52% of school-based clubs free to parents. Schools offered an average of 3.4 active clubs per week for 10-11-year-olds in 2022, with 34% partly/wholly subsidised. Qualitative analysis highlighted the impact of the cost-of-living crisis and COVID-19 pandemic on family resources, encouraging a shift to more affordable and convenient school-based active clubs, which negatively impacted the community-based active club environment. However, many schools struggled to meet this increased demand.

CONCLUSIONS

Findings emphasise the importance for policymakers to support schools to meet increased demand for clubs and community clubs to increase affordable and convenient physical activity opportunities. Targeted support is needed to prevent socioeconomic and gender inequalities.

Integrated working in local authority decision-making about air quality: a qualitative study in Southwest England

BACKGROUND

Exposure to poor air quality is one of the most significant environmental public health challenges. In the UK, local authorities (LAs) are responsible for monitoring and managing air quality. This article explores the need and mechanisms for cross-departmental working in LAs to make decisions about air quality issues.

METHODS

Semi-structured qualitative interviews with public health, environmental health and transport staff from LAs within the Southwest of UK. Interviews were conducted between April and August 2021 and analysed using a thematic approach.

RESULTS

In sum, 24 staff from 7 LAs participated. Local authority staff in public health, environmental health and transport teams recognized that managing air quality was a cross-departmental issue. To enable effective integrated working staff described four successful mechanisms: (i) policy commitments and political support; (ii) dedicated air quality steering groups; (iii) existing governance and oversight groups; and (iv) networking and relationships.

CONCLUSIONS

This study has identified mechanisms that LA staff have found support cross-departmental and integrated working on air quality issues. These are mechanisms that have helped environmental health staff work towards achieving compliance with pollution limits, and that have helped public health staff get air quality considerations recognized as a wider health issue.

The new normal for children's physical activity and screen viewing: a multi-perspective qualitative analysis of behaviours a year after the COVID-19 lockdowns in the UK

BACKGROUND

The COVID-19 pandemic significantly impacted children's physical activity. Recent evidence indicated children's accelerometer-measured physical activity levels have, on average, returned to near pre-pandemic levels in 2022, though sedentary behaviour remains higher. However, insufficient physical activity levels among children continues to be a critical public health issue in the UK, with only 41% meeting physical activity guidelines. This study aimed to provide in-depth analysis of how the pandemic has shaped children's physical activity patterns beyond the short-term periods following lockdowns and identify the new challenges to engaging children in physical activity.

METHODS

One-to-one interviews with parents (n = 22), school staff (n = 9), and six focus groups with children aged 10-11 years (n = 45) were conducted between February and July 2022. Topics explored changes to children's physical activity and sedentary behaviour patterns, including screen-viewing, and factors influencing any changes. The framework method was used for analysis.

RESULTS

Five themes were generated. Theme 1 described residual lockdown habits, including increased screen-viewing within the home, while activities outside the home continued to feel less spontaneous. Theme 2 highlighted an interrupted development of social, emotional, and physical skills among children compared to what would be expected pre-pandemic. This coincided with Theme 3 which reflected increased mental health challenges among families, creating complex barriers to children's physical activity. A new normal for child physical activity was evoked and explored in Theme 4, with greater dependence on structured and organised activities. However, Theme 5 highlighted that girls and children with lower socio-economic position may be especially at risk of decreased physical activity.

CONCLUSIONS

There is a new normal for children's physical activity that is characterised by increased dependence on structured and organised physical activities, such as active clubs, and less on unstructured and spontaneous physical activities, such as physical play. While this may suit many children, girls and children from lower socio-economic households face barriers to participating in the new normal. It is important that affordable and equitable opportunities are provided to all children to prevent physical activity and health inequalities.

Guidance on the use of complex systems models for economic evaluations of public health interventions

To help health economic modelers respond to demands for greater use of complex systems models in public health. To propose identifiable features of such models and support researchers to plan public health modeling projects using these models. A working group of experts in complex systems modeling and economic evaluation was brought together to develop and jointly write guidance for the use of complex systems models for health economic analysis. The content of workshops was informed by a scoping review. A public health complex systems model for economic evaluation is defined as a quantitative, dynamic, non-linear model that incorporates feedback and interactions among model elements, in order to capture emergent outcomes and estimate health, economic and potentially other consequences to inform public policies. The guidance covers: when complex systems modeling is needed; principles for designing a complex systems model; and how to choose an appropriate modeling technique. This paper provides a definition to identify and characterize complex systems models for economic evaluations and proposes guidance on key aspects of the process for health economics analysis. This document will support the development of complex systems models, with impact on public health systems policy and decision making.

Natural experiments for the evaluation of place-based public health interventions: a methodology scoping review

Introduction

Place-based public health evaluations are increasingly making use of natural experiments. This scoping review aimed to provide an overview of the design and use of natural experiment evaluations (NEEs), and an assessment of the plausibility of the as-if randomization assumption.

Methods

A systematic search of three bibliographic databases (Pubmed, Web of Science and Ovid-Medline) was conducted in January 2020 to capture publications that reported a natural experiment of a place-based public health intervention or outcome. For each, study design elements were extracted. An additional evaluation of as-if randomization was conducted by 12 of this paper's authors who evaluated the same set of 20 randomly selected studies and assessed 'as-if ' randomization for each.

Results

366 NEE studies of place-based public health interventions were identified. The most commonly used NEE approach was a Difference-in-Differences study design (25%), followed by before-after studies (23%) and regression analysis studies. 42% of NEEs had likely or probable as-if randomization of exposure (the intervention), while for 25% this was implausible. An inter-rater agreement exercise indicated poor reliability of as-if randomization assignment. Only about half of NEEs reported some form of sensitivity or falsification analysis to support inferences.

Conclusion

NEEs are conducted using many different designs and statistical methods and encompass various definitions of a natural experiment, while it is questionable whether all evaluations reported as natural experiments should be considered as such. The likelihood of as-if randomization should be specifically reported, and primary analyses should be supported by sensitivity analyses and/or falsification tests. Transparent reporting of NEE designs and evaluation methods will contribute to the optimum use of place-based NEEs.

Conducting school-based health surveys with secondary schools in England: advice and recommendations from school staff, local authority professionals, and wider key stakeholders, a qualitative study

BACKGROUND

Improving the health and well-being of young people is a public health priority. Schools present an ideal setting to implement strategies to improve young people's health and well-being. A key strategy involves conducting surveys to assess student health needs, inform interventions, and monitor health over time. Conducting research in schools is, however, challenging. Schools can find it difficult to participate and adhere to research processes, even when they are keen to be involved in research, because of competing priorities (e.g., attendance and educational achievement), as well as time and resource constraints. There is a lack of literature on the perspectives of school staff and other key stakeholders working in young people's health on how best to work with schools to conduct health research, and in particular, health surveys.

METHODS

Participants (n = 26) included members of staff from 11 secondary schools (covering students aged 11-16 years), 5 local authority professionals, and 10 wider key stakeholders in young people's health and well-being (e.g., a school governor, a national government member), based in South West England. Participants took part in semi-structured interviews that were conducted either over the phone or via an online platform. Data were analysed using the Framework Method.

RESULTS

Three main themes were identified: Recruitment and Retention, Practicalities of Data Collection in Schools, and Collaboration from Design to Dissemination. It is important to acknowledge the role of local authorities and academy trusts in the English education system, and work closely with these when conducting school-based health surveys. School staff prefer to be contacted about research via email and in the summer term, following exams. Researchers should contact a member of staff involved in student health/well-being, as well as senior leadership, during recruitment. Data collection during the start and end of the school year is undesirable. Research should be collaborative with school staff and young people, consistent with school priorities and values, and flexible and tailored to school timetables and resources.

