Lauren Copeland

Background: Poor sexual health, dating and relationship violence and sexual harassment pose significant public health concerns, especially for young people. There is potential for short- and long-term adverse medical, social, educational and economic outcomes. Objective: To optimise the intervention materials and examine the acceptability of implementing, trialling and estimating the cost of the Sexual health and healthy relationships for Further Education (SaFE) intervention, including an assessment of the feasibility of record linkage and a health economic analysis. Design and methods: Optimisation of intervention materials followed by two-arm repeated cross-sectional pilot cluster randomised controlled trial of the SaFE intervention compared to usual practice, including a process evaluation and a health economic assessment. Setting and participants: Optimisation took place using an iterative process with a series of key stakeholders. The pilot cluster randomised controlled trial took place in eight Further Education settings in South Wales and the West of England, United Kingdom. Participants included Further Education students and staff, and sexual health nurses. Intervention: The SaFE intervention had three components: (1) onsite access to sexual health and relationship services provided by sexual health nurses available for 2 hours, 2 days per week; (2) publicity about these services; and (3) Further Education staff training on how to promote sexual health, and recognise, prevent and respond to dating and relationship violence and sexual harassment. Main outcome measures: The primary outcome was feasibility, assessing whether the study met progression criteria relating to: (1) Further Education setting and student recruitment; (2) the acceptability of the intervention; and (3) qualitative data and documentary evidence from students, staff and sexual health nurses on acceptability, fidelity of implementation and receipt. We also assessed the completeness of primary, secondary and intermediate outcome measures and estimated cost of the intervention. Results: Three of the four progression criteria were met. Eight Further Education settings were recruited, randomised and retained. Of students approached, 60.7% (1124/1852) at baseline and 51.9% (1139/2193) at 12-month follow-up completed the questionnaire (target 60%). Over 80% of onsite sexual health services were attended by a nurse; onsite publicity about sexual health services was observed at all intervention settings; and 137 staff were trained. The SaFE intervention was viewed positively by students, staff and nurses but needed more time to embed. The prevalence of self-reported unprotected sex at last intercourse was 15.5% at baseline and 18.7% at follow-up. There was evidence of floor effects in the measure of dating and relationship violence victimisation in the last 12 months. We found low rates of missing data for almost all variables with no discernible differences across arms. Around a quarter of participants at baseline and follow-up said they were not at all, or not very comfortable providing consent to link to their routine health records. The estimated cost per Further Education setting was £38,363.09. Limitations: Coronavirus disease discovered in 2019 pandemic restrictions at Further Education settings meant the intervention was not implemented for as long as planned (up to 23 weeks vs. 39 weeks). Conclusions: Overall the SaFE intervention was implemented and well received by students, staff and nurses. Future work: If strategies to boost student recruitment to the survey can be identified and implemented, progression to a Phase III effectiveness trial of the SaFE intervention is warranted. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/149/12.

Objectives: Community sites, including schools, are important settings for interventions to promote children and young people’s mental health and wellbeing. A central provision to support mental health in the UK is school- and community-based counselling services. However, the evidence-base for school counselling services is limited by weak evaluation designs, lack of understanding of different counselling approaches in use, and a failure to conceptualise counselling services as part of a wider complex system. To address the last point, this article takes a complex system-focused perspective to explore how a ‘system disruption’, that is counselling service implementation, can be optimised in the Welsh education system. Design: The approach used in this study is a mixed-method qualitative design. Setting: Participants were recruited from school and community settings. They included children and young people, parents, carers, school staff, counsellors and stakeholders from health and education. Method: Consultations, key system stakeholder interviews and school case studies were conducted. All stakeholders were asked about their experiences of local authority-funded school- and community-based counselling services in Wales. Interview and consultation data were analysed using a thematic analysis approach. Results: Data converged into three main themes focusing on the specifics of counselling sessions, counselling services as part of universal mental health provision and a whole education system approach. These three themes are brought together into a complex systems-focused model of an optimised school- and community-based counselling service. Conclusion: The model offers an opportunity to address issues with current counselling services in Wales and improve outcomes and sustainability by increasing the likelihood they will become embedded in the whole education system.

