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Objective: Behavioral interventions targeting "free-living" physical activity (PA) and exercise that produce long-term glycemic control in adults with type 2 diabetes are warranted. However, little is known about how clinical teams should support adults with type 2 diabetes to achieve and sustain a physically active lifestyle.Research Design and Methods: We conducted a systematic review of randomized controlled trials (RCTs) (published up to January 2012) to establish the effect of behavioral interventions (compared with usual care) on free-living PA/exercise, HbA(1c), and BMI in adults with type 2 diabetes. Study characteristics, methodological quality, practical strategies for increasing PA/exercise (taxonomy of behavior change techniques), and treatment fidelity strategies were captured using a data extraction form.Results: Seventeen RCTs fulfilled the review criteria. Behavioural interventions showed statistically significant increases in objective (standardized mean difference [SMD] 0.45, 95% CI 0.21-0.68) and self-reported PA/exercise (SMD 0.79, 95% CI 0.59-0.98) including clinically significant improvements in HbA(1c) (weighted mean difference [WMD] -0.32%, 95% CI -0.44% to -0.21%) and BMI (WMD -1.05 kg/m(2), 95% CI -1.31 to -0.80). Few studies provided details of treatment fidelity strategies to monitor/improve provider training. Intervention features (e.g., specific behavior change techniques, interventions underpinned by behavior change theories/models, and use of ≥10 behaviour change techniques) moderated effectiveness of behavioral interventions.Conclusions: Behavioral interventions increased free-living PA/exercise and produced clinically significant improvements in long-term glucose control. Future studies should consider use of theory and multiple behavior change techniques associated with clinically significant improvements in HbA(1c), including structured training for care providers on the delivery of behavioural interventions. [ABSTRACT FROM AUTHOR]

Stage theories of health behavior change assume that individuals pass through qualitatively different stages on their way to the adoption of health behaviors. Three common stages (preintention, intention and action) can be defined by stage transitions included in current stage theories and supported by evidence. The present study examines whether transitions between these stages can be predicted by social cognition variables derived from prevailing health behavior theories. At two points in time, the motivation for interdental hygiene behaviors and oral self-care was assessed in 288 participants recruited in dental practices. Stage progression and regression over time were analyzed using discriminant function analysis. Progression from preintention to intention was predicted by action planning, whereas coping planning and self-efficacy predicted transitions from intention. Regression from action was predicted by self-efficacy. Results support the distinction of three common stages. Findings are discussed in terms of their contribution to health behavior theory. [ABSTRACT FROM AUTHOR]

Health behavior interventions may have different effects when targeting individuals at different stages of change. A 'motivation' stage, during which intentions are formed, has been distinguished from a 'volition' stage, implying that the latter requires self-regulatory effort in implementing and maintaining behavior. To test this stage assumption, an action control intervention (self-monitoring tool for dental flossing) matched to the volition stage and mismatched to the motivation stage was provided to 151 university students, with follow-up measures of action control and flossing after 2 and 6 weeks. Separate regression analyses for motivational and volitional participants indicated that only volitional participants benefited from the volitional intervention. This supports the usefulness of stage assumptions and the advantage of tailoring interventions to participants who reside either in the motivational or in the volitional stage. [ABSTRACT FROM AUTHOR]

Prevailing social cognition models consider behavioural intentions as immediate precursors of actions. This view ignores the role of more proximal self-regulatory processes, such as action control. The latter emerges after an intention has been formed and is supposed to maintain the level of intentions over time and to translate them into action. Three facets of action control were examined in terms of their predictive power for changes in intentions and for physical exercise: (a) awareness of standards, (b) self-monitoring, and (c) self-regulatory effort. A parsimonious 6-item instrument was administered to 122 cardiac patients at six weekly measurement points in time following rehabilitation. A distinction was made between the level of action control and the degree of change in action control, applying a latent growth model. While awareness of standards remained stable, the other two facets exhibited a linear change over the six-week period. Level and change were distinct predictors of physical exercise and changes in intentions. These findings emphasize the importance of self-regulatory mechanisms in the first weeks of trying to overcome a sedentary lifestyle. Action control may be a promising construct to narrow the intention-behaviour gap. [ABSTRACT FROM AUTHOR]

In cardiac rehabilitation programs, patients learn how to adopt a healthier lifestyle, including regular, strenuous physical activity. Long-term success is only modest despite good intentions. To improve exercise adherence, a 3-group experiment was designed that included innovative psychological interventions. All 3 groups underwent a standard care rehabilitation program. Patients in the 2 treatment groups were instructed not only to produce detailed action plans but also to develop barrier-focused mental strategies. On top of this, in 1 of these groups a weekly diary was kept for 6 weeks to increase a sense of action control. At the end of a standard cardiac rehabilitation program, 240 patients were randomly assigned to these treatment groups plus a standard care control group. Treatments resulted in more physical activity at follow-up and better adherence to recommended levels of exercise intensity. Moreover, self-regulatory skills such as planning and action control were improved by the treatments. Follow-up analyses demonstrated the mediating mechanisms of self-regulatory skills in the process of physical exercise maintenance. Findings imply that interventions targeting self-regulatory skills can enable post-rehabilitation patients to reduce behavioral risk factors and facilitate intended lifestyle changes. [ABSTRACT FROM AUTHOR]

Although some people may develop an intention to change their health behaviour, they might not take any action. This discrepancy has been labelled the 'intention-behaviour gap.' Detailed action planning, perceived self-efficacy, and self-regulatory strategies (action control) may mediate between intentions and behaviour. This was examined in a longitudinal sample of 307 cardiac rehabilitation patients who were encouraged to adopt or maintain regular exercise. At the first time point, the predictors of intention and intention itself were assessed. Two months and four months later, the mediators and outcomes were measured. Results confirmed that all the three factors (planning, maintenance self-efficacy, and action control) served to mediate between earlier exercise intentions and later physical activity, each of them making a unique contribution. The results have implications for research on the 'intention-behaviour gap,' and indicate that planning, maintenance self-efficacy and action control may be important volitional variables. [ABSTRACT FROM AUTHOR]

Background: People over the age of 70 carry the greatest burden of chronic disease, disability and health care use. Participation in physical activity is crucial for health, and walking accounts for much of the physical activity undertaken by sedentary individuals. Pedometers are a useful motivational tool to encourage increased walking and they are cheap and easy to use. The aim of this pilot study was to evaluate the feasibility of the use of pedometers plus a theory-based intervention to assist sedentary older women to accumulate increasing amounts of physical activity, mainly through walking.Methods: Female participants over the age of 70 were recruited from primary care and randomised to receive either pedometer plus a theory-based intervention or a theory-based intervention alone. The theory-based intervention consisted of motivational techniques, goal-setting, barrier identification and self-monitoring with pedometers and daily diaries. The pedometer group were further randomised to one of three target groups: a 10%, 15% or 20% monthly increase in step count to assess the achievability and acceptability of a range of targets. The primary outcome was change in daily activity levels measured by accelerometry. Secondary outcome measures were lower limb function, health related quality of life, anxiety and depression.Results: 54 participants were recruited into the study, with an average age of 76. There were 9 drop outs, 45 completing the study. All participants in the pedometer group found the pedometers easy to use and there was good compliance with diary keeping (96% in the pedometer group and 83% in the theory-based intervention alone group). There was a strong correlation (0.78) between accelerometry and pedometer step counts i.e. indicating that walking was the main physical activity amongst participants. There was a greater increase in activity (accelerometry) amongst those in the 20% target pedometer group compared to the other groups, although not reaching statistical significance (p = 0.192).Conclusion: We have demonstrated that it is feasible to use pedometers and provide theory-based advice to community dwelling sedentary older women to increase physical activity levels and a larger study is planned to investigate this further. [ABSTRACT FROM AUTHOR]

