Consumption of energy drinks by children and young people: a systematic review examining evidence of physical effects and consumer attitudes

OBJECTIVE

To update an earlier review, published in 2016, on the health and other outcomes associated with children and young people's consumption of energy drinks (EDs).

STUDY DESIGN

Review article.

SYSTEMATIC REVIEW

Systematic searches of nine databases (ASSIA, CINAHL, Cochrane Library, DARE, Embase, ERIC, MEDLINE, PsycINFO and Web of Science) retrieved original articles reporting the effects of EDs experienced by children and young people up to the age of 21 years. Searches were restricted by publication dates (January 2016 to July 2022) and language (English). Studies assessed as being weak were excluded from the review. Included studies underwent narrative synthesis.

RESULTS

A total of 57 studies were included. Boys consumed EDs more than girls. Many studies reported a strong positive association between ED consumption and smoking, alcohol use, binge drinking, other substance use and the intentions to initiate these behaviours. Sensation-seeking and delinquent behaviours were positively associated with ED consumption, as were short sleep duration, poor sleep quality and low academic performance. Additional health effects noted in the updated review included increased risk of suicide, psychological distress, attention-deficit hyperactivity disorder symptoms, depressive and panic behaviours, allergic diseases, insulin resistance, dental caries and erosive tooth wear.

CONCLUSIONS

This review adds to the growing evidence that ED consumption by children and young people is associated with numerous adverse physical and mental health outcomes. Where feasible and ethical, additional longitudinal studies are required to ascertain causality. The precautionary principle should be considered in regulatory policy and restriction of ED sales to this population.

PROSPERO REGISTRATION

CRD42021255484.

'How I'm feeling today, I probably won't be feeling tomorrow'. Using I-Poems to explore young people's changing emotions during the Covid-19 pandemic - A qualitative, longitudinal study

Background

Relatively little published qualitative research has explored children and young people's (CYP) prolonged or longitudinal experiences of the pandemic, and their emotional responses to such unreserved change to everyday life. As part of a broader, qualitative longitudinal study, this paper explores change and continuity in young people's emotions over time during the Covid-19 pandemic in North East England.

Methods

I-Poems were curated for each of the 26 young people in this study from serial interview transcripts and diary entries, collected over the course of 16 months. Creation of I-Poems require researchers to focus on sentences made by the interviewee that include the word "I," and without changing the order of those sentences, to present them in poetic stanzas.

Findings

Young people's voices and experiences became more poignant and powerful when their 'I' narrative was centralised, silencing the presence of the researcher. Further, presenting the data in this way allowed us to see how the following emotions shifted over time: grief, sadness, frustration, anger, anxiety, joy, pleasure, excitement. We contend that young people experienced significant rupture and change over the course of our 16 month project, with both positive and negative repercussions for their emotional wellbeing.

Conclusions

Large scale (quantitative and qualitative) studies remain much needed to focus on the long-term impacts of the pandemic on young people's social, emotional and cultural lives. Longitudinal and creative qualitative approaches (such as I-Poems) have the potential to centralise participant voice, break down power dynamics, and allow exploration of shifting experiences and emotions over time.

Systematic review of facilitators and barriers to community pharmacists’ role in licit opioid misuse prevention

Introduction

The prescribing rate of Opioids is increasing and is perceived as main contributor to opioid misuse.1,2 Community pharmacists can help reduce opioid misuse rates by carrying out licit opioid misuse prevention services.3 Understanding and reviewing the barriers and facilitators to community pharmacists’ involvement in the prevention of licit (over-the-counter and prescription) opioid misuse prevention services have the potential to significantly improve these services.

Aim

To identify, collate and synthesise existing evidence of stakeholders’ views regarding barriers and facilitators to community pharmacists’ role in licit opioid misuse.

Methods

A systematic review of original studies was carried out in MEDLINE, Embase, Scopus, Web of Science, CINAHL, and APA PsycINFO using search terms for community pharmacy, opioid misuse interventions and opioid misuse. Titles, abstract and full text were independently reviewed by two researchers and consensus on eligibility of included studies was reached. Studies were included if they were: either qualitative or mixed methods studies of community pharmacy and licit opioid misuse; published in English; either over-the-counter or prescription opioids. Quantitative, non-English studies; and studies on illicit opioids were excluded. Narrative synthesis was carried out by: developing a theory of change model, data extraction and thematic analysis, discussing relationship and robustness of studies. Quality assessment was carried out by the Joanna Briggs Institute critical appraisal checklist. Ethical approval was obtained from Newcastle University Faculty of Medical Sciences Research ethics committee.