Introduction: Provision of school‐ and community‐based counselling services differs in terms of funding, implementation and eligibility criteria across the UK. The existing evidence of the effectiveness of counselling services is mixed, with little consideration of service context, implementation or acceptability. This rapid review seeks to address the gaps in the extant evidence syntheses by exploring the effectiveness, implementation and acceptability of school‐ and community‐based counselling services in the UK.Methods: A systematic literature search was conducted in five electronic databases. Grey literature searches were conducted in 23 national government and third‐sector organisational websites. The searches focussed on studies examining counselling interventions aimed at children aged 7–18 years that examined either effectiveness, implementation, acceptability or context.Results: Fifty‐four studies were included in the review. The few RCT studies suggest that there is no clear evidence of effectiveness of the therapeutic approach, due to mixed findings. There is some tentative evidence for weaker study designs that counselling may have positive impacts across different settings. The service is highly valued by learners, teachers and parents and is believed to improve well‐being; however, it is often seen as a discrete service that is not well‐embedded within the education system.Conclusions: There is mixed evidence for the effectiveness of school‐ and community‐based counselling. However, this needs to be understood in the context of acceptability and implementation. Future work is needed to improve the implementation of services by considering the wider complexity of the systems in which these services are embedded.

Objectives Research on the adaptation of population health interventions for implementation in new contexts is rapidly expanding. This has been accompanied by a recent increase in the number of frameworks and guidance to support adaptation processes. Nevertheless, there remains limited exploration of the real-world experiences of undertaking intervention adaptation, notably the challenges encountered by different groups of stakeholders, and how these are managed. Understanding experiences is imperative in ensuring that guidance to support adaptation has practical utility. This qualitative study examines researcher and stakeholder experiences of funding, conducting and reporting adaptation research. Setting Adaptation studies. Participants Participants/cases were purposefully sampled to represent a range of adapted interventions, types of evaluations, expertise and countries. Semistructured interviews were conducted with a sample of researchers (n=23), representatives from research funding panels (n=6), journal editors (n=5) and practitioners (n=3). Measures A case study research design was used. Data were analysed using the framework approach. Overarching themes were discussed within the study team, with further iterative refinement of subthemes. Results The results generated four central themes. The first three relate to the experience of intervention adaptation (1) involving stakeholders throughout the adaptation process and how to integrate the evidence base with experience; (2) selecting the intervention and negotiating the mismatch between the original and the new context; and (3) the complexity and uncertainty when deciding the re-evaluation process. The final theme (4) reflects on participants’ experiences of using adaptation frameworks in practice, considering recommendations for future guidance development and refinement. Conclusion This study highlights the range of complexities and challenges experienced in funding, conducting and reporting research on intervention adaptation. Moving forward, guidance can be helpful in systematising processes, provided that it remains responsive to local contexts and encourage innovative practice.

Breastfeeding rates in many Global North countries are low. Qualitative research highlights that breastfeeding in public is a particular challenge, despite mothers often having the legal right to do so. To identify barriers and facilitators, we systematically searched the qualitative research from Organisation for Economic Co‐operation and Development countries relating to breastfeeding in public spaces from 2007 to 2021. Data were analysed using the Thematic Synthesis technique. The review was registered with PROSPERO (registration number: CRD42017081504). Database searching identified 3570 unique records. In total, 74 papers, theses, or book chapters, relating to 71 studies, were included, accounting for over 17,000 mothers. Overall, data quality was high. Our analysis identified that five core factors influenced mothers' thought processes and their breastfeeding in public behaviour: legal system; structural (in)equality; knowledge; beliefs and the social environment. Macro‐level factors relating to legislation and inequality urgently require redress if breastfeeding rates are to be increased. Widespread culture change is also required to enhance knowledge, change hostile beliefs and thus the social environment in which mother/infant dyads exist. In particular, the sexualisation of breasts, disgust narratives and lack of exposure among observers to baby‐led infant feeding patterns resulted in beliefs which created a stigmatising environment. In this context, many mothers felt unable to breastfeed in public; those who breastfed outside the home were usually highly self‐aware, attempting to reduce their exposure to conflict. Evidence‐based theoretically informed interventions to remove barriers to breastfeeding in public are urgently required.

