Antonia Marsden

Objective: People with inflammatory arthritis (InfA) frequently experience work instability, absenteeism, and reduced productivity, culminating in early job loss. This study evaluated the effectiveness and cost-effectiveness of WORKWELL job retention vocational rehabilitation (JRVR) delivered by occupational therapists, compared with a control group receiving written self-help advice. Methods: A pragmatic, multicentre randomized controlled trial was conducted across 18 UK National Health Service (NHS) Trusts. Employed adults (n = 249) with InfA experiencing moderate to severe work instability were randomized (1:1) to intervention or control groups. WORKWELL included structured work assessment, individually tailored action plans, and interventions over 2–4 months. Follow-up was at 6, 12 and 36 months. The primary outcome was measured using the Work Limitations Questionnaire-25 (WLQ-25). Analyses used linear mixed-effects regression adjusted for baseline characteristics and occupational skill level. A NHS perspective was used for the within-trial cost-effectiveness analysis. Much of the trial was affected by the COVID-19 pandemic. Results: At 12 months, there was no significant difference in WLQ-25 between groups (adjusted mean difference: −1.8; 95% CI −7.4–3.8; P = 0.53), or in most secondary outcomes at 12 or 36 months. However, absenteeism showed a relative reduction of 46% at 12 months (P = 0.08), and employment retention at 36 months was higher in the intervention (93%) than in the control group (85%). The intervention was not cost-effective from an NHS perspective. Conclusion: WORKWELL did not lead to improved work productivity compared with self-help advice. Future research should explore more flexible delivery methods, including digital tools, to support sustainable employment for people with InfA. A plain-language abstract is available in the supplementary material. Trial registration: ClinicalTrials.gov, http://clinicaltrials.gov, NCT03942783. ISRCTN Registry, ISRCTN61762297, https://doi.org/10.1186/ISRCTN61762297.

Background: Diabetes self-management education and support (DSMES) programs can improve health outcomes, but engagement is often low. “Healthy Living” is a web-based self-management program for people with type 2 diabetes, based on the “HeLP-Diabetes” intervention, which demonstrated effectiveness in a randomized controlled trial. Healthy Living was commissioned by the National Health Service in England and rolled out nationally into routine care in 2020. The program comprises web-based structured learning, unstructured articles (which users could access at any time), and tracking tools such as goal setting. It is important to assess not only the uptake of digital interventions but also the amount of time spent using the intervention and the content they engage with. There is currently limited research on the extent to which people engage with digital DSMES program content outside of a trial setting. Objective: This study aimed to investigate the overall usage and exposure to content of Healthy Living, including differences in usage/exposure by user characteristics. Methods: This study used a retrospective observational cohort study design to conduct a service evaluation of Healthy Living. Pseudonymous usage data from all people with type 2 diabetes (N=27,422) who activated a Healthy Living account between May 2020 and September 2023 were available, including (1) which program activities were accessed, (2) when activities were accessed, and (3) how long users spent on each activity. User demographic and usage information was summarized using means and SDs, medians and IQRs, or frequencies and percentages. Logistic regression evaluated the association between user demographics and usage. Results: Of the 27,422 users who activated a Healthy Living account, the mean age was 58.6 (SD 12.0) years, and the percentage of females was 56.8% (15,385/27,422). There was an even spread across deprivation quintiles. The median length of time spent on the program in total was 7.6 (IQR 0.6-27.6) minutes; 12,066 (44%) users spent 27,000 users. Given that higher usage of DSMES programs is associated with improved health outcomes in people with type 2 diabetes, further work needs to identify how to encourage increased engagement with the program.