Results

A total of 1,234 articles were retrieved from all database searches. After deduplication, title, abstract screening and data extraction, 10 studies were included. Barriers and facilitators identified are knowledge and skill, pharmacists’ attitude, relationship with prescribers, time, number of support staff, remuneration of service, scheduling of over-the-counter opioids, corporate pharmacy support, private counseling room and electronic programmes. The factors grouped as: capabilities are knowledge and skill; opportunities include relationship with prescribers, time, number of support staff, remuneration of services, scheduling of over-the-counter opioids, corporate pharmacy support, private counseling room and electronic programmes while motivation was Pharmacists’ attitude.

Discussion/Conclusion

Overall, Study opines that: (1) improving capabilities and opportunities will improve motivation of the Community Pharmacists; (2) improved motivation of Community Pharmacists will improve their involvement in the prevention of licit opioids misuse. (3) Improved capability could be achieved by implementation of policies that focus on: improving opioid misuse education at the undergraduate level and routine training of community pharmacists; while (4) improved opportunity could be achieved by implementing integrated pharmacy care model (a health system in which community pharmacists and prescribers collaborate), increased number of pharmacy support staff, remuneration for service, upscheduling of OTC opioids, pharmacy managers’ support, modifying the community pharmacy setting to include a private consultation area and efficient electronic systems. Findings of this study may not be generalized to developing countries because majority of the studies included in the review were carried out in developed countries. However, implementation of these factors (by policy makers, pharmacy managers) will improve community pharmacists’ attitude towards the provision of licit opioid misuse prevention services resulting in improved community pharmacists’ involvement in these services.

References

1. Davies E, Phillips C, Rance J, Sewell B. Examining patterns in opioid prescribing for non-cancer-related pain in Wales: preliminary data from a retrospective cross-sectional study using large datasets. British Journal of Pain. 2019;13(3):145-58.

2. Jani M, Birlie Yimer B, Sheppard T, Lunt M, Dixon WG. Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: A retrospective cohort study. PLoS Medicine. 2020;17(10):e1003270.

3. Society RP. Improving care, reducing harm and preventing death in people who use drugs: pharmacy's role 2021. Available from: https://www.rpharms.com/recognition/all-our-campaigns/policy-a-z/drug-deaths-and-the-role-of-the-pharmacy-team

Building capacity for mental health resilience – local impact of the UK Better Mental Health Fund

Background

COVID-19 as a public mental health emergency has exacerbated existing mental health inequalities. The UK government invited local authorities with areas of high deprivation to apply for a year of funding, in order to address the mental health impacts of COVID-19 and incentivize investment in prevention and promotion interventions for better mental health. South Tyneside Council in North East England made a successful bid to the Better Mental Health Fund (BMHF), and distributed grants to 7 organisations delivering 13 programs. A qualitative evaluation of these programs aimed to answer the following questions:

1. How were the funded programs implemented?

2. What difference did they make to local beneficiaries?

3. How might these programs and their impacts be sustained into the future?

4. Has the BMHF led to any wider impacts on organisations and local communities?

Methods

In-depth interviews with individuals, pairs and groups were conducted online or in person with service providers and beneficiaries. Non-verbatim transcripts were made from recordings, checked with verbatim transcripts from Teams and Zoom, and analyzed thematically to generate a coding frame. Throughout the analysis, comparisons were made between organizations and programs.

Results

Fifteen interviews involving 22 participants lasting up to an hour each were conducted. The main themes identified as impactful were 1) community approaches based on supportive and good relationships between the local authority public health lead and participating organizations (mainly voluntary agencies), enabling 2) capacity-building for mental health resilience and 3) community empowerment. This was despite the short turnaround of the grant application process, limited time to deliver on targets, and anxieties about future sustainability.

Conclusions

Short-term funding can build capacity in mental health resilience in deprived areas if administered by public health leaders who relate well with provider organizations.

Key messages

• Public health leaders who relate well with provider organizations are key drivers of community health promotion strategies that include mental health capacity building.

• Qualitative methods used in evaluations can inform public health commissioning by capturing the benefits and challenges of short-term funding for interventions promoting community mental health.