CONCLUSIONS

Overall the findings demonstrate that survey-based research methods should be school-led and tailored to each school.

Advertisement of unhealthy commodities in Bristol and South Gloucestershire and rationale for a new advertisement policy

BACKGROUND

Bristol City Council introduced a new advertisement policy in 2021/2022 which included prohibiting the advertising of unhealthy food and drink (HFSS), alcohol, gambling and payday loans across council-owned advertising spaces. This mixed methods study is part of the BEAR study, and aimed to explore the rationale and the barriers and facilitators to implementing the policy, and describe the perceived advertising environment prior to implementation.

METHODS

Semi-structured interviews were carried out with seven stakeholders involved in the design and implementation of the advertising policy. A stakeholder topic guide was developed before interviews took place to help standardise the lines of inquiry between interviewees. A resident survey was developed to collect socio-demographic data and, for the purpose of this study, information regarding observations of advertising for HFSS products, alcohol and gambling.

RESULTS

Fifty-eight percent of respondents residing in Bristol and South Gloucestershire reported seeing advertisements for unhealthy commodities in the week prior to completing the survey. This was highest for HFSS products (40%). 16% of residents reported seeing HFSS product advertisements specifically appealing to children. For HFSS products in particular, younger people were more likely to report seeing adverts than older people, as were those who were from more deprived areas. An advertisement policy that restricts the advertisement of such unhealthy commodities, and in particular for HFSS products, has the potential to reduce health inequalities. This rationale directly influenced the development of the advertisement policy in Bristol. Implementation of the policy benefitted from an existing supportive environment following the 'health in all policies' initiative and a focus on reducing health inequalities across the city.

CONCLUSIONS

Unhealthy product advertisements, particularly for unhealthy food and drinks, were observed more by younger people and those living in more deprived areas. Policies that specifically restrict such advertisements, therefore, have the potential to reduce health inequalities, as was the hope when this policy was developed. Future evaluation of the policy will provide evidence of any public health impact.

Perspectives on an enhanced 'Improving Access to Psychological Therapies' (IAPT) service addressing the wider determinants of mental health: a qualitative study

BACKGROUND

A new Health and Wellbeing pathway was introduced into the Improving Access to Psychological Therapies (IAPT) service in one geographical area of the UK in 2021 to address the wider determinants of mental health problems. It comprised assisted signposting to wider services and physical health promotion. This qualitative study aimed to understand stakeholders' experiences of implementing and receiving this new support and the barriers and facilitators to its delivery.

METHODS

Forty-seven interviews were conducted, with service developers (n = 6), service deliverers (n = 12), service users (n = 22) and community and clinical partners (n = 7), as part of a larger mixed-methods evaluation. Interviews were recorded, transcribed, and analysed using reflexive thematic analysis.

RESULTS

Three themes spanned all participant groups and represented key aspects of the service: (1) identifying suitability, (2) a holistic service, and (3) moving forward. The sub-themes represent the barriers and facilitators to processes working in practice, lending insight into potential service improvements. These included strengthening the quality of communication during referral and assessment, tailoring the support and delivery mode, and increasing transparency around continued care to drive sustained benefits.

LIMITATIONS

Service users may have been selected due to their positive experiences of IAPT and were not demographically representative of the population, although participants' experiences of the service did suggest variation in our sample.

CONCLUSIONS

The Health and Wellbeing pathway was perceived as having a positive impact on mental health and could reduce the burden on therapeutic services. However, service- and individual-level barriers need to be addressed to enhance statutory and community support links, manage service users' expectations, and improve accessibility for certain groups.

Using systems thinking to understand how the South West - School Health Research Network can improve adolescent health and well-being: A qualitative process evaluation

Schools offer a valuable setting to promote good health and mental well-being amongst young people. Schools are complex systems and therefore systems interventions are needed to improve pupil health and well-being. This paper presents a qualitative process evaluation of the South West- School Health Research Network, a systems level intervention. The evaluation is based on interviews with school staff, local authorities and wider stakeholders. Given the complexity of England's educational system there is a need to intervene and monitor health at multiple levels and to ensure close partnership working to effectively improve adolescent health through schools.

Short and medium-term effects of the COVID-19 lockdowns on child and parent accelerometer-measured physical activity and sedentary time: a natural experiment

BACKGROUND

The COVID-19 pandemic has resulted in marked impacts on children's physical activity, with large reductions in moderate-to-vigorous physical activity (MVPA) reported during lockdowns. Previous evidence showed children's activity levels were lower and sedentary time higher immediately post-COVID lockdown, while there was little change in parental physical activity. We need to know if these patterns persist.

METHODS

Active-6 is a natural experiment using repeated cross-sectional data conducted in two waves. Accelerometer data were collected on 393 children aged 10-11 and their parents from 23 schools in Wave 1 (June 2021-December 2021), and 436 children and parents from 27 schools in Wave 2 (January 2022-July 2022). These were compared to a pre-COVID-19 comparator group (March 2017-May 2018) of 1,296 children and parents in the same schools. Mean minutes of accelerometer-measured MVPA and sedentary time were derived for week- and weekend-days and compared across waves via linear multilevel models. We also analysed the date of data collection as a time series, to explore temporal patterns via generalised additive mixed models.

RESULTS

There was no difference in children's mean MVPA in Wave 2 (weekdays: -2.3 min; 95% CI: -5.9, 1.3 and weekends: 0.6 min; 95% CI: -3.5, 4.6) when compared to the pre-COVID-19 data. Sedentary time remained higher than pre-pandemic by 13.2 min (95% CI:5.3, 21.1) on weekdays. Differences compared to pre-COVID-19 changed over time, with children's MVPA decreasing over winter, coinciding with COVID-19 outbreaks, and only returning to pre-pandemic levels towards May/June 2022. Parents' sedentary time and weekday MVPA was similar to pre-COVID-19 levels, with MVPA higher than pre-pandemic by 7.7 min (95% CI: 1.4, 14.0) on weekends.

CONCLUSION

After an initial drop, children's MVPA returned to pre-pandemic levels by July 2022, while sedentary time remained higher. Parents' MVPA remained higher, especially at weekends. The recovery in physical activity is precarious and potentially susceptible to future COVID-19 outbreaks or changes in provision, and so robust measures to protect against future disruptions are needed. Furthermore, many children are still inactive, with only 41% meeting UK physical activity guidelines, and so there is still a need to increase children's physical activity.

Implementing a regional school health research network in england to improve adolescent health and well-being, a qualitative process evaluation

BACKGROUND

There is an increased need for prevention and early intervention surrounding young people's health and well-being. Schools offer a pivotal setting for this with evidence suggesting that focusing on health within schools improves educational attainment. One promising approach is the creation of School Health Research Networks which exist in Wales and Scotland, but are yet to be developed and evaluated in England.

METHODS

This qualitative process evaluation aimed to identify the main barriers and facilitators to implementing a pilot School Health Research Network in the South West of England (SW-SHRN). Semi-structured interviews were conducted with school staff, local authority members, and other key stakeholders. Interview data were analysed using the 7-stage framework analysis approach.