Background: Teachers are at heightened risk of poor mental health and well-being, which is likely to impact on the support they provide to students, and student outcomes. We conducted a cluster randomised controlled trial, to test whether an intervention to improve mental health support and training for high school teachers led to improved mental health and well-being for teachers and students, compared to usual practice. We also conducted a cost evaluation of the intervention. Methods and findings: The intervention comprised (i) Mental Health First Aid training for teachers to support students; (ii) a mental health awareness session; and (iii) a confidential staff peer support service. In total 25 mainstream, non-fee-paying secondary schools stratified by geographical area and free school meal entitlement were randomly allocated to intervention (n = 12) or control group (n = 13) after collection of baseline measures. We analysed data using mixed-effects repeated measures models in the intention-to-treat population, adjusted for stratification variables, sex, and years of experience. The primary outcome was teacher well-being (Warwick-Edinburgh Mental Well-being Scale). Secondary outcomes were teacher depression, absence, and presenteeism, and student well-being, mental health difficulties, attendance, and attainment. Follow-up was at months 12 (T1) and 24 (T2). We collected process data to test the logic model underpinning the intervention, to aid interpretation of the findings. A total of 1,722 teachers were included in the primary analysis. Teacher well-being did not differ between groups at T2 (intervention mean well-being score 47.5, control group mean well-being score 48.4, adjusted mean difference −0.90, 95% CI –2.07 to 0.27, p = 0.130). The only effect on secondary outcomes was higher teacher-reported absence among the intervention group at T2 (intervention group median number of days absent 0, control group median number of days absent 0, ratio of geometric means 1.04, 95% CI 1.00 to 1.09, p = 0.042). Process measures indicated little change in perceived mental health support, quality of relationships, and work-related stress. The average cost of the intervention was £9,103 per school. The study’s main limitations were a lack of blinding of research participants and the self-report nature of the outcome measures. Conclusions: In this study, we observed no improvements to teacher or student mental health following the intervention, possibly due to a lack of impact on key drivers of poor mental health within the school environment. Future research should focus on structural and cultural changes to the school environment, which may be more effective at improving teacher and student mental health and well-being. Trial registration: www.isrctn.com ISRCTN95909211.

Background Health and Safety Executive data show that teachers are at heightened risk of mental health difficulties, yet few studies have attempted to address this. Poor teacher mental health may impact on the quality of support provided to young people, who also report increased mental health difficulties themselves. Objective To test the effectiveness of an intervention aiming to improve secondary school teachers’ well-being through mental health support and training. Design A cluster randomised controlled trial with embedded process and economic evaluations. Setting Twenty-five mainstream, non-fee-paying secondary schools in the south-west of England and South Wales, stratified by geographical area and free school meal entitlement, randomly allocated to intervention or control groups following collection of baseline measures (n = 12, intervention; n = 13, control) between May and July 2016. Participants All teachers in the study schools at any data collection. All students in year 8 (baseline) and year 10 (final follow-up). Intervention Each intervention school received three elements: (1) a 1-day mental health first aid for schools and colleges training session delivered to 8% of all teachers; (2) a 1-hour mental health session delivered to all teachers; and (3) 8% of staff trained in the 2-day standard mental health first aid training course set up a confidential peer support service for colleagues. Control schools continued with usual practice. Main outcome measures The primary outcome was teacher well-being (using the Warwick–Edinburgh Mental Wellbeing Scale). Secondary outcomes were teacher depression, absence and presenteeism, and student well-being, mental health difficulties, attendance and attainment. Follow-up was at 12 and 24 months. Data were analysed using intention-to-treat mixed-effects repeated-measures models. Economic evaluation A cost–consequence analysis to compare the incremental cost of the intervention against the outcomes measured in the main analysis. Process evaluation A mixed-methods study (i.e. qualitative focus groups and interviews, quantitative surveys, checklists and logs) to examine intervention implementation, activation of the mechanisms of change outlined in the logic model, intervention acceptability and the wider context. Results All 25 schools remained in the study. A total of 1722 teachers were included in the primary analysis. We found no difference in mean teacher well-being between study arms over the course of follow-up (adjusted mean difference –0.90, 95% confidence interval –2.07 to 0.27). There was also no difference in any of the secondary outcomes (p-values 0.203–0.964 in the fully adjusted models). The average cost of the intervention was £9103 (range £5378.97–12,026.73) per intervention school, with the average cost to Welsh schools being higher because of a different delivery model. The training components were delivered with high fidelity, although target dosage was sometimes missed. The peer support service was delivered with variable fidelity, and reported usage by teachers was low (5.9–6.1%). The intervention had high acceptability, but participants reported low support from senior leadership, and minimal impact on school culture. Limitations Participants and the study team were unblinded, self-report for the main outcome measures and inaccurate measurement of peer support service usage. Conclusions The Wellbeing in Secondary Education (WISE) intervention was not effective at improving teacher or student well-being, or reducing mental health difficulties, possibly because of contextual barriers preventing it becoming embedded in school life. Future work Identification of ways in which to achieve system-level change and sustained support from senior leaders is important for future school-based mental health interventions. Trial registration Current Controlled Trials ISRCTN95909211. Funding This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information. Intervention costs were met by Public Health Wales, Public Health England and Bristol City Council.