Introduction: Anxiety problems are prevalent in childhood and, without intervention, can persist into adulthood. Effective evidence-based interventions for childhood anxiety disorders exist, specifically cognitive-behavioural therapy (CBT) in a range of formats. However, only a small proportion of children successfully access and receive treatment. Conducting mental health screening in schools and integrating evidence-based interventions for childhood anxiety problems may be an effective way to ensure support reaches children in need. The Identifying Child Anxiety Through Schools-Identification to Intervention (iCATS i2i) trial involves screening for childhood anxiety problems and offering a brief online parent-led CBT intervention. This paper presents the protocol for the process evaluation of the iCATS i2i trial, which aims to examine the implementation and acceptability of the study procedures, the mechanisms of change and whether any external factors had an impact on procedure engagement or delivery., Methods and Analysis: This process evaluation will use both quantitative and qualitative methods to evaluate the implementation and acceptability of and barriers/facilitators to engagement and delivery of the iCATS screening/intervention procedures. Quantitative data sources will include opt-out and completion rates of baseline measures and usage analytics extracted from the online intervention platform. Qualitative interviews will be conducted with children, parents, school staff, iCATS i2i clinicians and researchers delivering study procedures. The Medical Research Council framework for process evaluations will guide study design and analysis., Ethics and Dissemination: This study has received ethical approval from the University of Oxford Research Ethics Committee (R66068_RE003). Findings from the study will be disseminated via peer-reviewed publications in academic journals, conferences, digital and social media platforms and stakeholder meetings., Trial Registration: ISRCTN76119074., Competing Interests: Competing interests: TF's department receives funds from her advisory role at Place2Be, a third-sector organisation that provides mental health training and support to schools in the UK, and the rest of the authors declare no competing interest., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ.)

Background: Despite the high prevalence of obesity in Germany, few effective political measures have been implemented to protect population health and improve the sustainability of food systems. One argument frequently raised against policy implementation is the lack of acceptability for policy measures in the German population., Aim: We aimed to evaluate the acceptability of policy measures currently discussed in Germany's national nutrition strategy and how perceived policy characteristics and participant characteristics influence policy acceptability., Method: We conducted an online survey with 2001 participants between 06.12.2023 and 05.01.2024, in which we collected data on perceived policy characteristics (acceptability, equity, societal and personal effectiveness), as well as participant values and beliefs., Results: Most policies were highly acceptable, with policies such as the introduction of free school lunches (84 % acceptability), the introduction of a ban on fast food advertising aimed at children (71 %) or a sugar tax (53 %) being acceptable to a majority of the sample. The least acceptable policy was the introduction of a tax on animal products (36 %). Logistic regression analyses showed that perceived equity and societal and personal effectiveness predicted policy acceptability. Likewise, environmental values and beliefs about state intervention of participants influenced policy acceptability., Conclusion: The high acceptability observed in this study suggests an opportunity for German policymakers to implement evidence-based and acceptable nutritional strategies to improve population health., Competing Interests: Declaration of competing interest The authors declare that they have no competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Optimizing vaccine uptake is a public health challenge that requires the implementation of effective strategies. The asymmetric dominance (or decoy) effect describes the increasing likelihood of selecting an option when a clearly inferior alternative is offered. Therefore, we aimed to test the impact of offering decoy alternatives-less convenient vaccination appointments-on vaccination intentions. Participants aged 18-33 years, residing in England, and initially not intending to get vaccinated, completed three online experiments. Participants were randomly assigned to either a control or an experimental condition in each experiment. The asymmetrically dominated options were: an appointment in two weeks at a distant location (experiment 1); a later time at the participant's local GP, pharmacy, or community centre (experiment 2); and a later time at a distant location (experiment 3). The primary outcome was vaccination intention, while secondary outcomes included an active interest in reading additional information about the vaccination procedure, perceived difficulty and cognitive effort. Initial analysis revealed no evidence of an asymmetric dominance effect. However, further subgroup analysis, supported by formative research, indicated that ensuring decoy alternatives are clearly perceived as inferior could enhance the effectiveness of this approach for certain individuals., Competing Interests: Declarations. Competing interests: The authors declare no competing interests. Ethics approval and consent to participate: This research was approved by HSSREC (number 117/20–21) at the University of Warwick, and all methods were performed in accordance with the relevant guidelines and regulations. The study participants provided informed consent for their data to be used and published as part of this research project., (© 2024. The Author(s).)

Background: Cancer-related fatigue (CRF) is the most prevalent, distressing, and quality of life disturbing symptom during and after cancer treatment for many cancer types including breast cancer. The experience and burden of this symptom can induce a cognitive bias towards fatigue or a fatigue-related self-image, which can further increase the fatigue symptoms and related behaviour. For this, a Cognitive Bias Modification (CBM) eHealth app (IVY) has been developed. The app aims to counter the fatigue-related self-image and to modify it towards vitality, which might translate to less experienced fatigue and more experienced vitality. This study aims to evaluate the feasibility of the IVY CBM training and the research design of a wait-list control trial. If feasibility is judged sufficient, the effectiveness of the CBM app will also be analyzed on (1) underlying mechanisms (cognitive fatigue bias), (2) symptom fatigue (self-reported fatigue and vitality), and (3) related behaviours (avoidance and all-or-nothing behaviour)., Methods: This feasibility study addresses individuals being treated for breast cancer receiving (neo)adjuvant treatment or metastatic care. The number of target participants is 120 (60 (neo)adjuvant, and 60 metastatic) patients. Both groups will be randomized with 30 people in the IVY treatment group and 30 people in the delayed treatment control group. All participants will receive the training via the IVY app, in which participants categorize words related to vitality with words related to 'I' and words related to fatigue with words related to 'other'. If feasibility is judged sufficient, the effects of the training will be explored on 3 levels: (1) self-identity bias, which will be measured with a short computer task based on the Implicit Association Test (IAT), (2) avoidance and all-or-nothing behaviour, and (3) fatigue and vitality levels, which will all be measured with questionnaires., Discussion: This study aims to evaluate the feasibility of a larger-scale multi-centre Randomized Controlled Trial (RCT) to investigate a novel eHealth application and, if possible, to give indications on the effectiveness of this intervention to counter fatigue in individuals with breast cancer. Using the IVY CBM app requires very little effort, both in time and cognitive load, which could be especially beneficial for fatigue symptoms., Trial Registration: Registered at the Open Science Framework (OSF; https://osf.io/e85g7/ ) on October 20, 2023., Competing Interests: Declarations. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests., (© 2024. The Author(s).)