RESULTS

Four main themes were identified from the data: (1) 'Key barriers to SW-SHRN' (competing priorities of academic attainment and well-being, schools feeling overwhelmed with surveys and lack of school time and resource); (2) 'Key facilitators to SW-SHRN: providing evidence-based support to schools' (improved knowledge to facilitate change, feedback reports and benchmarking and data to inform interventions); (3) 'Effective dissemination of findings' (interpretation and implementation, embedding findings with existing evidence and policy, preferences for an online platform as well personalised communication and the importance of involving young people and families); and (4) 'Longer-term facilitators: ensuring sustainability' (keeping schools engaged, the use of repeat surveys to evaluate impact, informing school inspection frameworks and expanding reach of the network).

CONCLUSION

This study identifies several barriers to be addressed and facilitators to be enhanced in order to achieve successful implementation of School Health Research Networks in England which include providing a unique offering to schools that is not too burdensome, supporting schools to take meaningful action with their data and to work closely with existing organisations, services and providers to become meaningfully embedded in the system.

Assessing exposure to outdoor advertisement for products high in fat, salt and sugar (HFSS); is self-reported exposure a useful exposure metric?

BACKGROUND

Exposure to advertising of unhealthy commodities such as fast-food and gambling is recognised as a risk factor for developing non-communicable diseases. Assessment of the impact of such advertisement and the evaluation of the impact of any policies to restrict such advertisements on public health are reliant on the quality of the exposure assessment. A straightforward method for assessing exposure is to ask people whether they noticed any such advertisements in their neighbourhoods. However, the validity of this method is unclear. We assessed the associations between measured exposure to outdoor advertising, self-reported exposure, and self-reported consumption.

METHODS

We collected exposure information in January-March 2022 using two methods: (i) through a resident survey investigating advertising and consumption of unhealthy products, distributed across Bristol and neighbouring South Gloucestershire, and (ii) through in-person auditing. Self-reported exposure was obtained from the resident survey (N = 2,560) and measured exposure from photos obtained for all Council owned advertisement sites (N = 973 bus stops). Both data sources were geographically linked at lower-super-output-area level. Reporting ratios (RRs), 95% confidence intervals (CIs), and Cohen's kappas, are presented.

RESULTS

24% of advertisements displayed food and/or drink advertising. Bristol respondents in neighbourhoods displaying food/drink adverts were more likely to also report seeing these adverts compared to those in neighbourhoods without food/drink adverts (59% vs. 51%, RR = 1.15, 95%CI 1.01-1.31). There was no such association in South Gloucestershire (26% vs. 32%, RR = 0.82, 95%CI 0.58-1.14). Respondents in both Bristol and South Gloucestershire who recalled seeing advertising for unhealthy food and drink products were more likely to consume them (e.g. for fast-food: 22% vs. 11%, RR = 2.01, 95%CI 1.68-2.42). There was no such association between measured food and drink adverts in respondents' local areas and self-reported consumption of HFSS product (90.1% vs. 90.7%, RR = 0.99, 95%CI 0.96-1.03).

CONCLUSIONS

Self-reported outdoor advertisement exposure is correlated with measured exposure, making this a useful methodology for population studies. It has the added advantage that it correlates with consumption. However, given that measurement error can be significant and self-reported exposure is known to be susceptible to various biases, inferences from studies using this exposure metric should be made with caution.

Second Opinions for Patients With a Persistent Depressive Disorder: Effects on Severity of Depression and Quality of Life

BACKGROUND

A persistent depressive disorder has a major impact on both patients and health care systems. Despite the advice in guidelines to seek a second opinion if there is insufficient evidence of recovery after treatment, and the great number of second opinions in psychiatric care for patients with persistent depression, only a few studies have been published about their effects.

METHODS

Multilevel analyses were conducted to compare the mean test scores of a group of patients with a persistent depressive disorder who received the intervention of a second opinion with scores from a matched control group, at 3 time points: baseline, intervention, and follow-up.

RESULTS

A significant decrease in the severity of depression 3 months after the second opinion was found. No effects on quality of life or treatment satisfaction were found.

LIMITATIONS

The study sample was a convenience sample without randomization, and many values were missing in the data. In addition, a 3-month follow-up may have been too short to expect effects of the recommendations from the second opinion. The instructions concerning how to rate treatment satisfaction were also ambiguous.

CONCLUSIONS

A second opinion can be of value for persistent depression. Further research should address the question of whether the effect that was found is caused by the second opinion itself or is the result of subsequent changes in treatment.

Screen-viewing behaviours of children before and after the 2020-21 COVID-19 lockdowns in the UK: a mixed methods study

BACKGROUND

Restrictions during the COVID-19 pandemic have led to increased screen-viewing among children, especially during strict periods of lockdown. However, the extent to which screen-viewing patterns in UK school children have changed post lockdowns is unclear. The aim of this paper is to examine how screen-viewing changed in 10-11-year-old children over the 2020-21 COVID-19 pandemic, how this compares to before the pandemic, and the influences on screen-viewing behaviour.

METHODS

This is a mixed methods study with 10-11-year-olds from 50 schools in the Greater Bristol area, UK. Cross-sectional questionnaire data on minutes of weekday and weekend television (TV) viewing and total leisure screen-viewing were collected pre-COVID-19 in 2017-18 (N = 1,296) and again post-lockdowns in 2021 (N = 393). Data were modelled using Poisson mixed models, adjusted for age, gender, household education and seasonality, with interactions by gender and household education. Qualitative data were drawn from six focus groups (47 children) and 21 one-to-one parent interviews that explored screen-viewing behaviour during the pandemic and analysed using the framework method.

RESULTS

Total leisure screen-viewing was 11% (95% CI: 12%-18%) higher post-lockdown compared to pre-COVID-19 on weekdays, and 8% (95% CI: 6%-10%) on weekends, equating to around 12-15 min. TV-viewing (including streaming) was higher by 68% (95% CI: 63%-74%) on weekdays and 80% (95% CI: 75%-85%) on weekend days. Differences in both were higher for girls and children from households with lower educational attainment. Qualitative themes reflected an unavoidable increase in screen-based activities during lockdowns, the resulting habitualisation of screen-viewing post-lockdown, and the role of the parent in reducing post-2020/21 lockdown screen-viewing.

CONCLUSIONS

Although screen-viewing was higher post-lockdown compared to pre-COVID-19, the high increases reported during lockdowns were not, on average, sustained post-lockdown. This may be attributed to a combination of short-term fluctuations during periods of strict restrictions, parental support in regulating post-lockdown behaviour and age-related, rather than COVID-19-specific, increases in screen-viewing. However, socio-economic differences in our sample suggest that not all families were able to break the COVID-19-related adoption of screen-viewing, and that some groups may need additional support in managing a healthy balance of screen-viewing and other activities following the lockdowns.

Rethinking children's physical activity interventions at school: A new context-specific approach

Physical activity is important for children's health. However, evidence suggests that many children and adults do not meet international physical activity recommendations. Current school-based interventions have had limited effect on physical activity and alternative approaches are needed. Context, which includes school setting, ethos, staff, and sociodemographic factors, is a key and largely ignored contributing factor to school-based physical activity intervention effectiveness, impacting in several interacting ways.

Conceptualization

Current programs focus on tightly-constructed content that ignores the context in which the program will be delivered, thereby limiting effectiveness. We propose a move away from uniform interventions that maximize internal validity toward a flexible approach that enables schools to tailor content to their specific context.

