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BackgroundWhole-school interventions represent promising approaches to promoting adolescent sexual health, but they have not been rigorously trialled in the UK and it is unclear if such interventions are feasible for delivery in English secondary schools. The importance of involving intended beneficiaries, implementers and other key stakeholders in the co-production of such complex interventions prior to costly implementation and evaluation studies is widely recognised. However, practical accounts of such processes remain scarce. We report on co-production with specialist providers, students, school staff, and other practice and policy professionals of two new whole-school sexual heath interventions for implementation in English secondary schools.MethodsFormative qualitative inquiry involving 75 students aged 13–15 and 23 school staff. A group of young people trained to advise on public health research were consulted on three occasions. Twenty-three practitioners and policy-makers shared their views at a stakeholder event. Detailed written summaries of workshops and events were prepared and key themes identified to inform the design of each intervention.ResultsData confirmed acceptability of addressing unintended teenage pregnancy, sexual health and dating and relationships violence via multi-component whole-school interventions and of curriculum delivery by teachers (providing appropriate teacher selection). The need to enable flexibility for the timetabling of lessons and mode of parent communication; ensure content reflected the reality of young people’s lives; and develop prescriptive teaching materials and robust school engagement strategies to reflect shrinking capacity for schools to implement public-health interventions were also highlighted and informed intervention refinements.Our research further points to some of the challenges and tensions involved in co-production where stakeholder capacity may be limited or their input may conflict with the logic of interventions or what is practicable within the constraints of a trial.ConclusionsMulti-component, whole-school approaches to addressing sexual health that involve teacher delivered curriculum may be feasible for implementation in English secondary schools. They must be adaptable to individual school settings; involve careful teacher selection; limit additional burden on staff; and accurately reflect the realities of young people’s lives. Co-production can reduce research waste and may be particularly useful for developing complex interventions, like whole-school sexual health interventions, that must be adaptable to varying institutional contexts and address needs that change rapidly. When co-producing, potential limitations in relation to the representativeness of participants, the ‘depth’ of engagement necessary as well as the burden on participants and how they will be recompensed must be carefully considered. Having well-defined, transparent procedures for incorporating stakeholder input from the outset are also essential. Formal feasibility testing of both co-produced interventions in English secondary schools via cluster RCT is warranted.Trial registrationProject Respect:ISRCTN12524938. Positive Choices:ISRCTN65324176

Background ‘Dating and relationship violence’ is intimate partner violence during adolescence. Among dating adolescents in England, 66–75% of girls and 32–50% of boys report victimisation. Multicomponent school-based interventions might reduce dating and relationship violence. We optimised and piloted Project Respect, a new intervention in secondary schools in England, and study methods, to assess the value of a Phase III randomised controlled trial. Objectives To optimise Project Respect and to then conduct a pilot randomised controlled trial in southern England, addressing whether or not progression to a Phase III trial is justified in terms of prespecified criteria. To assess which of two dating and relationship violence scales is optimal, to assess response rates and to consider any necessary refinements. Design Optimisation activities aimed at intervention development and a pilot randomised controlled trial. Setting Optimisation in four secondary schools across southern England, varying by region and local deprivation. A pilot cluster randomised controlled trial in six other such schools (four intervention schools and two control schools), varying by region, attainment and local deprivation. Participants School students in years 8–10 at baseline and staff. Interventions Schools were randomised to the intervention or control arm in a 2 : 1 ratio; intervention comprised staff training, mapping ‘hotspots’ in school for dating and relationship violence, modifying staff patrols, school policy review, informing parents and carers, an application supporting student help-seeking, and a classroom curriculum for students in years 9 and 10 (including student-led campaigns). Main outcome measures Prespecified criteria for progression to Phase III of the trial, concerning acceptability, feasibility, fidelity and response rates. Primary health outcomes were assessed using the Safe Dates and short Conflicts in Adolescent Dating Relationships Inventory measures collected and analysed by individuals who were masked to allocation. Feasibility of economic analysis was assessed. Data sources Baseline and follow-up student and staff surveys, interviews, observations and logbooks. Results The intervention was optimised and approved by the Study Steering Committee. The student response rates in intervention and control groups were 1057 (84.8%) and 369 (76.6%) at baseline, and 1177 (76.8%) and 352 (83.4%) at follow-up, respectively. Safe Dates and the short Conflicts in Adolescent Dating Relationships Inventory had high levels of completion and reliability. At follow-up, prevalence of past-year dating and relationship violence victimisation was around 35% (Safe Dates scale and short Conflicts in Adolescent Dating Relationships Inventory). Staff response rates were very low. Training occurred in all four schools, with suboptimal fidelity. The curriculum was delivered with optimal fidelity in three schools. Other components were delivered inconsistently. Dating and relationship violence was addressed in control schools via violence prevention and responses, but not systematically. Intervention acceptability among students and staff was mixed. An economic evaluation would be feasible. Limitations One school did not undertake baseline surveys. Staff survey response rates were low and completion of the logbook was patchy. Conclusions Our findings suggest that progression to a Phase III trial of this intervention is not indicated because of limited fidelity and acceptability. Future work High prevalence of dating and relationship violence highlights the ongoing need for effective intervention. Potential intervention refinements would include more external support for schools and enhanced curriculum materials. Any future randomised controlled trials could consider having a longer lead-in from randomisation to intervention commencement, using the short Conflicts in Adolescent Dating Relationships Inventory as the primary outcome and not relying on staff surveys. Trial registration Current Controlled Trials ISRCTN65324176. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 5. See the NIHR Journals Library website for further project information.