Background: Severe and multiple disadvantage (SMD) is the combined effect of experiencing homelessness, substance use and repeat offending. People experiencing SMD have high burden of physical and mental health issues. Oral health is one of the most common health problems in people experiencing SMD which interacts with substance use, smoking, and unhealthy diet to create a cycle of harm and disadvantage. However, burden of these conditions is worsened by poor access to health services. This study aimed to identify pathways to improve engagement and access to health interventions, for oral health, substance and alcohol use, smoking and diet., Methods: Using a qualitative methodology, interviews/focus groups were conducted with: (a) people experiencing SMD in Newcastle Upon Tyne/Gateshead; and (b) frontline staff, volunteer workers, policy makers and commissioners from London, Plymouth and Newcastle Upon Tyne/Gateshead. Data was analysed iteratively using thematic analysis., Results: Twenty-eight people experiencing SMD (age range: 27-65 years; 21% females) and 78 service providers (age range: 28-72 years, 63% females) were interviewed or included in focus groups. Data were organized into two overarching factors: barriers to accessing health interventions and improving access to health interventions. Barriers included: wider disadvantages of people experiencing SMD leading to low priority for support for oral health and associated health behaviours, psychosocial factors, waiting period and physical space. Factors that improved access to interventions included: positive relationships between service provider and person experiencing SMD, including a support worker, location of services and outreach services., Conclusions: The findings suggest the need for flexibility in offering services for oral health and related health behaviours for people experiencing SMD. Training health care providers and co-developing services with people with lived experience of SMD can help prevent (re)stigmatization. Systems-based approach to address factors on an environmental, organizational, inter-personal and individual level is needed. The results from this study could be extrapolated to other health intervention such as vaccinations and sexual and reproductive health., Competing Interests: The authors have declared that no competing interests exist. The funders had no role in the design of the study, in the collection, analysis, or interpretation of data, in the writing of the manuscript, or in the decision to publish the results., (Copyright: © 2024 Jain et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Patient complaints in healthcare settings can provide feedback for monitoring and improving healthcare services. Behavioural responses to complaints (e.g., talking or apologising to a patient) can influence the trajectory of a complaint for instance, whether a complaint is escalated or not. We aimed to explore healthcare professional (HCP) and service user (patient and carer) views on complaints' management and the perceived factors influencing responses to complaints within a healthcare setting by applying behavioural frameworks., Method: A qualitative study was conducted using online or phone-based interviews with eleven HCPs and seven patients or carers. All participants (N = 18) had experience responding to or submitting a formal complaint in secondary and tertiary public healthcare settings in the United Kingdom. The interviews were structured using the Capability-Opportunity-Motivation-Behaviour (COM-B) Model. We analysed the transcripts using inductive thematic analysis. Then, themes were deductively mapped onto the COM-B Model and the more granular Theoretical Domains Framework (TDF)., Results: Ten themes were generated from the analysis representing the influences on HCPs' responses to complaints from HCP and patient/carer perspectives. This included (with TDF/COM-B in brackets): 'Knowledge of complaint procedure' (Knowledge/Capability), 'Training and level of skill in complaints handling' (Skills/Capability), 'Regulation of emotions associated with complaints' (Behavioural regulation/Capability), 'Confidence in handling complaints' (Beliefs about capabilities/Motivation), 'Beliefs about the value of complaints' (Beliefs about consequences/Motivation) and 'Organisational culture regarding complaints' (Social influences/Opportunity). Staff highlighted strong support systems and open discussions as part of positive organisational cultures regarding complaints (Social influences/Opportunity), and a lack of certainty around when to treat issues raised by patients as a formal complaint or informal feedback (Knowledge/Capability)., Conclusion: Our study findings highlight the importance of strong support systems and organisational openness to patient feedback. These findings can be used to design targeted interventions to support more effective responses and enhance patient-centred approaches to complaints management in healthcare settings., Patient and Public Contribution: Patient and public involvement (PPI) was integral in this research. The NIHR PRU in Behavioural and Social Sciences had a dedicated PPI strategy group consisting of six external representatives from the patient and public community (Newcastle University, 2024). These six PPI members actively participated in shaping the research by reviewing and providing feedback on all questionnaire items before the data collection. They were actively involved in supporting participant recruitment by advertising this study on their PPI platform, The Voice R,1 and through their online social networks. During the analysis stages of the research, preliminary findings were discussed with the PPI group to support 'sense checking' and interpretation of the results., (© 2024 The Author(s). Health Expectations published by John Wiley & Sons Ltd.)

Background: Virtual wards (VWs) are being introduced within the National Health Service (NHS) in England as a new way of delivering care to patients who would otherwise be hospitalized. Using digital technologies, patients can receive acute care, remote monitoring, and treatment in their homes. Integrated care system commissioners are employees involved in the planning of, agreeing to, and monitoring of services within NHS England and have an important role in the adoption and implementation of VWs in clinical practice., Objective: This study aims to develop an understanding of the acceptability and feasibility of adopting and implementing VWs in England from integrated care system commissioners' perspectives, including the identification of barriers and facilitators to implementation., Methods: Qualitative semistructured interviews were conducted with 20 commissioners employed by NHS England (NHSE) in various geographic regions of England. Thematic analysis was conducted, structured using the framework approach, and informed by the Consolidated Framework for Implementation Research. The COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines were followed., Results: Four overarching themes were identified reflecting the acceptability and feasibility of key adoption and implementation processes: (1) assessing the need for VWs, (2) coordinating a system approach, (3) agreeing to Program Outcomes: NHSE Versus Organizational Goals, and (4) planning and adapting services. Commissioners expressed the need for system-level change in care provision within the NHS, with VWs perceived as a promising model that could reform patient-centered care. However, there was uncertainty over the financial sustainability of VWs, with questions raised as to whether they would be funded by the closure of hospital beds. There was also uncertainty over the extent to which VWs should be technology-enabled, and the specific ways technology may enhance condition-specific pathways. Differing interpretations of the NHSE instructions between different health care sectors and a lack of clarity in definitions, as well as use of hospital-centric language within national guidance, were considered hindrances to convening a system approach. Furthermore, narrow parameters of success measures in terms of goals and outcomes of VWs, unrealistic timescales for planning and delivery, lack of interoperability of technology and time-consuming procurement procedures, liability concerns, and patient suitability for technology-enabled home-based care were identified as barriers to implementation. Motivated and passionate clinical leads were considered key to successful implementation., Conclusions: VWs have the potential to reform patient-centered care in England and were considered a promising approach by commissioners in this study. However, there should be greater clarity over definitions and specifications for technology enablement and evidence provided about how technology can enhance patient care. The use of less hospital-centric language, a greater focus on patient-centered measures of success, and more time allowance to ensure the development of technology-enabled VW services that meet the needs of patients and staff could enhance adoption and implementation., (©Laura J McGowan, Fiona Graham, Jan Lecouturier, Louis Goffe, Carlos Echevarria, Michael P Kelly, Falko F Sniehotta. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 27.11.2024.)