Evaluation designs

Evaluation of context-specific interventions should explicitly consider context. This is challenging in cluster randomized controlled trial designs. Thus, alternative designs such as natural experiment and stepped-wedge designs warrant further consideration.

Primary outcome

A collective focus on average minutes of moderate-to-vigorous intensity physical activity may not always be the most appropriate choice. A wider range of outcomes may improve children's physical activity and health in the long-term. In this paper, we argue that greater consideration of school context is key in the design and analysis of school-based physical activity interventions and may help overcome existing limitations in the design of effective interventions and thus progress the field. While this focus on context-specific interventions and evaluation is untested, we hope to stimulate debate of the key issues to improve future physical activity intervention development and implementation.

Study protocol for First Dental Steps Intervention: feasibility study of a health visitor led infant oral health improvement programme

BACKGROUND

Dental caries in childhood is a burden on the daily lives of children and their families, and associated with poor oral health in adulthood. In England, dental caries is the most common reason for young children to be admitted to hospital. It is believed that most tooth extractions (due to decay) for children aged 10 years and under, could be avoided with improved prevention and early management. National public health policy recommendations in England include specific oral health initiatives to tackle tooth decay. One of these initiatives is delivered as part of the Healthy Child Programme and includes providing workforce training in oral health, integrating oral health advice into home visits, and the timely provision of fluoride toothpaste. This protocol seeks to assess the delivery of the First Dental Steps intervention and uncertainties related to the acceptability, recruitment, and retention of participants.

METHODS

This study seeks to explore the feasibility and acceptability of the First Dental Steps intervention and research methods. First Dental Steps intervention will be delivered in local authority areas in South West England and includes oral health training for health visitors (or community nursery nurses) working with 0-5-year-olds and their families. Further, for vulnerable families, integrating oral health advice and the provision of an oral health pack (including a free flow cup, an age appropriate toothbrush, and 1450 ppm fluoride toothpaste) during a mandated check by a health visitor. In this study five local authority areas will receive the intervention. Interviews with parents receiving the intervention and health visitors delivering the intervention will be undertaken, along with a range of additional interviews with stakeholders from both intervention and comparison sites (four additional local authority areas).

DISCUSSION

This protocol was written after the start of the COVID-19 pandemic, as a result, some of the original methods were adjusted specifically to account for disruptions caused by the pandemic. Results of this study will primarily provide evidence on the acceptability and feasibility of both the First Dental Steps intervention and the research methods from the perspective of both families and stakeholders.

'A priori' external contextual factors and relationships with process indicators: a mixed methods study of the pre-implementation phase of 'Communities in Charge of Alcohol'

BACKGROUND

It is widely recognised that complex public health interventions roll out in distinct phases, within which external contextual factors influence implementation. Less is known about relationships with external contextual factors identified a priori in the pre-implementation phase. We investigated which external contextual factors, prior to the implementation of a community-centred approach to reducing alcohol harm called 'Communities in Charge of Alcohol' (CICA), were related to one of the process indicators: numbers of Alcohol Health Champions (AHCs) trained.

METHODS

A mixed methods design was used in the pre-implementation phase of CICA. We studied ten geographic communities experiencing both high levels of deprivation and alcohol-related harm in the North West of England. Qualitative secondary data were extracted from pre-implementation meeting notes, recorded two to three months before roll-out. Items were coded into 12 content categories using content analysis. To create a baseline 'infrastructure score', the number of external contextual factors documented was counted per area to a maximum score of 12. Descriptive data were collected from training registers detailing training numbers in the first 12 months. The relationship between the baseline infrastructure score, external contextual factors, and the number of AHCs trained was assessed using non-parametric univariable statistics.

RESULTS

There was a positive correlation between baseline infrastructure score and total numbers of AHCs trained (Rs = 0.77, p = 0.01). Four external contextual factors were associated with significantly higher numbers of lay people recruited and trained: having a health care provider to coordinate the intervention (p = 0.02); a pool of other volunteers to recruit from (p = 0.02); a contract in place with a commissioned service (p = 0.02), and; formal volunteer arrangements (p = 0.03).

CONCLUSIONS

Data suggest that there were four key components that significantly influenced establishing an Alcohol Health Champion programme in areas experiencing both high levels of deprivation and alcohol-related harm. There is added value of capturing external contextual factors a priori and then testing relationships with process indicators to inform the effective roll-out of complex interventions. Future research could explore a wider range of process indicators and outcomes, incorporating methods to rate individual factors to derive a mean score.

TRIAL REGISTRATION

ISRCTN81942890, date of registration 12/09/2017.

Prenatal alcohol prevention in the UK: mapping the landscape through systematic collaborative review

BACKGROUND

UK policy makers have called for urgent action to reduce prenatal alcohol exposure (PAE), but evidence on what is effective is scarce. We aimed to identify, evaluate, and synthesise evidence on content, process aspects, and effectiveness of UK PAE prevention initiatives.

METHODS

We conducted a systematic search of published and grey literature on UK PAE prevention (PROSPERO: CRD42020209460); consultations with 61 academic, practice, policy, third sector, and public stakeholders; and semi-structured 12 interviews with pregnant people (who were aged ≥18 years and ≥12 weeks' gestation) and service providers to discuss experiences of PAE prevention. Participants were purposively sampled to cover each UK region and identified through maternity sites, social media and, for stakeholder consultees, researcher networks. Information from relevant PAE prevention initiatives from the literature was independently extracted by two reviewers. Ethical approval and informed consent were obtained for interviews, which were recorded and transcribed. Qualitative evidence was synthesised using thematic analysis. Quantitative data will be summarised using descriptive statistics and meta-analysis.

FINDINGS

We identified 14 PAE prevention initiatives through literature searches (22 of 4064 results were eligible), stakeholder consultation, and interviews. Initiatives included screening and intervention, campaigns, and education or training. Seven initiatives were identified in the north of England. Two initiatives were identified in Scotland and two in Wales. The East of England, West Midlands, and South East of England had one each. None were identified in Southwest of England or Northern Ireland. Barriers to prevention included absence of resources, excessive workload, concerns around blame, and COVID-19. Enablers included workforce training and trust between pregnant people and service providers. Effectiveness of evidence was scarce.

INTERPRETATION

Key strengths include extensive searches and multidisciplinary consultation. Data collection and analyses are ongoing and will be finalised before November, 2022. This research will provide a comprehensive analysis of current provision, providing crucial evidence to inform research and practice.

FUNDING

The National Institute for Health and Care Research.

Creation of a Pilot School Health Research Network in an English Education Infrastructure to Improve Adolescent Health and Well-Being: A Study Protocol

Schools play a significant role in promoting health and well-being and the reciprocal links between health and educational attainment are well-evidenced. Despite recognition of the beneficial impact of school-based health improvement programmes, significant barriers to improving health and well-being within schools remain. This study pilots a School Health Research Network in the South West of England (SW-SHRN), a systems-based health intervention bringing together schools, academic health researchers and public health and/or education teams in local authorities to share knowledge and expertise to improve the health and well-being of young people. A maximum of 20 secondary schools will be recruited to the pilot SW-SHRN. All students in Years 8 (age 12-13) and 10 (age 14-15) will be invited to complete a health and well-being questionnaire, generating a cohort of approximately 5000 adolescents. School environment questionnaires will also be completed with each school to build a regional picture of existing school health policies and programmes. Each school will be provided with a report summarising data for their students benchmarked against data for all schools in the network. Quantitative analysis will model associations between health risk behaviours and mental health outcomes and a qualitative process evaluation will explore the feasibility and sustainability of the network. This study will create adolescent health data to help provide schools and local authorities with timely and robust information on the health and well-being of their students and help them to identify areas in which public health interventions may be required. SW-SHRN will also help public health professionals focus their resources in the areas most at need.