Gateways not gatekeepers – reaching seldom-heard groups to gather public health community insights

Background

Each local authority in England must develop a Health and Wellbeing Strategy (HWS) in collaboration with NHS partners to plan and support delivery of local improvements in health and wellbeing. HWSs often draw on diverse sources but few are informed by consultative exercises involving citizens. South Tyneside Council in Northern England sought to ensure their new HWS was community-informed, specifically including seldom-heard groups and individuals. Specific objectives of this community insights research were to:

1.Target sampling and recruitment activities at typically marginalized, vulnerable or otherwise underrepresented groups

2.Explore the health and wellbeing-related views and priorities of these groups to address health inequalities

Methods

A mapping exercise was undertaken to identify organisations who might act as gatekeepers to accessing participants from underrepresented groups. Focus groups were held in settings-based venues where members would be comfortable and known to one another. Representatives of voluntary and community sector (VCS) organisations often helped to co-facilitate the discussions.

Results

119 participants took part in 16 group discussions. Three were held online, two were outdoors, while 11 involved community venues where the groups regularly met. We reached older and younger people, minority ethnic groups, and vulnerable men and women, including residents who had experienced homelessness, mental health issues, substance misuse, offending, domestic violence and learning disabilities. Participants were largely concerned with the wider determinants of health (such as poverty, employment, and leisure spaces), shifting the narrative away from individual lifestyle factors that tend to be the focus of much public health discourse.

Conclusions

Gatekeepers from the VCS were essentially gateways, enabling us to include underrepresented voices in local consultation processes and generate new insights to inform the South Tyneside HWS.

Key messages

Evaluation of an Educational Outreach Campaign (IMPACT) on Pain Management Delivered to General Practices in Walsall

Introduction

Opioid class drugs are a commonly prescribed form of analgesic widely used in the treatment of acute, cancer and chronic non-cancer pain. Up to 90% of individuals presenting to pain centres receive opioids, with doctors in the UK prescribing more and stronger opioids (1). Concern is increasing that patients with chronic pain are inappropriately being moved up the WHO ‘analgesic ladder’, originally developed for cancer pain, without considering alternatives to medications, (2). UK guidelines on chronic non-cancer pain management recommend weak opioids as a second-line treatment, when the first-line non-steroidal anti-inflammatory drugs / paracetamol) ineffective, and for short-term use only. A UK educational outreach programme by the name IMPACT (Improving Medicines and Polypharmacy Appropriateness Clinical Tool) was conducted on pain management. This research evaluated the IMPACT campaign, analysing the educational impact on the prescribing of morphine, tramadol and other high-cost opioids, in the Walsall CCG.

Methods

Standardised training material was delivered to 50 practices between December 2018 and June 2019 by IMPACT pharmacists. The training included a presentation on pain control, including dissemination of local and national guidelines, management of neuropathic, low back pain and sciatica as well as advice for prescribers on prescribing opioids in long-term pain, with the evidence-base. Prescribing trends in primary care were also covered in the training, and clinicians were provided with resources to use in their practice. Data analysis included reviewing prescribing data and evaluating the educational intervention using feedback from participants gathered via anonymous questionnaires administered at the end of the training. Prescribing data analysis was conducted by Keele University’s Medicines Management team via the ePACT 2 system covering October 2018 to September 2019 (two months before and three months after the intervention) were presented onto graphs to form comparisons in prescribing trends of the Midland CCG compared to England.

Results

Questionnaires completed at the end of sessions showed high levels of satisfaction, with feedback indicating that participants found the session well presented, successful at highlighting key messages, and effective in using evidence-based practice. 88% of participants agreed the IMPACT campaign increased their understanding of the management and assessment of pain, and prescribing of opioids and other resources available to prescribers. The majority (85%) wished to see this form of education being repeated regularly in the future for other therapeutic areas. Analysis of the prescribing data demonstrated that the total volume of opioid analgesics decreased by 1.7% post-intervention in the Midlands CCG in response to the pharmacist-led educational intervention. As supported by literature, the use of educational strategies, including material dissemination and reminders as well as group educational outreach was effective in engaging clinicians, as demonstrated by the reduction in opioid prescribing and high GP satisfaction in this campaign.

Conclusion

The IMPACT campaign was effective at disseminating pain-specific guidelines for opioid prescribing to clinicians, leading to a decrease in overall prescribing of opioid analgesics. Educational outreach as an approach is practical and a valuable means to improve prescribing by continuing medical education.