Regular testing using rapid antigen lateral flow tests (LFTs) was an important prevention strategy during the COVID-19 pandemic. However, falsification of home LFTs was a concern. Using a large quota-representative sample of adults ( n  = 1295) in England, we conducted a vignette survey consisting of four hypothetical scenarios of LFT falsification behaviours (FBs) to examine whether prosocial personality traits were associated with attitudes towards and intentions for falsifying home LFTs during the pandemic. Results show that higher levels of affective empathy for people vulnerable to COVID-19 and Honesty-Humility from the HEXACO model of Personality are associated with non-acceptability of LFT FBs and intentions to not engage with them. However, affective empathy explained more of the variation compared to the facet-level measures of Honesty-Humility for both attitude and intention. Public health communications aimed at encouraging personal protective behaviours should consider the role of empathy and prosocial messages., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Understanding the behavioural factors influencing flu vaccination is crucial for mitigating seasonal infection outbreaks. This study utilised the Precaution Adoption Process Model (PAPM) to examine the public's decision-making about seasonal flu vaccination through an online cross-sectional survey with 2004 participants in England, UK. Results showed varying stages of decision-making: 7% in Stage 2 (unengaged), 10% in Stage 3 (undecided), 7% in Stage 4 (decided not to vaccinate), 39% in Stage 5 (decided to vaccinate) and 38% in Stage 6 (vaccinated). Regression modelling revealed factors common across stages and unique to certain stages, such as flu vaccination history distinguishing those who received the vaccine. Vaccine knowledge (Stage 2), perceived benefits (Stage 4), perceived control and fear of needles (Stage 5) were uniquely associated with specific PAPM stages. The study discusses policy implications for integrating these findings to improve flu vaccination uptake, highlighting the importance of tailored strategies based on decision-making stages., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Selenium has potential safeguarding properties against cognitive decline, because of its role in protecting DNA, proteins, and lipids in the brain from oxidative damage. However, acute and chronic overexposure to selenium can be neurotoxic., Objective: The aim of this analysis was to explore the association between selenium status [serum selenium and selenoprotein P (SELENOP) concentrations and glutathione peroxidase 3 (GPx3) activity] and cognitive function in 85-y olds living in Northeast England at baseline and ≤5 y of follow-up., Methods: Global cognitive performance was assessed in 755 participants from the Newcastle 85+ study using the standardized Mini-Mental State Examination and attention-specific cognition was assessed using composite scores derived from the Cognitive Drug Research System. Serum selenium, SELENOP, and GPx3 activity were measured at baseline by total reflection X-ray fluorescence, enzyme-linked immunosorbent assay, and coupled-enzyme reaction, respectively. Regression analyses explored linear and nonlinear associations between continuous values and tertiles of selenium status biomarkers, respectively, and cognitive function at baseline. Generalized linear mixed models explored associations between continuous values and tertiles of selenium status biomarkers, and global cognitive decline over 5 y, and attention-specific cognitive decline over 3 y., Results: Over 3 and 5 y, none of the selenium biomarkers were associated with the rate of cognitive decline. At baseline, in fully adjusted models, higher serum selenium was nonlinearly associated with global cognition (β = 0.05 ± 0.01, P = 0.387 linear, β = 0.04 ± 0.01, P = 0.002 nonlinear). SELENOP and GPx3 activity were not associated with any cognitive outcomes., Conclusions: There were no associations between selenium status and cognitive decline. However, serum selenium, but not SELENOP or GPx3 activity, was positively associated nonlinearly with global cognition at baseline. Furthermore, these associations were not evident during follow-up, potentially because of residual confounding and reverse causation., Competing Interests: Conflict of interest LS holds shares on selenOmed GmbH, a company involved in selenium status assessment. All other authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: UK local authority public health teams (LAPHT) supported delivery of the Covid-19 vaccination programme, particularly to disadvantaged populations. We explored the challenges encountered and lessons learnt by LAPHTs in tackling low Covid-19 vaccine uptake. The aim of this study was to understand what works, and how, in addressing local inequalities in relation to uptake of the Covid-19 vaccination with a view to generalising insights to building back fairer after the pandemic and into the future., Study Design: Qualitative., Method: We conducted in-depth on-line interviews with Directors of Public Health or their representatives from 21 English local authorities covering a total population of over 8 million people. Data were analysed thematically., Results: Accessing the requisite (and accurate) data, engaging with communities, and working with National Health Service (NHS) organisations presented challenges in delivering initiatives to improve vaccine uptake, particularly for disadvantaged groups. LAPHT's assets beneficial to the programme - in-depth knowledge and experience of their communities and locality - were not considered in the national vaccination programme. Community engagement and relationships with local NHS featured heavily in the majority of LAPHTs responses to improving vaccine uptake rates., Conclusions: Incorporating local public health infrastructure, expertise and existing relationships into national vaccination planning during epidemics or pandemics is crucial. Community engagement and good relationships with NHS staff help to reach and serve disadvantaged populations. How these can be developed and maintained in the longer term without future investment was a concern. Future research should explore the design and implementation of PH and NHS joint service delivery models to tackle health inequalities, informed by experiences of the Covid-19 vaccination programme and with input from community partners., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: Poor adherence to photoprotection in Xeroderma Pigmentosum (XP) increases morbidity and shortens lifespan due to skin cancers., Objective: To test a highly personalised intervention (XPAND) to reduce the dose of ultraviolet radiation (UVR) reaching the face in adults with XP, designed using known psychosocial determinants of poor photoprotection., Methods: A two-arm parallel group randomised controlled trial, including patients with sub-optimal photoprotection to receive XPAND or a delayed intervention control arm that received XPAND the following year. XPAND comprises seven one-to-one sessions targeting photoprotection barriers (e.g., misconceptions about UVR) supported by personalised text messages, activity sheets, and educational materials incorporating behaviour change techniques. The primary outcome, mean daily UVR dose-to-face across 21 days in June-July 2018, was calculated by combining UVR exposure at the wrist with a face photoprotection activity diary. Secondary outcomes were UVR dose-to-face across 21 days in August 2018, time spent outside, photoprotective measures used outside, mood, automaticity, confidence-to-photoprotect. Financial costs and quality-adjusted life years (QALYs) were calculated., Results: 16 patients were randomised, 13 provided sufficient data for primary outcome analysis. The XPAND group (n=8) had lower mean daily UVR dose-to-face [0.03 SED (SD 0.02] compared to control (n=7) [0.36 SED (SD 0.16)] (adjusted difference=-0.25, p<0.001, Hedge's g=2.2). No significant between-group differences were observed in time spent outside, photoprotection outside, mood, or confidence. The delayed intervention control showed improvements in UVR dose-to-face (adjusted difference=-0.05, Hedge's g=-0.1) , time outside (adjusted difference=-69.9, Hedge's g=-0.28), and photoprotection (adjusted difference=-0.23, Hedge's g=0.45), after receiving XPAND. XPAND was associated with lower treatment costs (£-2642; 95% CI: -£8715 to £3873) and fewer QALYs (-0.0141; 95% CI: -0.0369 to 0.0028)., Conclusions: XPAND was associated with a lower UVR dose-to-face in XP patients and was cost-effective., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Association of Dermatologists.)

Background: The path of a complaint and patient satisfaction with complaint resolution is often dependent on the responses of healthcare professionals (HCPs). It is therefore important to understand the influences shaping HCP behaviour. This systematic review aimed to (1) identify the key actors, behaviours and factors influencing HCPs' responses to complaints, and (2) apply behavioural science frameworks to classify these influences and provide recommendations for more effective complaints handling behaviours., Methods: A systematic literature review of UK published and unpublished (so-called grey literature) studies was conducted (PROSPERO registration: CRD42022301980). Five electronic databases [Scopus, MEDLINE/Ovid, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Health Management Information Consortium (HMIC)] were searched up to September 2021. Eligibility criteria included studies reporting primary data, conducted in secondary and tertiary care, written in English and published between 2001 and 2021 (studies from primary care, mental health, forensic, paediatric or dental care services were excluded). Extracted data included study characteristics, participant quotations from qualitative studies, results from questionnaire and survey studies, case studies reported in commentaries and descriptions, and summaries of results from reports. Data were synthesized narratively using inductive thematic analysis, followed by deductive mapping to the Theoretical Domains Framework (TDF)., Results: In all, 22 articles and three reports met the inclusion criteria. A total of 8 actors, 22 behaviours and 24 influences on behaviour were found. Key factors influencing effective handling of complaints included HCPs' knowledge of procedures, communication skills and training, available time and resources, inherent contradictions within the role, role authority, HCPs' beliefs about their ability to handle complaints, beliefs about the value of complaints, managerial and peer support and organizational culture and emotions. Themes mapped onto nine TDF domains: knowledge, skills, environmental context and resources, social/professional role and identity, social influences, beliefs about capability, intentions and beliefs about consequences and emotions. Recommendations were generated using the Behaviour Change Wheel approach., Conclusions: Through the application of behavioural science, we identified a wide range of individual, social/organizational and environmental influences on complaints handling. Our behavioural analysis informed recommendations for future intervention strategies, with particular emphasis on reframing and building on the positive aspects of complaints as an underutilized source of feedback at an individual and organizational level., (© 2024. The Author(s).)