Background More people are living longer lives leading to a growth in the population of older adults, many of whom have comorbidities and low levels of physical function. Physical activity in later life can prevent or delay age-related disability. Identifying a cost-effective means of increasing physical activity in older adults therefore remains an important public health priority. Physical Activity Facilitation (PAF) is an intervention shown to increase physical activity in adults with depression. The PAF model was modified for a population of older adults at risk of disability. This study aimed to assess the feasibility of undertaking a definitive RCT of the PAF intervention in the target population. Methods A pilot randomised controlled trial (RCT) was delivered through primary care. Patients at risk of disability and who were not meeting recommended levels of physical activity were recruited through postal invitation and direct approach in the practice waiting room. Those meeting eligibility criteria were enrolled and randomised at a 2:1 ratio to the PAF intervention and control. Behaviour change techniques were used by facilitators with participants over the telephone and face-to-face for 6 months. Outcome measures including physical function, physical activity, depression, social support, and quality of life were collected at baseline and at 6 months. Results A high proportion of patients responded to the initial invitation (68%), yet many were ineligible due to high levels of self-reported physical activity and baseline physical function. Fifty-one participants were recruited to the trial, with an average age of 74 years (range 65–89), and there were high rates of adherence and retention to the study (94% follow-up at 6 months). The majority of outcome data collected from participants was complete; however, the validated scale used to measure self-reported physical activity was associated with high levels of missing data. Conclusions The findings of this pilot RCT suggest that it is feasible to deliver a definitive RCT of the PAF intervention in this population. Further work is required to improve the efficiency of recruitment and to minimise missing data from self-reported physical activity measures. Trial registration Current controlled trials ISRCTN80470273. Registered 25 October 2013. Electronic supplementary material The online version of this article (10.1186/s40814-019-0414-9) contains supplementary material, which is available to authorized users.

Background Previous studies linking social activity and disability have been limited by focussing on self-reported physical performance in older adults (>65). We examined whether social participation in mid-life is associated with objective and subjective measures of physical performance in older age. Methods Participants of the Medical Research Council National Survey of Health and Development reported their involvement in social activities at ages 43 and 60–64 years; frequency of such involvement was classified into thirds. Physical performance was measured at age 60–64 using: grip strength; standing balance; chair rises; timed get-up-and-go; self-reported physical function from the Short Form-36. Multivariable regression was used to examine longitudinal associations between social participation and each physical performance measure. We also investigated whether change in social participation between 43 and 60–64 was associated with each outcome. Results In fully adjusted models, higher frequency of social participation at 43 was associated with faster chair rise (1.42 repetitions/min, 95% CI 0.45–2.39) and timed get-up-and-go speed (2.47 cm/s, 95% CI 0.27–4.67) and lower likelihood of self-report limitations (OR of low physical function 0.67, 95% CI 0.50–0.91) at 60–64 compared with low frequency. Better performance in objectively measured outcomes was observed only if higher social participation persisted over time whereas lower odds of self-reported limitations were found in all groups when compared to those with persistently low participation (ORs 0.43–0.56, all P≤0.02). Conclusion Our findings suggest that associations between higher levels of social participation in mid-life and better physical performance exist only if this social participation persists through to older age.