References

1. Els, C., Jackson, T., Kunyk, D., Lappi, V., Sonnenberg, B., Hagtvedt, R., Sharma, S., Kolahdooz, F. and Straube, S. (2017). Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews. This provided the statistic of percentage receiving opioids that present to pain centres.

2. Heit, H. (2010). Tackling the Difficult Problem of Prescription Opioid Misuse. Annals of Internal Medicine, 152(11), p.747. Issues with prescriptions and inappropriate moving up the WHO ladder.

What is the role of community fridges in the UK? An exploratory mixed methods study

Background

More than one-quarter of the world's population is experiencing severe or moderate food insecurity, yet one-third of all food produced is lost or wasted. In response to this paradox, countries such as Spain, Germany and the UK have introduced community fridges: 'a public space where organisations and households can make perishable foods that would have been wasted available to the community'. The UK is home to the world's first national community fridge network, comprising 90 operational fridges that have so far redistributed 780 tonnes of surplus food. Other fridges exist outside of this network but little is known about what they do or who they serve. The objective of this study was to explore the role of community fridges in the UK.

Methods

A mixed methods approach was used, involving an online survey of community fridge organisers and telephone interviews with a purposively selected sample of respondents. The survey was piloted before being distributed via email and social media. Forty-seven responses were received from individuals representing 42 community fridges, and in-depth interviews were conducted with eight respondents. Data were analysed using thematic analysis.

Results

Three main roles fulfilled by community fridges were identified: reducing food waste; helping those in need; and building a sense of community. Some participants were reluctant to describe their work as being linked to food insecurity, citing the potential for stigmatisation. Others indicated that their primary goal was to tackle hunger in a non-stigmatising way, by providing free access to nutritious foods. A minor theme involved creating opportunities to build community cohesion.

Conclusions

Community fridges may form part of efforts to reduce food waste and tackle growing levels of food insecurity in the UK. This is an area ripe further for research, given the potential to promote sharing and social cohesion but also the risks in terms of stigma, hygiene and food safety.

Key messages

The UK is home to the world's first national community fridge network, but little is currently known about what these fridges do or who they serve. Community fridges have a role in reducing food waste, addressing food insecurity and building community cohesion, although stigma remains a concern.

Breastfeeding-related social media: an online survey of UK mothers’ perceptions

Background

Breastfeeding is beneficial for both maternal and infant health, contributing to reduced risk of infections and chronic disease. Despite public health efforts, just 1% of mother-infant dyads in the UK meet international recommendations to breastfeed exclusively until six months. Numerous studies have investigated the influences on suboptimal breastfeeding rates, exposing a myriad of interconnected physiological, psychological and social barriers. Conversely, social support has been shown to be positively associated with breastfeeding duration. The objective of this study was to determine whether and how UK mothers use social media to access breastfeeding advice and support.

Methods

An online survey was developed, piloted and distributed via social media using a snowball sampling approach. Responses to closed questions were analysed using SPSS and appropriate statistical tests performed. Free-text responses were analysed manually using thematic analysis.

Results

The survey was completed by 1012 mothers, with 992 (98%) reporting use of social media for breastfeeding advice and/or support. Responses revealed a largely positive perception of breastfeeding-related social media. Supportive peer networks and easily accessible information were highlighted as unique features that help to encourage and normalise breastfeeding. Non-university educated mothers were significantly more likely to report this support as “very influential” with regard to how comfortable they felt breastfeeding in public (p = 0.006). Peer-led groups were preferentially used over professional-led groups, particularly by younger women (p = 0.007).

Conclusions

There is growing interest in social media as a health platform, particularly in light of recent funding cuts impacting on access to formal support services. By supporting mothers and normalising breastfeeding, social media may help to increase UK breastfeeding rates and reduce health inequalities.

Key messages

Many mothers successfully use breastfeeding-related social media for information and support, with a preference for peer-led as opposed to professional-led groups. Future research should explore how public health services can update their practice to better harness these platforms for breastfeeding promotion.

Energy drink consumption pattern among university students in North East England

Background

Energy drinks (EDs) are popular beverages with young people, particularly in the UK. There is an emerging evidence base on the negative health impacts in children and adolescents, largely relating to the high caffeine and sugar contents of these drinks. However, no studies have been conducted to date focusing on university students in the UK. The purpose of this study was to investigate factors underpinning ED consumption, as well as health effects reported by students.

Methods

An online survey was conducted with a non-representative sample of 900 students from the five universities in the North East of England. This included questions on ED consumption, perceived stress (10-item PSS), general health status, personal wellbeing (ONS4), lifestyle and use of other substances such as alcohol. Responses were analysed using SPSS.