Measuring how PH stakeholders seek to influence alcohol premises licensing in England and Scotland: the Public Health engagement In Alcohol Licensing (PHIAL) measure

OBJECTIVE

In the United Kingdom, some public health teams (PHTs) routinely engage with local alcohol premises licensing systems, through which licenses to sell alcohol are granted. We aimed to categorize PHT efforts and to develop and apply a measure of their efforts over time.

METHOD

Preliminary categories of PHT activity were developed based on prior literature and were used to guide data collection with PHTs in 39 local government areas (27 in England; 12 in Scotland), sampled purposively. Relevant activity from April 2012 to March 2019 was identified through structured interviews (N = 62), documentation analysis, and follow-up checks, and a grading system was developed. The measure was refined based on expert consultation and used to grade relevant PHT activity for the 39 areas in 6-month periods.

RESULTS

The Public Health engagement In Alcohol Licensing (PHIAL) Measure includes 19 activities in six categories: (a) staffing; (b) reviewing license applications; (c) responding to license applications; (d) data usage; (e) influencing licensing stakeholders or policy; and (f) public involvement. PHIAL scores for each area demonstrate fluctuation in type and level of activity between and within areas over time. Participating PHTs in Scotland were more active on average, particularly on senior leadership, policy development, and working with the public. In England, activity to influence license applications before decision was more common, and a clear increase in activity is apparent from 2014 onward.

CONCLUSIONS

The novel PHIAL Measure successfully assessed diverse and fluctuating PHT engagement in alcohol licensing systems over time and will have practice, policy, and research applications.

A multi-perspective qualitative exploration of the reasons for changes in the physical activity among 10-11-year-old children following the easing of the COVID-19 lockdown in the UK in 2021

Background

Active-6 is exploring how the COVID-19 pandemic has impacted physical activity behaviour among Year 6 children (aged 10–11 years) and their parents in Southwest England. Initial findings from the Active-6 project have shown a 7–8 min decrease in moderate-to-vigorous physical activity and an increase in sedentary behaviour among children following the easing of restrictions in the UK in latter half of 2021. This finding suggests that the pandemic has had a persistent impact on child physical activity behaviour. This paper explored the possible mechanisms behind these changes.

Methods

Interviews with parents (n = 21), members of school staff (n = 9) and focus groups with children aged 10–11 years (n = 47) were conducted between August and December 2021 to discuss the impact of the pandemic on child physical activity behaviour. The framework method was used for analysis.

Results

Five themes spanning two key stages of the pandemic were described. Three themes related to the period of lockdowns and fluctuating restrictions (March 2020 – April 2021). These included: Theme 1) Lockdown: A short-lived adventure; Theme 2) Access to facilities during restrictions; and Theme 3) The importance of the parent. A further two themes were identified related to the period following the gradual easing of restrictions in April 2021. These included: Theme 4) An overwhelming return to normal; and Theme 5) Reopening fatigue.

Conclusions

The analysis suggested that feelings of novelty experienced during the initial stages of lockdown waned as restrictions were prolonged, creating an increasingly challenging period for parents and their children. However, during periods of restrictions, the importance of parental encouragement and access to appropriate facilities in the local and home environment helped facilitate physical activity. Following the easing of COVID-19 restrictions, emotional overwhelm and physical fatigue among children, stemming from a sedentary and socially isolated life in lockdown and other restrictions, were key contributors to the decreased moderate to vigorous physical activity and increased sedentary behaviour that was observed in a related quantitative study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01356-3.

Impact of public health team engagement in alcohol licensing on health and crime outcomes in England and Scotland: A comparative timeseries study between 2012 and 2019

BACKGROUND

Public health teams (PHTs) in England and Scotland engage to varying degrees in local alcohol licensing systems to try to reduce alcohol-related harms. No previous quantitative evidence is available on the effectiveness of this engagement. We aimed to quantify the effects of PHT engagement in alcohol licensing on selected health and crime outcomes.

METHODS

39 PHTs in England (n = 27) and Scotland (n = 12) were recruited (of 40 contacted) for diversity in licensing engagement level and region, with higher activity areas matched to lower activity areas. Each PHT's engagement in licensing for each 6 month period from April 2012 to March 2019 was quantified using a new measure (PHIAL) developed using structured interviews, documentary analyses, and expert consultation. Outcomes examined were ambulance callouts, alcohol-related hospital admissions, alcohol-related and alcohol-specific mortality and violent, sexual and public order offences. Timeseries were analysed using multivariable negative binomial mixed-effects models. Correlations were assessed between each outcome and 18-month average PHIAL score (primary metric), cumulative PHIAL scores and change in PHIAL scores. Additionally, 6-month lagged correlations were also assessed.

FINDINGS

There was no clear evidence of any associations between the primary exposure metric and the public health or crime outcomes examined, nor between cumulative PHIAL scores or change in PHIAL score and any outcomes. There were no significant associations in England or Scotland when analysed separately or between outcomes and lagged exposure metrics.

INTERPRETATION

There is no clear evidence that allocating PHT resources to engaging in alcohol licensing is associated with downstream reductions in alcohol-related health harms or crimes, in the short term or over a seven year follow-up period. Such engagement likely has benefits in shaping the licensing system to take account of health issues longer term, but as current systems cannot reduce alcohol availability or contain online sales, their potential benefits are somewhat constrained.

FUNDING

The ExILEnS project is funded by the NIHR Public Health Research Programme (project number 15/129/11). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

“We are our own worst enemy”: a qualitative exploration of work-related stress in the construction industry

Purpose

Around 400,000 working days per year are lost in the construction industry due to stress, depression or anxiety, but a large proportion of the industry – those primarily not based “on-site” – is not included in these statistics. Little research has been conducted in this group about their experiences of occupational stress. The authors explored how stress was experienced and managed by construction professionals and its perceived impact on health.

Design/methodology/approach

The authors interviewed 32 construction professionals in a British construction company, with varying levels of seniority and years in the industry. Interviews were transcribed, coded and analysed thematically.

Findings

Stress was viewed an inevitable and increasing part of the construction industry, exacerbated by recent economic challenges. Participants talked about a culture of stress and overwork but often felt unable to challenge it due to job insecurity. Senior management acknowledged stress was a problem within the industry and something that potentially threatened company productivity. Company-wide initiatives had been implemented to address stress levels (e.g. Mental Health First Aiders), but were criticised for ignoring underlying issues. Informal means of managing stress were identified, such as careful consideration of team dynamics, which allowed employees to form close bonds and using “banter” and camaraderie to relieve stress. However, the persistence of a macho male image meant some participants were reluctant to talk about their feelings at work. Participants described individual coping strategies, such as exercise, but these were hard to prioritise in challenging times.

Originality/value

There is growing recognition that health and well-being must be given greater priority in the construction industry. Industry pressures and competitive practices undermine efforts to improve staff well-being. Action must be taken at senior levels to address this conflict, while building on existing informal mechanisms of support and stress relief.

Accelerometer-measured physical activity and sedentary time among children and their parents in the UK before and after COVID-19 lockdowns: a natural experiment

BACKGROUND

Restrictions due to the coronavirus disease 2019 (COVID-19) pandemic reduced physical activity provision for both children and their parents. Recent studies have reported decreases in physical activity levels during lockdown restrictions, but these were largely reliant on self-report methods, with data collected via unrepresentative self-report surveys. The post-pandemic impacts on children's activity levels remain unknown. A key question is how active children become once lockdown restrictions are lifted.