Background: The adaptation of interventions for new contexts is a rapidly developing research area. To date there is no consensus-based guidance to support decision-making and recommend adaptation processes. The ADAPT study is developing such guidance. This aim of the qualitative component of the study was to explore stakeholders’ understandings of adaptation, as to date there has limited consideration of how different concepts and meanings shape decision-making and practice. Methods: A case study research design was used. Participants/cases were purposefully sampled based on study outcome, study design, expertise, context and country. Semi-structured interviews were conducted with a sample of researchers (n = 23); representatives from research funding panels (n = 6); journal editors (n = 5) and practitioners (n = 3). Data were analysed using the Framework approach. Overarching themes were discussed with the ADAPT study team, with further iterative refinement of subthemes. Results: The results generated four central themes. Four themes related to stakeholders’ understanding: 1) definitions of adaptation and related concepts; 2) rationales for undertaking adaptation; 3) the appropriate timing for adaptation; and 4) ensuring fidelity when implementing adapted interventions. Conclusion: The findings highlight the lack of clarity around key concepts and uncertainty about central decision-making processes, notably why interventions should be adapted, when and to what extent. This has informed the ADAPT study’s guidance, shaping the scope and nature of recommendations to be included and surfacing key uncertainties that require future consideration.

Background: Knowledge of the prevalence of morbidity secondary to stroke is important for health care professionals, health care commissioners, third sector organizations, and stroke survivors to understand the likely progress of poststroke sequelae and to aid in commissioning decisions, planning care, and adjusting to life after stroke. Objective: The primary aim of the Morbidity PRevalence Estimate In StrokE (MORe PREcISE) study is to determine the prevalence of morbidity secondary to a stroke, predictors of morbidity, and trends in quality of life and functional status using patient-reported outcomes, cognitive and functional assessments. Methods: A total of 500 participants will be recruited across Wales and England within 14 days following an admission to a stroke unit for either an ischemic or hemorrhagic stroke as part of a multicenter cohort study. Participants are assessed at baseline <= 14 days poststroke and subsequently at 90 (+/- 14) days and 180 (+/- 14) days poststroke. At each time point, data will be collected relating to the following domains: participant demographics, routine clinical, patient reported, cognitive status, emotional well-being, and functional ability. Results: Recruitment commenced in October 2018 with 20 sites opened as of September 2019 and was closed on October 31, 2019. Conclusions: The primary outcome is the prevalence of morbidity at 6 months secondary to a stroke. Further analysis will consider temporal changes in the health-related domains to describe trends among baseline, 3-, and 6-month time points.

Background: This study examines primary schoolchildren’s perceptions of e-cigarettes and tobacco cigarettes, and associations with parental smoking, vaping and socioeconomic status. Methods: Survey of 2218 10–11-year-old children in 73 schools in Wales. Results: Overall, 36% reported that a parent figure smoked compared to 21% for vaping, with parental smoking lower in affluent families (OR = 0.72; 95% CI = 0.68 to 0.76). Overall, 1% had tried a cigarette, while 5% had tried an e-cigarette. Most said they would not smoke or vape in 2 years’ time; susceptibility to vaping (20%) was higher than smoking (12%). Exposure to and perceptions of tobacco cigarettes were more positive for children of smokers. Having a parent who vaped was associated with exposure to and positive perceptions of e-cigarettes, but not smoking. Most children perceived e-cigarettes as used by adults to stop smoking (64%). Susceptibility to smoking (OR = 0.57; 95% CI = 0.41 to 0.79) and vaping (OR = 0.78; 95% CI = 0.62 to 0.99) were lower among children who perceived e-cigarettes as cessation aids. Conclusions: Parental smoking continues to be concentrated in poorer families. This study provides no evidence that parental vaping in the absence of smoking is associated with more positive perceptions of tobacco cigarettes. Communicating to children the role of e-cigarettes as cessation devices for smokers may help to limit their appeal to young people.