Background/Objectives: Physical restraints and seclusion remain ethically contested interventions in psychiatric care, raising significant concerns regarding patient safety, dignity, and therapeutic impact. Despite growing international momentum towards restraint-reduction strategies, their use persists across the Eastern Mediterranean Region (EMR), an area that has been the subject of limited systematic attention. This review synthesises evidence on the knowledge, attitudes, and experiences of nurses and individuals with mental illness regarding these practices in EMR psychiatric settings. Methods: Following PRISMA 2020 guidelines (PROSPERO: CRD42023383751), we systematically searched nine electronic databases for studies published up to June 2023, supplemented by backward and forward citation searching. Multiple reviewers independently screened records against predefined eligibility criteria, with disagreements resolved through consensus. Methodological quality was assessed using Joanna Briggs Institute (JBI) Critical Appraisal tools, and reporting quality was evaluated using an adapted CROSS checklist; these two appraisal dimensions were conducted and reported independently. Findings were integrated through narrative synthesis. Results: From 4634 identified records, 19 studies conducted across 11 EMR countries met the inclusion criteria. Nursing knowledge deficits were identified across multiple settings, and attitudes towards restraint practices were predominantly negative. Individuals with mental illness consistently described restraint as humiliating, punitive, and physically distressing. Recurrent challenges identified across studies included inadequate staff training, chronic understaffing, and limited access to restraint-reduction alternatives. Conclusions: Substantial gaps in nursing knowledge and training persist across the EMR. The findings of this review, while derived predominantly from cross-sectional studies with convenience samples, suggest that evidence-based education programmes, standardised restraint-reduction policies, and patient-centred care frameworks warrant prioritisation to safeguard the rights, safety, and dignity of individuals with mental illness in this region. Longitudinal and experimental research is needed to confirm these directions and establish their effectiveness within EMR contexts.

Background/Objectives: The use of physical and mechanical restraints and seclusion in psychiatric facilities to manage violent and aggressive behaviours has long been a contentious issue, balancing patient safety with ethical considerations. With advancements in psychiatry and increased understanding of mental illness, there have been expectations that such interventions would no longer be required; however, their use persists in clinical practice. Management policies differ across countries and are largely influenced by legal frameworks. This study aimed to identify the factors influencing the incidence of these interventions across two psychiatric facilities in Saudi Arabia and to examine associations among inpatient variables. Methods: A prospective cohort study was conducted over six months (September 2021–March 2022) across two psychiatric facilities in Saudi Arabia (Eradah Complex, n = 1120; King Fahd University Hospital (KFUH), n = 268). Data from 333 restriction events were analysed using descriptive statistics, chi-square tests, and negative binomial regression to calculate incidence rates and explore associated factors. Results: The findings revealed a complex interplay of factors related to patient characteristics and clinical and environmental conditions within the facilities. Key contributing variables included symptom deterioration and the duration of observation required. Longer observation periods were associated with certain diagnoses, particularly schizophrenia and mood disorders. Conclusions: Restraints and seclusion remain influenced by multiple interacting factors within psychiatric settings. These findings highlight the need to reduce their use and ensure they are applied cautiously, with greater emphasis on minimising patient trauma and promoting safer, person-centred care.

BACKGROUND Diabetes self-management education and support (DSMES) programs can improve health outcomes, but engagement is often low. “Healthy Living” is a web-based self-management program for people with type 2 diabetes, based on the “HeLP-Diabetes” intervention, which demonstrated effectiveness in a randomized controlled trial. Healthy Living was commissioned by the National Health Service in England and rolled out nationally into routine care in 2020. The program comprises web-based structured learning, unstructured articles (which users could access at any time), and tracking tools such as goal setting. It is important to assess not only the uptake of digital interventions but also the amount of time spent using the intervention and the content they engage with. There is currently limited research on the extent to which people engage with digital DSMES program content outside of a trial setting. OBJECTIVE This study aimed to investigate the overall usage and exposure to content of Healthy Living, including differences in usage/exposure by user characteristics. METHODS This study used a retrospective observational cohort study design to conduct a service evaluation of Healthy Living. Pseudonymous usage data from all people with type 2 diabetes (N=27,422) who activated a Healthy Living account between May 2020 and September 2023 were available, including (1) which program activities were accessed, (2) when activities were accessed, and (3) how long users spent on each activity. User demographic and usage information was summarized using means and SDs, medians and IQRs, or frequencies and percentages. Logistic regression evaluated the association between user demographics and usage. RESULTS Of the 27,422 users who activated a Healthy Living account, the mean age was 58.6 (SD 12.0) years, and the percentage of females was 56.8% (15,385/27,422). There was an even spread across deprivation quintiles. The median length of time spent on the program in total was 7.6 (IQR 0.6-27.6) minutes; 12,066 (44%) users spent 27,000 users. Given that higher usage of DSMES programs is associated with improved health outcomes in people with type 2 diabetes, further work needs to identify how to encourage increased engagement with the program. CLINICALTRIAL