METHODS

Active-6 is a repeated cross-sectional natural experiment. Accelerometer data from 1296 children aged 10-11 and their parents were collected in 50 schools in the Greater Bristol area, UK in March 2017-May 2018 (pre-COVID-19 comparator group), and compared to 393 children aged 10-11 and parents in 23 of the same schools, collected in May-December 2021. Mean minutes of accelerometer-measured moderate-to-vigorous physical activity (MVPA) were derived for weekdays and weekend and compared pre- and post-lockdown via linear multilevel models.

RESULTS

After adjusting for seasonality, accelerometer wear time and child/parent demographics, children's mean weekday and weekend MVPA were 7.7 min (95% CI: 3.5 to 11.9) and 6.9 min (95% CI: 0.9 to 12.9) lower in 2021 than in 2018, respectively, while sedentary time was higher by 25.4 min (95% CI: 15.8 to 35.0) and 14.0 min (95% CI: 1.5 to 26.5). There was no evidence that differences varied by child gender or household education. There was no significant difference in parents' MVPA or sedentary time, either on weekdays or weekends.

CONCLUSIONS

Children's MVPA was lower by 7-8 min/day in 2021 once restrictions were lifted than before the pandemic for all groups, on both weekdays and weekends. Previous research has shown that there is an undesirable age-related decline in children's physical activity. The 8-min difference reported here would be broadly comparable to the decline that would have previously been expected to occur over a three-year period. Parents' physical activity was similar to pre-pandemic levels. Our results suggest that despite easing of restrictions, children's activity levels have not returned to pre-pandemic levels. There is an urgent need to understand why these changes have occurred and how long they are maintained.

The Impact of the Universal Infant Free School Meal Policy on Dietary Quality in English and Scottish Primary School Children: Evaluation of a Natural Experiment

The Universal Infant Free School Meal (UIFSM) policy was introduced in September 2014 in England and January 2015 in Scotland and offered all infant schoolchildren (ages 4-7 years) a free school lunch, regardless of income. Yet, impacts of UIFSM on dietary intakes or social inequalities are not known. A difference-in-differences study using the National Diet and Nutrition Survey assessed pooled pre-UIFSM (2010-2014) and post-UIFSM (2014-2017) dietary data. English or Scottish infant schoolchildren (4-7 years; n = 458) were the intervention group, with junior schoolchildren (8-11 years; n = 401) as controls. We found that implementation of UIFSM led to an increase in infant schoolchildren having a school meal. Impacts on key food groups such as fruit and vegetables or sweetened beverages were not seen. However, there was evidence that the UIFSM policy lowered consumption of foods associated with packed lunches, such as crisps, and some nutrients, such as total fat and sodium. Policy impacts differed by income group, with larger effect sizes in low-income children. In conclusion, evaluation of UIFSM demonstrated some improvements in dietary quality but the findings suggest school meal quality needs to be improved to fully realise the benefits of UIFSM.

Changes in household food and drink purchases following restrictions on the advertisement of high fat, salt, and sugar products across the Transport for London network: A controlled interrupted time series analysis

BACKGROUND

Restricting the advertisement of products with high fat, salt, and sugar (HFSS) content has been recommended as a policy tool to improve diet and tackle obesity, but the impact on HFSS purchasing is unknown. This study aimed to evaluate the impact of HFSS advertising restrictions, implemented across the London (UK) transport network in February 2019, on HFSS purchases.

METHODS AND FINDINGS

Over 5 million take-home food and drink purchases were recorded by 1,970 households (London [intervention], n = 977; North of England [control], n = 993) randomly selected from the Kantar Fast Moving Consumer Goods panel. The intervention and control samples were similar in household characteristics but had small differences in main food shopper sex, socioeconomic position, and body mass index. Using a controlled interrupted time series design, we estimated average weekly household purchases of energy and nutrients from HFSS products in the post-intervention period (44 weeks) compared to a counterfactual constructed from the control and pre-intervention (36 weeks) series. Energy purchased from HFSS products was 6.7% (1,001.0 kcal, 95% CI 456.0 to 1,546.0) lower among intervention households compared to the counterfactual. Relative reductions in purchases of fat (57.9 g, 95% CI 22.1 to 93.7), saturated fat (26.4 g, 95% CI 12.4 to 40.4), and sugar (80.7 g, 95% CI 41.4 to 120.1) from HFSS products were also observed. Energy from chocolate and confectionery purchases was 19.4% (317.9 kcal, 95% CI 200.0 to 435.8) lower among intervention households than for the counterfactual, with corresponding relative reductions in fat (13.1 g, 95% CI 7.5 to 18.8), saturated fat (8.7 g, 95% CI 5.7 to 11.7), sugar (41.4 g, 95% CI 27.4 to 55.4), and salt (0.2 g, 95% CI 0.1 to 0.2) purchased from chocolate and confectionery. Relative reductions are in the context of secular increases in HFSS purchases in both the intervention and control areas, so the policy was associated with attenuated growth of HFSS purchases rather than absolute reduction in HFSS purchases. Study limitations include the lack of out-of-home purchases in our analyses and not being able to assess the sustainability of observed changes beyond 44 weeks.

CONCLUSIONS

This study finds an association between the implementation of restrictions on outdoor HFSS advertising and relative reductions in energy, sugar, and fat purchased from HFSS products. These findings provide support for policies that restrict HFSS advertising as a tool to reduce purchases of HFSS products.

Restricting the advertising of high fat, salt and sugar foods on the Transport for London estate: Process and implementation study

INTRODUCTION

One in five UK children aged 10-11 years live with obesity. They are more likely to continue living with obesity into adulthood and to develop obesity-related chronic health conditions at a younger age. Regulating the marketing of high fat, salt and sugar (HFSS) foods and beverages has been highlighted as a promising approach to obesity prevention. In 2019, Transport for London implemented restrictions on the advertisement of HFSS products across its network. This paper reports on a process evaluation of the design and implementation of this intervention.

METHODS

In 2019-2020, we conducted semi-structured interviews with 23 stakeholders. Interviews with those responsible for implementation (n = 13) explored stakeholder roles, barriers and facilitators to policy development/implementation and unintended consequences. Interviews with food industry stakeholders (n = 10) explored perceptions and acceptability of the policy, changes to business practice and impact on business. Data were analysed using a general inductive approach.

RESULTS

Practical challenges included limited time between policy announcement and implementation, translating the concept of 'junk food' into operational policy, the legal landscape, and reported uneven impacts across industry stakeholders. Political challenges included designing a policy the public views as appropriate, balancing health and financial impacts, and the perceived influence of political motivations. Consultation during policy development and close communication with industry reportedly facilitated implementation, as did the development of an exceptions process that provided a review pathway for HFSS products that might not contribute to children's HFSS consumption.

CONCLUSIONS

Findings suggest that restricting the outdoor advertisement of HFSS foods and beverages at scale is feasible within a complex policy and business landscape. We outline practical steps that may further facilitate the development and implementation of similar policies and we report on the importance of ensuring such policies are applied in a way that is perceived as reasonable by industry and the public.