Amidst the global momentum of behavioral insights (BI), there has been a shift from mostly nudge-based BI applications to systemic approaches. This is particularly pressing in public health, where interacting issues regularly produce unanticipated consequences. Regardless, little is known about adopting complex systems approaches in behavioral public policy. This study aims to capture current practices of international BI experts on the definition, application, drivers, and hindering factors in adopting complex systems approaches in public policy. Semi-structured individual expert interviews (n = 12) of international BI experts with extensive experience in educating, cooperating with, and/or advising public servants were analyzed with inductive content analysis. While the working definition of BI aligned with published definitions, experts varied in their descriptions of complex systems approaches and its significance for public policy, including socioecological aspects, systematic BI use across policy stages, recognizing intertwined behavior, and lack of ready-made solutions. They emphasized the importance of systems approaches, identifying drivers (e.g. need for a broader focus) and hindrances (e.g. pressure for quick results). Embracing complex systems in behavioral public policy provides a holistic perspective, extending beyond simple nudges, sometimes presumed as universally applicable. While complexity perspectives would align with policymakers' worldview, applications require more work to tailor to local situations and to evaluate. Recognizing that, given their distinct expertise content, BI expertise can be quite different from complex systems expertise. The field would benefit from clear descriptions and specialized training for effective integration and advocacy for these approaches., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.)

Background: People experiencing homelessness co-occurring with substance use or offending ('severe and multiple disadvantage' SMD) often have high levels of poor oral health and related health behaviours (particularly, substance use, smoking, poor diet). This systematic review aimed to assess the effectiveness and cost-effectiveness of interventions in adults experiencing SMD to improve oral health and related health behaviours., Methods and Findings: From inception to February 2023, five bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus) and grey literature were searched. Two researchers independently screened the search results. Randomized controlled trials (RCTs), comparative studies and economic evaluations were included that reported outcomes on oral health and the related health behaviours. Risk of bias was assessed and results narratively synthesized. Meta-analyses were performed where appropriate. This review was registered with PROSPERO (reg. no: CRD42020202416). Thirty-eight studies were included (published between 1991 and 2023) with 34 studies reporting about effectiveness. Most studies reported on substance use (n = 30). Interventions with a combination of housing support with substance use and mental health support such as contingent work therapy appeared to show some reduction in substance use in SMD groups. However, meta-analyses showed no statistically significant results. Most studies had short periods of follow-up and high attrition rates. Only one study reported on oral health; none reported on diet. Three RCTs reported on smoking, of which one comprising nicotine replacement with contingency management showed improved smoking abstinence at 4 weeks compared to control. Five studies with economic evaluations provided some evidence that interventions such as Housing First and enhanced support could be cost-effective in reducing substance use., Conclusion: This review found that services such as housing combined with other healthcare services could be effective in improving health behaviours, particularly substance use, among SMD groups. Gaps in evidence also remain on oral health improvement, smoking, and diet. High quality studies on effectiveness with adequate power and retention are needed to address these significant health challenges in SMD populations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 McGowan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In DiRECT, a randomised controlled effectiveness trial, weight management intervention after 2 years resulted in mean weight loss of 7·6 kg, with 36% of participants in remission of type 2 diabetes. Of 36 in the intervention group who maintained over 10 kg weight loss at 2 years, 29 (81%) were in remission. Continued low-intensity dietary support was then offered up to 5 years from baseline to intervention participants, aiming to maintain weight loss and gain clinical benefits. This extension study was designed to provide observed outcomes at 5 years., Methods: The DiRECT trial took place in primary care practices in the UK. Participants were individuals aged 20-65 years who had less than 6 years' duration of type 2 diabetes, a BMI greater than 27 kg/m 2 , and were not on insulin. The intervention consisted of withdrawal of antidiabetic and antihypertensive drugs, total diet replacement (825-853 kcal per day formula diet for 12-20 weeks), stepped food reintroduction (2-8 weeks), and then structured support for weight-loss maintenance. After sharing the 2-year results with all participants, UK National Health Service data were collected annually until year 5 from remaining intervention participants who received low-intensity dietary support, intervention withdrawals, and the original randomly allocated groups. The primary outcome was remission of type 2 diabetes; having established in the DiRECT trial that sustained weight loss was the dominant driver of remission, this was assumed for the Extension study. The trial is registered with the ISRCTN registry, number 03267836., Findings: Between July 25, 2014, and Aug 5, 2016, 149 participants were randomly assigned to the intervention group and 149 were assigned to the control group in the original DiRECT study. After 2 years, all intervention participants still in the trial (101 [68%] of 149) were approached to receive low-intensity support for a further 3 years. 95 (94%) of 101 were able to continue and consented and were allocated to the DiRECT extension group. 54 participants were allocated to the non-extension group, where intervention was withdrawn. At 5 years, DiRECT extension participants (n=85) lost an average of 6·1 kg, with 11 (13%) of 85 in remission. Compared with the non-extension group, DiRECT extension participants had more visits with HbA 1c <48 mmol/mol (<6·5%; 36% vs 17%, p=0·0004), without glucose-lowering medication (62% vs 30%, p<0·0001), and in remission (34% vs 12%, p<0·0001). Original control participants (n=149) had mean weight loss 4·6 kg (n=82), and 5 (5%) of 93 were in remission. Compared with control participants, original intervention participants had more visits with weight more than 5% below baseline (61% vs 29%, p<0·0001), HbA 1c below 48 mmol/mol (29% vs 15%, p=0·0002), without antidiabetic medication (51% vs 16%, p<0·0001), and in remission (27% vs 4%, p<0·0001). Of those in remission at year 2, 26% remained in remission at 5 years. Serious adverse events in the original intervention group (4·8 events per 100 patient-years) were under half those in the control group (10·2 per 100 patient-years, p=0·0080)., Interpretation: The extended DiRECT intervention was associated with greater aggregated and absolute weight loss, and suggested improved health status over 5 years., Funding: Diabetes UK., Competing Interests: Declaration of interests MEJL reports grants and personal fees unconnected with the present work from Counterweight, Novo Nordisk, Novartis, and Eli Lilly. RT has received lecture fees from Novartis and Eli Lilly, and has served on an advisory panel for Wilmington Healthcare. NB reports employment and shareholding in Counterweight, and PhD fees funded by Cambridge Weight Plan (outside the submitted work). GT received funding for PhD fees and conference attendance from Cambridge Weight Plan outside the submitted work. WSL reports support for conference attendance from Cambridge Weight Plan outside the submitted work. NS reports grants and personal fees from AstraZeneca, Boehringer Ingelheim, Novartis, and Roche Diagnostics; and personal fees from Abbott Laboratories, Amgen, Eli Lilly, Hanmi Pharmaceuticals, Janssen, Merck Sharp & Dohme, Novo Nordisk, Pfizer, and Sanofi, outside the submitted work. LM reports employment by Counterweight during the conduct of study, was previously a shareholder in Counterweight, and previous employment from Cambridge Weight Plan outside the submitted work. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: NULevel was a randomized control trial to evaluate a technology-assisted weight loss maintenance (WLM) program in the UK. The program included: (a) a face-to-face goal-setting session; (b) an internet platform, a pedometer, and wirelessly connected scales to monitor and report diet, physical activity, and weight, and; (c) regular automated feedback delivered by mobile phone, tailored to participants' progress. Components were designed to target psychological processes linked to weight-related behavior. Though intervention participants showed increased physical activity, there was no difference in WLM between the intervention and control groups after 12 months (Sniehotta FF, Evans EH, Sainsbury K, et al. Behavioural intervention for weight loss maintenance versus standard weight advice in adults with obesity: A randomized controlled trial in the UK (NULevel Trial). PLoS Med. 2019; 16(5):e1002793. doi:10.1371/journal.pmed.1002793). It is unclear whether the program failed to alter targeted psychological processes, or whether changes in these processes failed to influence WLM., Purpose: We evaluate whether the program influenced 16 prespecified psychological processes (e.g., self-efficacy and automaticity toward diet and physical activity), and whether these processes (at 6 months) were associated with successful WLM (at 12 months)., Methods: 288 adults who had previously lost weight were randomized to the intervention or control groups. The control group received wireless scales and standard advice via newsletters. Assessments occurred in person at 0, 6, and 12 months., Results: The intervention significantly altered 10 of the 16 psychological processes, compared with the control group. However, few processes were associated with WLM, leading to no significant indirect effects of the intervention via the processes on WLM., Conclusions: Changes in targeted processes were insufficient to support WLM. Future efforts may more closely examine the sequence of effects between processes, behavior, and WLM., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.)