Background: Type 2 diabetes is considered a critical challenge to modern healthcare systems. The National Health Service Diabetes Prevention Programme delivered an evidence-based behaviour change programme at a national scale to reduce the incidence of type 2 diabetes in England. Objective(s): The Diabetes Prevention – Long-term Multimethod Assessment research programme provided a comprehensive assessment of the delivery of the National Health Service Diabetes Prevention Programme and its effectiveness and cost-effectiveness. Design: Mixed-methods research including qualitative methods, observations, patient surveys and secondary analysis of administrative and survey data using statistical and econometric methods. Setting: Community settings in England delivering the commissioned intervention, supported by general practices responsible for recruitment and referral. Participants: Patients in community settings identified as being at high risk of type 2 diabetes offered and participating in the National Health Service Diabetes Prevention Programme, and staff involved in the organisation and delivery of the service. Interventions: The National Health Service Diabetes Prevention Programme, including its evidence-based behaviour change intervention (using both face-to-face and digital platforms) and the associated services for patient recruitment. Main outcome measures: Incidence of type 2 diabetes, cost-effectiveness, access to the programme and fidelity of intervention delivery. Data sources: Interviews with patients and staff, document analysis and observations of the National Health Service Diabetes Prevention Programme delivery, patient surveys, secondary data (including National Health Service Diabetes Prevention Programme data, national surveys and audits). Results: The National Health Service Diabetes Prevention Programme was associated with significant reductions in incidence of type 2 diabetes and was highly likely to be cost-effective. Analyses of the delivery of the programme highlighted several aspects which impacted access to the programme and the fidelity with which the behaviour change intervention was delivered. For example, uptake and adherence were influenced by participants’ psychosocial beliefs (e.g. chance of getting type 2 diabetes and whether taking part would reduce this). There were large differences between general practices in how many people they referred to the programme, with practices that offered higher-quality care for people with diabetes referring more. Variation in retention and outcomes was associated with differences in providers. Limitations: Analysis of administrative data to explore effectiveness and cost-effectiveness may be influenced by confounding. Recruitment of diverse and representative samples for surveys, interviews and observations was likely impacted by selection. Conclusions: The National Health Service Diabetes Prevention Programme is highly likely to be cost-effective. Data from Diabetes Prevention – Long-term Multimethod Assessment have been used to improve aspects of programme delivery and could suggest further enhancements to improve recruitment, retention and fidelity. Future work: Future research should address the question of whether the National Health Service Diabetes Prevention Programme prevents or delays type 2 diabetes when longer-term follow-up data are available. We identified factors that could be targeted to impact on recruitment, retention and inequalities, and recommend a robust assessment of the link between fidelity and outcomes. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number 16/48/07.

Following the adaptation of a patient-reported experience measure (PREM) of "Audiology Care", based on the Consumer Quality Index (CQI), from a Dutch to a UK context, we compared patient experiences of the prescription and fitting process for first-time adult hearing aid (HA) users in two different venues affiliated to the same organisation. The adapted PREM consisted of 32 questions and 7 subscales. The PREM was posted to a group of 1821 NHS patients who had received a first HA fitting via a social enterprise within the past 12 months at either a Hospital or High Street venue. 967 (53%, 796 Hospital, 171 High Street) patients responded and were included in the study. For two out of seven subscales the mean patient ratings for the two venues showed statistically significant differences: "Accommodation and Facilities" and "Waiting Times". In both cases the differences were very small. Internal consistency of subscales ranged from 0.36-0.81 with only three subscales showing good or acceptable values: "Conduct of Employees", "Expertise of Employees" and "Arranging Appointments". This translated and adapted PREM can be a useful tool to standardise assessment and reporting of patient experiences of first-time HA users in the UK.

[This corrects the article DOI: 10.2196/49089.].