Results

84% of respondents (n = 756) had consumed EDs at least once, mainly while partying or during revision. Of these ED consumers, 542 (71.7%) reported experiencing symptoms following intake, with the most common being elevation of heart rate and palpitations. No associations were found between ED consumption and perceived stress or wellbeing, but an inverse U-shaped association was observed with self-reported health (i.e. lowest consumption among those who rated their health as either “very good” or “bad”). Consumers were more likely to be male, White, from the UK, less affluent backgrounds, and report having no religion. Co-consumption with alcohol was common in the cohort (46.2%). Those who used substances such as cigarettes, e-cigarettes and cannabis were also more likely to be ED consumers.

Conclusions

ED consumption is highly prevalent in the student population, linked to socioeconomic and cultural factors rather than perceived stress or wellbeing. Prevention campaigns targeting students should aim to raise awareness of the consequences of chronic and acute ED consumption, particularly in conjunction with other substances.

Key messages

ED consumption is highly prevalent in the student population, often in conjunction with alcohol. Consumption is linked to socioeconomic and cultural factors rather than perceived stress or personal wellbeing.

Capacity for evidence-informed policymaking across Europe: development and piloting of a multistakeholder survey

OBJECTIVES

Evidence-informed policymaking (EIP) is increasingly viewed as a complex endeavour that requires integration of research evidence with available resources and the preferences of those affected by the policy. The first technical expert meeting to enhance EIP in the World Health Organization (WHO) European Region identified the scope to develop and conduct a survey to gather insights into the generation, translation and application of research evidence across the region. This article describes the process of developing and piloting a multistakeholder survey (promoted and technically supported by WHO/Europe) on the topic of capacity for EIP.

STUDY DESIGN

Rapid review and pilot cross-sectional survey.

METHODS

A survey instrument was developed based on findings from the published literature and refined with input from EIP experts/champions. The online survey was then piloted using various recruitment strategies designed to maximise its reach among the key target groups (senior researchers, knowledge brokers and members of civil society).

RESULTS

The rapid review revealed a clear gap in the evidence base in relation to broader surveys of capacity for EIP, as opposed to evidence-based practice at an individual level. Thirteen responses to the pilot survey were received from individuals in 10 European countries. Reported barriers to EIP included a lack of understanding among policymakers and a lack of interaction with researchers. There were examples of efforts to enhance capacity for EIP, both at region or country level and through membership of international networks and collaborations. However, few examples were given of the application and impact of research evidence on the policymaking process.

CONCLUSION

This research has demonstrated the feasibility of developing and piloting a multicountry, multistakeholder survey to generate better understanding of evidence use in health policymaking. Next steps include incorporating the lessons learned into a revised version of the survey to be implemented with all 53 WHO/Europe Member States.

'It is not a quick fix' structural and contextual issues that affect implementation of integrated health and well-being services: a qualitative study from North East England

OBJECTIVE

The objective of this article is to examine the factors affecting the design, commissioning and delivery of integrated health and well-being services (IHWSs), which seek to address multiple health-related behaviours, improve well-being and tackle health inequalities using holistic approaches.

STUDY DESIGN

Qualitative studies embedded within iterative process evaluations.

METHODS

Semi-structured interviews conducted with 16 key informants as part of two separate evaluations of IHWSs in North East England, supplemented by informal observations of service delivery. Transcripts and fieldnotes were analysed thematically.

RESULTS

The study findings identify a challenging organisational context in which to implement innovative service redesign, as a result of budget cuts and changes in NHS and local authority capacity. Pressures to demonstrate outcomes affected the ability to negotiate the practicalities of joint working. Progress is at risk of being undermined by pressures to disinvest before the long-term benefits to population health and well-being are realised. The findings raise important questions about contract management and relationships between commissioners and providers involved in implementing these new ways of working.

CONCLUSIONS

These findings provide useful learning in terms of the delivery and commissioning of similar IHWSs, contributing to understanding of the benefits and challenges of this model of working.

Can lay health trainers increase uptake of NHS Health Checks in hard-to-reach populations? A mixed-method pilot evaluation

BACKGROUND

The NHS Health Check Programme was launched in England in 2009, offering a vascular risk assessment to people aged 40-74 years without established disease. Socio-economic deprivation is associated with higher risk of cardiovascular disease and lower uptake of screening. We evaluated the potential impact of a community-based health check service that sought to address health inequalities through the involvement of lay health trainers.