Objectives: To examine the effectiveness of shared medical appointments (SMAs) compared with one-to-one appointments in primary care for improving health outcomes and reducing demand on healthcare services by people with one or more long-term conditions (LTCs)., Design: A systematic review of the published literature., Data Sources: Six databases, including MEDLINE and Web of Science, were searched 2013-2023. Relevant pre-2013 trials identified by forward and backward citation searches of the included trials were included., Eligibility Criteria: Randomised controlled trials of SMAs delivered in a primary care setting involving adults over 18 years with one or more LTCs. Studies were excluded if the SMA did not include one-to-one patient-clinician time. All countries were eligible for inclusion., Data Extraction and Synthesis: Data were extracted and outcomes narratively synthesised, meta-analysis was undertaken where possible., Results: Twenty-nine unique trials were included. SMA models varied in terms of components, mode of delivery and target population. Most trials recruited patients with a single LTC, most commonly diabetes (n=16). There was substantial heterogeneity in outcome measures. Meta-analysis showed that participants in SMA groups had lower diastolic blood pressure than those in usual care (d=-0.086, 95% CI=-0.16 to -0.02, n=10) (p=0.014). No statistically significant differences were found across other outcomes. Compared with usual care, SMAs had no significant effect on healthcare service use. For example, no difference between SMAs and usual care was found for admissions to emergency departments at follow-up (d=-0.094, 95% CI=-0.27 to 0.08, n=6, p=0.289)., Conclusions: There was a little difference in the effectiveness of SMAs compared with usual care in terms of health outcomes or healthcare service use in the short-term (range 12 weeks to 24 months). To strengthen the evidence base, future studies should include a wider array of LTCs, standardised outcome measures and more details on SMA components to help inform economic evaluation., Prospero Registration Number: CRD42020173084., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pregnancy weight management interventions can improve maternal diet, physical activity, gestational weight gain, and postnatal weight retention. UK guidelines were published in 2010 but health professionals report multiple complex barriers to practice. GLOWING used social cognitive theory to address evidence-based barriers to midwives' implementation of weight management guidelines into routine practice. This paper reports the pilot trial outcomes relating to feasibility and acceptability of intervention delivery and trial procedures., Methods: GLOWING was a multi-centre parallel-group pilot cluster RCT comparing the delivery of a behaviour change intervention for midwives (delivered as training workshops) with usual practice. The clusters were four NHS Trusts in Northeast England, randomised to intervention or control arms. Blinding of allocation was not possible due to the nature of the intervention. We aimed to deliver the intervention to all eligible midwives in the intervention arm, in groups of 6 midwives per workshop, and to pilot questionnaire data collection for a future definitive trial. Intervention arm midwives' acceptability of GLOWING content and delivery was assessed using a mixed methods questionnaire, and pregnant women's acceptability of trial procedures by interviews. Quantitative data were analysed descriptively and qualitative data thematically., Results: In intervention arm Trusts, 100% of eligible midwives (n = 67) were recruited to, and received, the intervention; however, not all workshops had the planned number of attendees (range 3-8). The consent rate amongst midwives randomised (n = 100) to complete questionnaires was 74% (n = 74) (95% CI 65%, 83%), and overall completion rate 89% (n = 66) (95% CI 82%, 96%). Follow-up response rate was 66% (n = 49) (95% CI 55%, 77%), with a marked difference between intervention (39%, n = 15) and control (94%, n = 34) groups potentially due to the volume of research activities. Overall, 64% (n = 47) (95% CI 53%, 75%) completed both baseline and follow-up questionnaires. Midwives viewed the intervention as acceptable and directly relevant to routine practice. The least popular components related to scripted role-plays. Pregnant women viewed the recruitment and trial processes to be acceptable., Conclusions: This rigorously conducted pilot study demonstrated feasibility intervention delivery and a high level of acceptability amongst participants. It has provided information required to refine the intervention and trial protocol, enhancing confidence that a definitive trial could be carried out., Trial Registration: ISRCTN46869894; retrospectively registered 25th May 2016, www.isrctn.com/ISRCTN46869894 ., (© 2024. The Author(s).)

During the COVID-19 pandemic, lateral flow tests (LFTs) were used to regulate access to work, education, social activities, and travel. However, falsification of home LFT results was a concern. Falsification of test results during an ongoing pandemic is a sensitive issue. Consequently, respondents may not answer truthfully to questions about LFT falsification behaviours (FBs) when asked directly. Indirect questioning techniques such as the Extended Crosswise model (ECWM) can provide more reliable prevalence estimates of sensitive behaviors than direct questioning. Here we report the prevalence of LFT FBs in a representative sample in England (n = 1577) using direct questioning (DQ) and the ECWM. We examine the role of demographic and psychological variables as predictors of LFT FBs. We show that the prevalence estimates of the FBs in the DQ condition were significantly lower than the ECWM estimates, e.g., reporting a negative result without conducting a test: 5.7% DQ vs 18.4% ECWM. Moral norms, subjective norms, anticipated regret, perception of risk to self, and trust in government predicted some of the FBs. Indirect questioning techniques can help provide more realistic and higher quality data about compliance with behavioural regulations to government and public health agencies., (© 2024. The Author(s).)

Background: The Identifying Child Anxiety Through Schools-identification to intervention (iCATS-i2i) trial is being conducted to establish whether 'screening and intervention', consisting of usual school practice plus a pathway comprising screening, feedback and a brief parent-led online intervention (OSI: Online Support and Intervention for child anxiety), bring clinical and health economic benefits compared to usual school practice and assessment only - 'usual school practice', for children aged 8-9 years in the following: (1) the 'target population', who initially screen positive for anxiety problems according to a two-item parent-report child anxiety questionnaire - iCATS-2, and (2) the 'total population', comprising all children in participating classes. This article describes the detailed statistical analysis plan for the trial., Methods and Design: iCATS-i2i is a definitive, superiority, pragmatic, school-based cluster randomised controlled trial (with internal pilot), with two parallel groups. Schools are randomised 1:1 to receive either screening and intervention or usual school practice. This article describes the following: trial objectives and outcomes; statistical analysis principles, including detailed estimand information necessary for aligning trial objectives, conduct, analyses and interpretation when there are different analysis populations and outcome measures to be considered; and planned main analyses, sensitivity and additional analyses., Trial Registration: ClinicalTrials.gov ISRCTN76119074. Registered on 4 January 2022., (© 2024. The Author(s).)