This article consists of a citation of a published article describing research funded by the Health and Social Care Delivery Research programme under project number 16/48/07, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1136/jech-2022-219654 Background: The NHS Diabetes Prevention Programme (DPP) in England is a behavioural intervention for preventing type 2 diabetes mellitus (T2DM) among people with non-diabetic hyperglycaemia (NDH). How this programme affects inequalities by age, sex, limiting illnesses or disability, ethnicity or deprivation is not known. Methods: We used multinomial and binary logistic regression models to compare whether the population with NDH at different stages of the programme are representative of the population with NDH: stages include (1) prevalence of NDH (using survey data from UK Household Longitudinal Study (n=794) and Health Survey for England (n=1383)); (2) identification in primary care and offer of programme (using administrative data from the National Diabetes Audit (n=1 267 350)) and (3) programme participation (using programme provider records (n=98024)). Results: Predicted probabilities drawn from the regressions with demographics as each outcome and dataset identifier as predictors showed that younger adults (aged under 40) (4% of the population with NDH (95% CI 2.4% to 6.5%)) and older adults (aged 80 and above) (12% (95% CI 9.5% to 14.2%)) were slightly under-represented among programme participants (2% (95% CI 1.8% to 2.2%) and 8% (95% CI 7.8% to 8.2%) of programme participants, respectively). People living in deprived areas were under-represented in eight sessions (14% (95% CI 13.7% to 14.4%) vs 20% (95% CI 16.4% to 23.6%) in the general population). Ethnic minorities were over-represented among offers (35% (95% CI 35.1% to 35.6%) vs 13% (95% CI 9.1% to 16.4%) in general population), though the proportion dropped at the programme completion stage (19% (95% CI 18.5% to 19.5%)). Conclusion: The DPP has the potential to reduce ethnic inequalities, but may widen socioeconomic, age and limiting illness or disability-related inequalities in T2DM. While ethnic minority groups are over-represented at the identification and offer stages, efforts are required to support completion of the programme. Programme providers should target under-represented groups to ensure equitable access and narrow inequalities in T2DM. Funding: This publication was funded by the Health and Social Care Delivery Research programme as a part of award number 16/48/07. DOI: https://doi.org/10.1136/jech-2022-219654 This article reports on one component of the research award Evaluating the NHS Diabetes Prevention Programme (NHS DPP): the DIPLOMA research programme (Diabetes Prevention Long term Multimethod Assessment). For more information about this research please view the award page [https://fundingawards.nihr.ac.uk/award/16/48/07]

This article consists of a citation of a published article describing research funded by the Health and Social Care Delivery Research programme under project number 16/48/07, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1186/s12913-023-10002-y Background: The National Health Service Diabetes Prevention Programme (NHS DPP) was commissioned by NHS England in 2016 and rolled out in three ‘waves’ across the whole of England. It aims to help people with raised blood glucose levels reduce their risk of developing type 2 diabetes through behaviour change techniques (e.g., weight loss, dietary changes and exercise). An independent, longitudinal, mixed methods evaluation of the NHS DPP was undertaken. We report the findings from the implementation work package: a qualitative interview study with designated local leads, responsible for the local commissioning and implementation of the programme. The aim of the study was to explore how local implementation processes were enacted and adapted over time. Methods: We conducted a telephone interview study across two time-points. Twenty-four semi-structured interviews with local leads across 19 sampled case sites were undertaken between October 2019 and January 2020 and 13 interviews with local leads across 13 sampled case sites were conducted between July 2020 and August 2020. Interviews aimed to reflect on the experience of implementation and explore how things changed over time. Results: We identified four overarching themes to show how implementation was locally enacted and adapted across the sampled case sites: 1. Adapting to provider change; 2. Identification and referral; 3. Enhancing uptake in underserved populations; and 4. Digital and remote service options. Conclusion: This paper reports how designated local leads, responsible for local implementation of the NHS DPP, adapted implementation efforts over the course of a changing national diabetes prevention programme, including how local leads adapted implementation during the COVID-19 pandemic. This paper highlights three main factors that influence implementation: the importance of facilitation, the ability (or not) to tailor interventions to local needs and the role of context in implementation. Funding: This publication was funded by the Health and Social Care Delivery Research programme as a part of award number 16/48/07. DOI: https://doi.org/10.1186/s12913-023-10002-y This article reports on one component of the research award Evaluating the NHS Diabetes Prevention Programme (NHS DPP): the DIPLOMA research programme (Diabetes Prevention Long term Multimethod Assessment). For more information about this research please view the award page [https://fundingawards.nihr.ac.uk/award/16/48/07]