Association between cigarette smoking status and voting intentions: Cross sectional surveys in England 2015-2020

BACKGROUND AND AIMS

Cigarette smoking takes place within a cultural and social context. Political views and practices are an important part of that context. To gain a better understanding of smoking, it may be helpful to understand its association with voting patterns as an expression of the political views and practices of the population who smoke. This study aimed to assess the association between cigarette smoking and voting intentions and to examine how far any association can be explained by sociodemographic factors and alcohol use.

METHODS

Pooled monthly representative repeat cross-sectional household surveys of adults (16+) in England (N = 55,482) between 2015 and 2020 were used to assess the association between cigarette smoking status and voting intentions, and whether this was accounted for by age, occupational grade, gender, region and alcohol use. Voting intention was measured by asking 'How would you vote if there were a General Election tomorrow?' Respondents chose from a list of the major English political parties or indicated their intention not to vote.

RESULTS

In adjusted multinomial regression, compared with intending to vote Conservative (majority party of government during the period), being undecided (aOR1.22 [1.13-1.33] <0.001), intending to vote Labour (aOR1.27 [1.16-1.36] <0.001), to vote "Other" (aOR1.54 [1.37-1.72] <0.001), or not to vote (aOR1.93 [1.77-2.11] <0.001) was associated with higher odds of current relative to never smoking rates. Intending to vote for the Liberal Democrats was associated with a significant lower odds of current smoking prevalence (aOR0.80 [0.70-0.91] <0.001) compared with intending to vote Conservative.

CONCLUSIONS

Controlling for a range of other factors, current as compared with never-smokers appear more likely to intend not to vote, to be undecided, to vote for Labour or a non-mainstream party, and less likely to vote for the Liberal Democrats, compared with the Conservative party.

Interpretation of Timetrends (1996-2017) of the Incidence of Selected Cancers in England in Relation to Mobile Phone Use as a Possible Risk Factor

Radiofrequency (RF) radiation from mobile phones has been classified as possibly carcinogenic to humans (2b) by IARC. However, to date, the discussion on whether mobile phone use is a cancer risk factor has not been solved. In this context of continuing uncertainty, it is important to continue to monitor cancer incidence trends. Annual incidence rates and directly age-standardized rates of selected cancers by sex and 5-year age groups for 1996 to 2017 for England were obtained from the UK Office for National Statistics. Interpretation in light of mobile phone use as a contributing risk factor was conducted for cancers of the brain, parotid gland, thyroid, and colorectal cancer, which have all been hypothesized to be associated with RF exposure. Brain and parotid gland cancers were updated by an additional 10 years following a previous publication, and continue to provide little evidence of an association with mobile phone use. Although mobile phone use as a potential risk factor contributing to increased incidence of colorectal or thyroid cancer could not be excluded based on these ecological data, it is implausible that it is an important risk factor for either. In the absence of clarity from epidemiological studies, it remains important to continue to monitor trends. However, for the time being, and in agreement with data from other countries, there is little evidence of an association between mobile phone use and brain or parotid gland cancer, while the hypotheses of associations with thyroid or colorectal cancer are similarly weak. © 2021 Bioelectromagnetics Society.

Media representations of opposition to the 'junk food advertising ban' on the Transport for London (TfL) network: A thematic content analysis of UK news and trade press

BACKGROUND

Advertising of less healthy foods and drinks is hypothesised to be associated with obesity in adults and children. In February 2019, Transport for London implemented restrictions on advertisements for foods and beverages high in fat, salt or sugar across its network as part of a city-wide strategy to tackle childhood obesity. The policy was extensively debated in the press. This paper identifies arguments for and against the restrictions. Focusing on arguments against the restrictions, it then goes on to deconstruct the discursive strategies underpinning them.

METHODS

A qualitative thematic content analysis of media coverage of the restrictions (the 'ban') in UK newspapers and trade press was followed by a document analysis of arguments against the ban. A search period of March 1, 2018 to May 31, 2019 covered: (i) the launch of the public consultation on the ban in May 2018; (ii) the announcement of the ban in November 2018; and (iii) its implementation in February 2019. A systematic search of printed and online publications in English distributed in the UK or published on UK-specific websites identified 152 articles.

RESULTS

Arguments in favour of the ban focused on inequalities and childhood obesity. Arguments against the ban centred on two claims: that childhood obesity was not the 'right' priority; and that an advertising ban was not an effective way to address childhood obesity. These claims were justified via three discursive approaches: (i) claiming more 'important' priorities for action; (ii) disputing the science behind the ban; (iii) emphasising potential financial costs of the ban.

CONCLUSION

The discursive tactics used in media sources to argue against the ban draw on frames widely used by unhealthy commodities industries in response to structural public health interventions. Our analyses highlight the need for interventions to be framed in ways that can pre-emptively counter common criticisms.

Evaluating the effects of the Licensing Act 2003 on the characteristics of drinking occasions in England and Wales: a theory of change-guided evaluation of a natural experiment

BACKGROUND AND AIMS

The Licensing Act 2003 deregulated trading hours in England and Wales. Previous evaluations have focused upon consumption and harm outcomes, finding mixed results. Several evaluations speculated on the reasons for their results, noting the role of changes in the characteristics of drinking occasions. This study aimed to test proposed mechanisms of effect for the Licensing Act 2003 by evaluating changes in characteristics of drinking occasions. Design, Setting and Participants Interrupted monthly time-series analysis of effects in England and Wales versus a Scottish control series, using 2001-08 data collected via 7-day drinking occasions diaries by the market research company Kantar (n = 89 192 adults aged 18+).

MEASUREMENTS

Outcomes were start- and end-time of each reported occasion; variation in finish time; prevalence of pre-loading, post-loading and late-night drinking; and alcohol consumption (in units).

FINDINGS

After the introduction of the Act, occasions shifted later at night in England and Wales [finish time +11.4 minutes; 95% confidence interval (CI) = 3.6-19.2]. More occasions involved pre-loading in England and Wales relative to Scotland (0.02% increase; 95% CI = 0.01-0.03). There was no evidence of changes in variation in finish time, post-loading, late-night drinking or alcohol consumption.

CONCLUSIONS

The Licensing Act 2003 in England and Wales appears to have had only limited effects on the characteristics of drinking occasions. This may help to explain its lack of substantial impacts on alcohol harms.

How can communities influence alcohol licensing at a local level? Licensing officers' perspectives of the barriers and facilitators to sustaining engagement in a volunteer-led alcohol harm reduction approach

Despite the World Health Organization's assertion that communities need to become involved in reducing alcohol harm, evidence of community engagement in alcohol licensing decision-making in England remains limited. The evaluation of the Communities in Charge of Alcohol (CICA) programme offers policymakers, Licensing authorities and public health practitioners, evidence regarding a specific volunteer-led, place-based approach, designed to enable community engagement in licensing with the aim of reducing localised alcohol harm. This study explored factors affecting the sustainable involvement of volunteers in alcohol licensing decision-making from six licensing officers' perspectives, through semi-structured interviews. Routinely collected crime, disorder, and hospital admissions data were reviewed for further context as proxy indicators for alcohol-related harm. Licensing officers perceived sustainable engagement to be impacted by: (i) the extent of alignment with statutory requirements and local political support; (ii) the ability of licensing officers to operationalise CICA and support local assets, and; (iii) the opportunity for, and ability of, volunteers to raise licensing issues. The perspectives of licensing officers indicate complexities inherent in seeking to empower residents to engage in licensing decision-making at a community level. These relate to statutory and political factors, funding, social norms regarding engagement in licensing decision-making, and the need for networks between critical actors including responsible authorities and communities. The evidence indicates that after increasing community capacity to influence alcohol availability decision-making at a local level, communities continue to struggle to influence statutory processes to affect alcohol availability where they live and work. More understanding of how to enable effective community engagement is required.