Objectives: Among people experiencing severe and multiple disadvantage (SMD), poor oral health is common and linked to smoking, substance use and high sugar intake. Studies have explored interventions addressing oral health and related behaviours; however, factors related to the implementation of these interventions remain unclear. This mixed-methods systematic review aimed to synthesise evidence on the implementation and sustainability of interventions to improve oral health and related health behaviours among adults experiencing SMD., Methods: Bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature were searched from inception to February 2023. Studies meeting the inclusion criteria were screened and extracted independently by two researchers. Quality appraisal was undertaken, and results were synthesised using narrative and thematic analyses., Results: Seventeen papers were included (published between 1995 and 2022). Studies were mostly of moderate quality and included views from SMD groups and service providers. From the qualitative synthesis, most findings were related to aspects such as trust, resources and motivation levels of SMD groups and service providers. None of the studies reported on diet and none included repeated offending (one of the aspects of SMD). From the quantitative synthesis, no difference was observed in programme attendance between the interventions and usual care, although there was some indication of sustained improvements in participation in the intervention group., Conclusion: This review provides some evidence that trust, adequate resources and motivation levels are potentially important in implementing interventions to improve oral health and substance use among SMD groups. Further research is needed from high quality studies and focusing on diet in this population., Prospero Registration Number: CRD42020202416., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Homelessness overlapping with substance use and offending is described as severe and multiple disadvantage (SMD). People experiencing SMD have poor oral health along with high levels of related behaviours such as substance use, smoking, and poor diet. Existing evidence largely describes the prevalence of oral health problems, substance use, and smoking in SMD groups. Little is known about interventions that can address these conditions in SMD groups. We aimed to review the effectiveness and cost-effectiveness of interventions on oral health and related health behaviours in adults experiencing SMD., Methods: For this systematic review, we searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature for papers published from inception to February 2023. Two researchers independently reviewed the searches. Randomised controlled trials (RCTs), comparative studies and economic evaluations were included. Risk of bias was assessed. Population included adults experiencing SMD (including homelessness and substance use or repeat offending). Outcomes included oral health, and related behaviours (substance use, smoking, poor diet). Results were narratively synthesised. This review was registered with PROSPERO, CRD42020202416., Findings: The review included 38 studies (published between 1991 and 2023), with 34 reporting effectiveness. These studies comprised of 23 RCTs and 11 quasi-experimental studies conducted in the USA (25 studies), Canada (seven studies), France (one study), and Spain (one study). The interventions involving multiple components, such as housing services with substance use and mental health support, effectively reduced substance use in SMD groups; these were mostly individual-level interventions. However, these studies had short follow-up periods and high attrition rates. Only one study addressed oral health outcomes, none focused on diet, and three RCTs covered smoking, with one intervention showing smoking abstinence at 4 weeks. Some limited evidence suggested cost-effectiveness of substance use interventions., Interpretation: This review found that integrating services such as housing with other health-care services together could be effective in improving health behaviours, especially substance use among SMD groups. More evidence is needed specifically on oral health, smoking, and diet-related interventions. The generalisability of findings of this review is limited to high-income countries and shorter-term outcomes., Funding: National Institute for Health and Care Research (NIHR) Policy Research Programme., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Purpose: Preventing weight regain can only be achieved by sustained changes in energy balance-related behaviors that are associated with weight, such as diet and physical activity. Changes in motivation and self-regulatory skills can support long-term behavioral changes in the context of weight loss maintenance. We propose that experiencing a supportive climate care is associated with enhanced satisfaction of basic psychological needs, intrinsic goals, and autonomous motivation. These factors are expected to be associate with the utilization of self-regulation skills, leading to more sustained behavior changes and ultimately preventing weight regain. This hypothesis was tested in this ancillary analysis of the NoHoW trial, where the study arms were pooled and followed for 12 months., Methods: The NoHoW was a three-center, large-scale weight regain prevention full factorial trial. In this longitudinal study, data were collected in adults who lost > 5% weight in the past year (N = 870, complete data only, 68.7% female, 44.10 ± 11.86 years, 84.47 ± 17.03 kg) during their participation in a 12-month digital behavior change intervention. Weight and validated measures of motivational- and self-regulatory skills-related variables were collected at baseline, six- and 12 months. Change variables were used in Mplus' path analytical models informed by NoHoW's logic model., Results: The bivariate correlations confirmed key mediators' potential effect on weight outcomes in the expected causal direction. The primary analysis showed that a quarter of the variance (r2 = 23.5%) of weight regain prevention was achieved via the mechanisms of action predicted in the logic model. Specifically, our results show that supportive climate care is associated with needs satisfaction and intrinsic goal content leading to better weight regain prevention via improvements in self-regulatory skills and exercise-controlled motivation. The secondary analysis showed that more mechanisms of action are significant in participants who regained or maintained their weight., Conclusions: These results contribute to a better understanding of the mechanisms of action leading to behavior change in weight regain prevention. The most successful participants used only a few intrinsic motivation-related mechanisms of action, suggesting that habits may have been learned. While developing a digital behavior change intervention, researchers and practitioners should consider creating supportive climate care to improve needs satisfaction and intrinsic goal contents., Trial Registration: ISRCTN, ISRCTN88405328 , registered 12/22/2016., (© 2023. The Author(s).)

Behaviour change interventions for weight management have found varied effect sizes and frequent weight re-gain after weight loss. There is interest in exploring whether differences in eating behaviour can be used to develop tailored weight management programs. This secondary analysis of an 18-month weight maintenance randomised controlled trial (RCT) aimed to investigate the association between individual variability in weight maintenance success and change in eating behaviour traits (EBT). Data was analysed from the NoHoW trial (Scott et al., 2019), which was designed to measure processes of change after weight loss of ≥5% body weight in the previous year. The sample included 1627 participants (mean age = 44.0 years, SD = 11.9, mean body mass index (BMI) = 29.7 kg/m 2 , SD = 5.4, gender = 68.7% women/31.3% men). Measurements of weight (kg) and 7 EBTs belonging to domains of reflective, reactive, or homeostatic eating were taken at 4 time points up to 18-months. Increases in measures of 'reactive eating' (binge eating, p < .001), decreases in 'reflective eating' (restraint, p < .001) and changes in 'homeostatic eating' (unlimited permission to eat, p < .001 and reliance on hunger and satiety cues, p < .05) were significantly and independently associated with concomitant weight change. Differences in EBT change were observed between participants who lost, maintained, or re-gained weight for all EBTs (p < .001) except for one subscale of intuitive eating (eating for physical reasons, p = .715). Participants who lost weight (n = 322) exhibited lower levels of reactive eating and higher levels of reflective eating than participants who re-gained weight (n = 668). EBT domains can identify individuals who need greater support to progress in weight management interventions. Increasing reflective eating and reducing reactive eating may enhance weight management success., Competing Interests: Declaration of competing interest Conflict of interest. None to be declared., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Preconception obesity is associated with adverse pregnancy outcomes and deprivation. The postnatal period provides an opportunity for preconception intervention. There is a lack of published postnatal behaviour and weight data to inform intervention needs. Secondary analysis of the GLOWING study explored postnatal diet, physical activity (PA) and weight among women living with obesity in deprivation. Thirty-nine women completed food frequency and PA questionnaires and provided weight measurement(s) between 3-12 months postnatal. Women's diet and PA fell short of national guidelines, especially for fruit/vegetables (median 1.6-2.0 portions/day) and oily fish (0-4 g/day). PA was predominantly light intensity. Patterns in weight change across time points indicated postnatal weight loss compared with 1st (median -0.8 to -2.3 kg) and 3rd-trimester weights (-9.0 to -11.6 kg). Weight loss was higher among women without excessive gestational weight gain (GWG) (-2.7 to -9.7 kg) than those with excessive GWG (2.3 to -1.8 kg), resulting in postnatal weight measurements lower than their 1st trimester. These pilot data suggest preconception interventions should commence in pregnancy with a focus on GWG, and postnatal women need early support to achieve guideline-recommendations for diet and PA. Further research in a larger population could inform preconception intervention strategies to tackle inequalities in maternal obesity and subsequent pregnancy outcomes.