METHODS

Key stakeholder discussions (n = 20), secondary analysis of client monitoring data (n = 774) and patient experience questionnaires (n = 181).

RESULTS

The health check programme was perceived as an effective way of engaging people in conversations about their health. More than half (57.6%) of clients were aged under 50 years and a similar proportion (60.5%) were from socio-economically deprived areas. Only 32.7% from the least affluent areas completed a full health check in comparison with 44.4% from more affluent areas. Eligible men were more likely than eligible women to complete a health check (59.4 versus 33.8%).

CONCLUSIONS

A community-based, health trainer-led approach may add value by offering an acceptable alternative to health checks delivered in primary care settings. The service appeared to be particularly successful in engaging men and younger age groups. However, there exists the potential for intervention-generated inequalities.

An evidence synthesis of qualitative and quantitative research on component intervention techniques, effectiveness, cost-effectiveness, equity and acceptability of different versions of health-related lifestyle advisor role in improving health

BACKGROUND

There is a need to identify and analyse the range of models developed to date for delivering health-related lifestyle advice (HRLA), or training, for effectiveness and cost-effectiveness in improving the health and well-being of individuals and communities in the UK, with particular reference to the reduction of inequalities.

OBJECTIVES

To identify the component intervention techniques of lifestyle advisors (LAs) in the UK and similar contexts, and the outcomes of HRLA interventions.

DATA SOURCES

Stakeholder views, secondary analysis of the National Survey of Health Trainer Activity, telephone survey of health trainer leads/coordinators. A search of a range of electronic databases was undertaken [including the Applied Social Sciences Index and Abstracts (ASSIA), EMBASE, NHS Economic Evaluation Database (NHS EED), MEDLINE, Psyc INFO, etc.], as well searching relevant journals and reference lists, conducted from inception to September 2008.

REVIEW METHODS

Identified studies were scanned by two reviewers and those meeting the following criteria were included: studies carrying out an evaluation of HRLA; those taking place in developed countries similar to the UK context; those looking at adult groups; interventions with the explicit aim of health improvement; interventions that involved paid or voluntary work with an individual or group of peers acting in an advisory role; advice delivered by post, online or electronically; training, support or counselling delivered to patients, communities or members of the public. After quality assessment, studies were selected for inclusion in the review. Data were abstracted from each study according to an agreed procedure and narrative, and realist and economic approaches were used to synthesise the data. Cost-effectiveness analysis of interventions was undertaken.

RESULTS

In total, 269 studies were identified but 243 were excluded. The 26 included studies addressing chronic care, mental health, breastfeeding, smoking, diet and physical activity, screening and human immunodeficiency virus (HIV) infection prevention. Overall, there was insufficient evidence to either support or refute the use of LAs to promote health and improve quality of life (QoL), and thus uncertainty about the interventions' cost-effectiveness. However, the economic analysis showed that LA interventions were cost-effective in chronic care and smoking cessation, inconclusive for breastfeeding and mental health and not cost-effective for screening uptake and diet/physical activity. LA interventions for HIV prevention were cost-effective, but not in a UK context.

LIMITATIONS

The wide variety of LA models, delivery settings and target populations prevented the reviewers from establishing firm causal relationships between intervention mode and study outcomes.

CONCLUSIONS

Evidence was variable, giving only limited support to LAs having a positive impact on health knowledge, behaviours and outcomes. Levels of acceptability appeared to be high. LAs acted as translational agents, sometimes removing barriers to prescribed behaviour or helping to create facilitative social environments. Reporting of processes of accessing or capitalising on indigenous knowledge was limited. Ambiguity was apparent with respect to the role and impact of lay and peer characteristics of the interventions. A future programme of research on HRLA could benefit from further emphasis on identification of needs, the broadening of population focus and intervention aims, the measurement of outcomes and the reviewing of evidence.

FUNDING

This study was funded by the Health Technology Assessment programme of the National Institute for Health Research.

Sensorineural deafness, enamel abnormalities and nail abnormalities: a case report of Heimler syndrome in identical twin girls

We report monozygotic twin girls with a combination of bilateral severe sensorineural deafness diagnosed at the age of 3 years, normal primary dentition but enamel hypoplasia affecting the secondary dentition and Beau's lines and leukonychia of the nails. This constellation of findings has been previously described in three case reports as Heimler syndrome, first documented in 1991.