Quantitative Bias Analysis of the Association between Occupational Radiation Exposure and Ischemic Heart Disease Mortality in UK Nuclear Workers

The scientific question of whether protracted low-dose or low-dose-rate exposure to external radiation is causally related to the risk of circulatory disease continues to be an important issue for radiation protection. Previous analyses of a matched case-control dataset nested in a large cohort of UK nuclear fuel cycle workers indicated that there was little evidence that observed associations between external radiation dose and ischemic heart disease (IHD) mortality risk [OR = 1.35 (95% CI: 0.99-184) for 15-year-lagged exposure] could alternatively be explained by confounding from pre-employment tobacco smoking, BMI or blood pressure, or from socioeconomic status or occupational exposure to excessive noise or shiftwork. To improve causal inference about the observed external radiation dose and IHD mortality association, we estimated the potential magnitude and direction of non-random errors, incorporated sensitivity analyses and simulated bias effects under plausible scenarios. We conducted quantitative bias analyses of plausible scenarios based on 1,000 Monte Carlo samples to explore the impact of exposure measurement error, missing information on tobacco smoking, and unmeasured confounding, and assessed whether observed associations were reliant on the inclusion of specific matched pairs using bootstrapping with 10% of matched pairs randomly excluded in 1,000 samples. We further explored the plausibility that having been monitored for internal exposure, which was an important confounding factor in the case-control analysis for which models were adjusted, was indeed a confounding factor or whether it might have been the result of some form of selection bias. Consistent with the broader epidemiological evidence-base, these analyses provide further evidence that the dose-response association between cumulative external radiation exposure and IHD mortality is non-linear in that it has a linear shape plateauing at an excess risk of 43% (95% CI: 7-92%) on reaching 390 mSv. Analyses of plausible scenarios of patterns of missing data for tobacco smoking at start of employment indicated that this resulted in relatively little bias towards the null in the original analysis. An unmeasured confounder would have had to have been highly correlated (rp > 0.60) with cumulative external radiation dose to importantly bias observed associations. The confounding effect of "having been monitored for internal dose" was unlikely to have been a true confounder in a biological sense, but instead may have been some unknown factor related to differences over time and between sites in selection criteria for internal monitoring, possibly resulting in collider bias. Plausible patterns of exposure measurement error negatively biased associations regardless of the modeled scenario, but did not importantly change the shape of the observed dose-response associations. These analyses provide additional support for the hypothesis that the observed association between external radiation exposure and IHD mortality may be causal.

Workplace interventions that aim to improve employee health and well-being in male-dominated industries: a systematic review

The published evidence on whether workplace health and well-being interventions are as effective in male-dominated industries compared with mixed-gender environments has not been synthesised. We performed a systematic review of workplace interventions aimed at improving employee health and well-being in male-dominated industries. We searched Web of Knowledge, PubMed, Medline, Cochrane Database and Web of Science for articles describing workplace interventions in male-dominated industries that address employee health and well-being. The primary outcome was to determine the effectiveness of the intervention and the process evaluation (intervention delivery and adherence). To assess the quality of evidence, Cochrane Collaboration’s Risk of Bias Tool was used. Due to the heterogeneity of reported outcomes, meta-analysis was performed for only some outcomes and a narrative synthesis with albatross plots was presented. After full-text screening, 35 studies met the eligibility criteria. Thirty-two studies delivered the intervention face-to-face, while two were delivered via internet and one using postal mail. Intervention adherence ranged from 50% to 97%, dependent on mode of delivery and industry. 17 studies were considered low risk of bias. Albatross plots indicated some evidence of positive associations, particularly for interventions focusing on musculoskeletal disorders. There was little evidence of intervention effect on body mass index and systolic or diastolic blood pressure. Limited to moderate evidence of beneficial effects was found for workplace health and well-being interventions conducted within male-dominated industries. Such interventions in the workplace can be effective, despite a different culture in male-dominated compared with mixed industries, but are dependent on delivery, industry and outcome. CRD42019161283.

Primary Care implementation of Germ Defence, a digital behaviour change intervention to improve household infection control during the COVID-19 pandemic: A structured summary of a study protocol for a randomised controlled trial

OBJECTIVES

To examine the effectiveness of randomising dissemination of the Germ Defence behaviour change website via GP practices across England UK.

TRIAL DESIGN

A two-arm (1:1 ratio) cluster randomised controlled trial implementing Germ Defence via GP practices compared with usual care.

PARTICIPANTS

Setting: All Primary care GP practices in England.

PARTICIPANTS

All patients aged 16 years and over who were granted access by participating GP practices.

INTERVENTION AND COMPARATOR

Intervention: We will ask staff at GP practices randomised to the intervention arm to share the weblink to Germ Defence with all adult patients registered at their practice during the 4-month trial implementation period and care will otherwise follow current standard management. Germ Defence is an interactive website ( http://GermDefence.org/ ) employing behaviour change techniques and practical advice on how to reduce the spread of infection in the home. The coronavirus version of Germ Defence helps people understand what measures to take and when to take them to avoid infection. This includes hand washing, avoiding sharing rooms and surfaces, dealing with deliveries and ventilating rooms. Using behaviour change techniques, it helps users think through and adopt better home hygiene habits and find ways to solve any barriers, providing personalised goal setting and tailored advice that fits users' personal circumstances and problem solving to overcome barriers. Comparator: Patients at GP practices randomised to the usual care arm will receive current standard management for the 4-month trial period after which we will ask staff to share the link to Germ Defence with all adult patients registered at their practice.

MAIN OUTCOMES

The primary outcome is the effects of implementing Germ Defence on prevalence of all respiratory tract infection diagnoses during the 4-month trial implementation period. The secondary outcomes are: 1) incidence of COVID-19 diagnoses 2) incidence of COVID-19 symptom presentation 3) incidence of gastrointestinal infections 4) number of primary care consultations 5) antibiotic usage 6) hospital admissions 7) uptake of GP practices disseminating Germ Defence to their patients 8) usage of the Germ Defence website by individuals who were granted access by their GP practice RANDOMISATION: GP practices will be randomised on a 1:1 basis by the independent Bristol Randomised Trials Collaboration (BRTC). Clinical Commission Groups (CCGs) in England will be divided into blocks according to region, and equal numbers in each block will be randomly allocated to intervention or usual care. The randomisation schedule will be generated in Stata statistical software by a statistician not otherwise involved in the enrolment of general practices into the study.

BLINDING (MASKING)

The principal investigators, the statistician and study collaborators will remain blinded from the identity of randomised practices until the end of the study.

NUMBERS TO BE RANDOMISED (SAMPLE SIZE)

To detect planned effect size (based on PRIMIT trial, Little et al, 2015): 11.1 million respondents from 6822 active GP practices. Assuming 25% of these GP practices will engage, we will contact all GP practices in England spread across 135 Clinical Commissioning Groups.

TRIAL STATUS

Protocol version 2.0, dated 13 January 2021. Implementation is ongoing. The implementation period started on 10 November 2020 and will end on 10 March 2021.

TRIAL REGISTRATION

This trial was registered in the ISRCTN registry ( isrctn.com/ ISRCTN14602359 ) on 12 August 2020.

FULL PROTOCOL

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.