Aims: The aim of this narrative review was to identify important knowledge gaps in behavioural science relating to type 2 diabetes prevention, to inform future research in the field., Methods: Seven researchers who have published behaviour science research applied to type 2 diabetes prevention independently identified several important gaps in knowledge. They met to discuss these and to generate recommendations to advance research in behavioural science of type 2 diabetes prevention., Results: A total of 21 overlapping recommendations for a research agenda were identified. These covered issues within the following broad categories: (a) evidencing the impact of whole population approaches to type 2 diabetes prevention, (b) understanding the utility of disease-specific approaches to type 2 diabetes prevention such as Diabetes Prevention Programmes (DPPs) compared to generic weight loss programmes, (c) identifying how best to increase reach and engagement of DPPs, whilst avoiding exacerbating inequalities, (d) the need to understand mechanism of DPPs, (e) the need to understand how to increase maintenance of changes as part of or following DPPs, (f) the need to assess the feasibility and effectiveness of alternative approaches to the typical self-regulation approaches that are most commonly used, and (g) the need to address emotional aspects of DPPs, to promote effectiveness and avoid harms., Conclusions: There is a clear role for behavioural science in informing interventions to prevent people from developing type 2 diabetes, based on strong evidence of reach, effectiveness and cost-effectiveness. This review identifies key priorities for research needed to improve existing interventions., (© 2023 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Objective: Many adolescents report a lack of physical activity (PA) and excess screen time (ST). Psychological theories aiming to understand these behaviours typically focus on predictors of only one behaviour. Yet, behaviour enactment is often a choice between options. This study sought to examine predictors of PA and ST in a single model. Variables were drawn from dual process models, which portray behaviour as the outcome of deliberative and automatic processes., Design: 411 Finnish vocational school students (age 17-19) completed a survey, comprising variables from the Reasoned Action Approach (RAA) and automaticity pertaining to PA and ST, and self-reported PA and ST four weeks later., Main Outcome Measures: Self-reported time spent on PA and ST and their predictors., Results: PA and ST correlated negatively (r = -.17, p = .03). Structural equation modelling revealed that intentions and habit for PA predicted PA while ST was predicted by intentions and habit for ST and negatively by PA intentions. RAA-cognitions predicted intentions., Conclusion: PA and ST and their psychological predictors seem to be weakly interlinked. Future studies should assess more behaviours and related psychological influences to get a better picture of connections between different behaviours., HighlightsPhysical activity and screen time are largely mutually exclusive classes of behaviours and might therefore be related in terms of their psychological predictors.411 adolescent vocational school students self-reported variables from the Reasoned Action Approach and behavioural automaticity related to physical activity and leisure time screen time behaviours as well as those behaviours.Structural equation modelling revealed expected within-behaviour predictions but, against expectations, no strong connections between the two behaviour classes in terms of their predictors. Only intentions to engage in physical activity negatively predicted screen time.Future research should aim to measure a wider range of mutually exclusive classes of behaviours that cover a large share of the day to uncover relations between behaviours and their respective predictors.

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., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Albers, Rinaldi, Brown, Mason, d'Apice, McGill, McQuire, Craig, Laverty, Beeson, Campbell, Egan, Gibson, Fuller, Dillon, Taylor-Robinson, Jago, Tilling, Barr, Sniehotta, Hickman, Millett and de Vocht.)

Background: Increasing physical activity and limiting sedentary time may minimize weight recurrence after bariatric surgery. However, few studies have evaluated potential associations of objectively-measured physical activity and sedentary time with post-surgical weight recurrence over time., Aims: To evaluate associations of change in physical activity and sedentary time with weight recurrence after bariatric surgery., Methods: Participants from the Oslo Bariatric Surgery Study, a prospective cohort study, wore an ActiGraph monitor for seven days at 1- and 5 years after surgery to assess daily physical activity and sedentary time. Participants' weight was measured at in-person clinic visits. Chi-square Test and Paired-samples T-test evaluated group differences and change over time, while Pearson's Correlation, multiple logistic and linear regression investigated associations between variables., Results: Five years after surgery 79 participants (70.5% response rate, 81% female) (mean (sd) age: 54.0 (±9.3), BMI: 32.1 (±4.7)) had valid monitor data. Participants increased their sedentary time (71.4 minutes/day (95% CI: 54.2-88.6, p = <0.001)) and reduced daily steps (-1411.1 (95% CI: 737.8-208.4), p = <0.001), light physical activity (-54.1 min/day (95% CI: 40.9-67.2, p = <0.001)), and total physical activity (-48.2 (95% CI: 34.6-63.3), p = <0.001) from 1- to 5 years after surgery. No change was found for moderate-to-vigorous intensity physical activity. No associations were found between changes in steps, physical activity or sedentary time and weight recurrence., Conclusion: Participants increased sedentary time and decreased light- and total physical activity between 1- and 5 years post-surgery. Overall, changes in physical activity and sedentary time were not associated with weight recurrence. Interventions to help patients increase physical activity and limit sedentary time after bariatric surgery are needed., (© 2023. The Author(s).)

Background: There is limited evidence on what shapes the acceptability of population level dietary and active-travel policies in England. This information would be useful in the decision-making process about which policies should be implemented and how to increase their effectiveness and sustainability. To fill this gap, we explored public and policymakers' views about factors that influence public acceptability of dietary and active-travel policies and how to increase public acceptability for these policies., Methods: We conducted online, semi-structured interviews with 20 members of the public and 20 policymakers in England. A purposive sampling frame was used to recruit members of the public via a recruitment agency, based on age, sex, socioeconomic status and ethnicity. Policymakers were recruited from existing contacts within our research collaborations and via snowball sampling. We explored different dietary and active-travel policies that varied in their scope and focus. Interviews were transcribed verbatim and analysed using thematic reflexive analysis with both inductive and deductive coding., Results: We identified four themes that informed public acceptability of dietary and active-travel policies: (1) perceived policy effectiveness, i.e., policies that included believable mechanisms of action, addressed valued co-benefits and barriers to engage in the behaviour; (2) perceived policy fairness, i.e., policies that provided everyone with an opportunity to benefit (mentioned only by the public), equally considered the needs of various population subgroups and rewarded 'healthy' behaviours rather than only penalising 'unhealthy' behaviours; (3) communication of policies, i.e., policies that were visible and had consistent and positive messages from the media (mentioned only by policymakers) and (4) how to improve policy support, with the main suggestion being an integrated strategy addressing multiple aspects of these behaviours, inclusive policies that consider everyone's needs and use of appropriate channels and messages in policy communication., Conclusions: Our findings highlight that members' of the public and policymakers' support for dietary and active-travel policies can be shaped by the perceived effectiveness, fairness and communication of policies and provide suggestions on how to improve policy support. This information can inform the design of acceptable policies but can also be used to help communicate existing and future policies to maximise their adoption and sustainability., (© 2023. Crown.)