Background Dating and relationship violence (DRV)—intimate partner violence during adolescence—encompasses physical, sexual and emotional abuse. DRV is associated with a range of adverse health outcomes including injuries, sexually transmitted infections, adolescent pregnancy and mental health issues. Experiencing DRV also predicts both victimisation and perpetration of partner violence in adulthood. Prevention targeting early adolescence is important because this is when dating behaviours begin, behavioural norms become established and DRV starts to manifest. Despite high rates of DRV victimisation in England, from 22 to 48% among girls and 12 to 27% among boys ages 14–17 who report intimate relationships, no RCTs of DRV prevention programmes have taken place in the UK. Informed by two school-based interventions that have shown promising results in RCTs in the USA—Safe Dates and Shifting Boundaries—Project Respect aims to optimise and pilot a DRV prevention programme for secondary schools in England. Methods Design: optimisation and pilot cluster RCT. Trial will include a process evaluation and assess the feasibility of conducting a phase III RCT with embedded economic evaluation. Cognitive interviewing will inform survey development. Participants: optimisation involves four schools and pilot RCT involves six (four intervention, two control). All are secondary schools in England. Baseline surveys conducted with students in years 8 and 9 (ages 12–14). Follow-up surveys conducted with the same cohort, 16 months post-baseline. Optimisation sessions to inform intervention and research methods will involve consultations with stakeholders, including young people. Intervention: school staff training, including guidance on reviewing school policies and addressing ‘hotspots’ for DRV and gender-based harassment; information for parents; informing students of a help-seeking app; and a classroom curriculum for students in years 9 and 10, including a student-led campaign. Primary outcome: the primary outcome of the pilot RCT will be whether progression to a phase III RCT is justified. Testing within the pilot will also determine which of two existing scales is optimal for assessing DRV victimisation and perpetration in a phase III RCT. Discussion This will be the first RCT of an intervention to prevent DRV in the UK. If findings indicate feasibility and acceptability, we will undertake planning for a phase III RCT of effectiveness. Trial registration ISRCTN, ISRCTN 65324176. Registered 8 June 2017. Electronic supplementary material The online version of this article (10.1186/s40814-019-0391-z) contains supplementary material, which is available to authorized users.

Vaccination of immunocompromised patients is recommended in many national guidelines to protect against severe or complicated influenza infection. However, due to uncertainties over the evidence base, implementation is frequently patchy and dependent on individual clinical discretion. We conducted a systematic review and meta‐analysis to assess the evidence for influenza vaccination in this patient group. Healthcare databases and grey literature were searched and screened for eligibility. Data extraction and assessments of risk of bias were undertaken in duplicate, and results were synthesised narratively and using meta‐analysis where possible. Our data show that whilst the serological response following vaccination of immunocompromised patients is less vigorous than in healthy controls, clinical protection is still meaningful, with only mild variation in adverse events between aetiological groups. Although we encountered significant clinical and statistical heterogeneity in many of our meta‐analyses, we advocate that immunocompromised patients should be targeted for influenza vaccination.

Healthcare workers (HCWs) are at increased risk of exposure to\udrespiratory pathogens and may transmit infection to vulnerable\udpatients. This study summarises a recent systematic review, which\udaimed to assess evidence that influenza or pneumococcal\udvaccination of HCWs provides indirect protection for those patients\udmost at risk of severe or complicated acute respiratory infection. A\udnumber of healthcare databases and sources of grey literature were\udsearched using a predefined strategy, and citations screened for\udeligibility in accordance with specified inclusion criteria. Risk of bias\udwas assessed using validated tools and results summarised\udqualitatively. Twenty papers were included in the final review, all of\udwhich considered influenza vaccination of HCW. As such, planned\udsubanalysis of pneumococcal vaccination was discarded. The\udmajority of primary research studies included (11/14) were\udconducted in long-term care facilities, but there was marked\udheterogeneity in terms of the population, intervention/exposure and\udoutcomes considered. Consistency in the direction of effect was\udobserved across several different outcome measures, suggesting that\udinfluenza vaccination of HCWs is likely to offer some protection.\udFurther evidence is, however, required from acute care settings.

Background There is increasing emphasis on involving intended beneficiaries and other stakeholders in the development of public health interventions to maximise acceptability and remove barriers to adoption, implementation, and maintenance before costly implementation. Yet the processes whereby key actors are engaged in intervention development are rarely reported, and frameworks for carrying out such work remain limited. We outline our approach to involving stakeholders in the optimisation of two school-based relationships and sex education programmes (Project Respect and Positive Choices) and reflect on the challenges of co-producing with teachers, students, and other partners. Methods Systematic optimisation of both interventions involved a review of existing literature on effective approaches; consultation with staff and students on intervention content and delivery; drafting of intervention materials; further consultation with schools; and then intervention refinement in preparation for a pilot. Seven focus groups took place in southeast and southwest England involving 75 students aged 13–15 years and 22 school staff. A group of young people trained to advise on public health research were consulted on two occasions and a wide range of sexual health and sex education practitioners and policy makers shared their views at a stakeholder event. Findings Consultation provided useful insights to inform intervention adaption in relation to who should deliver the programmes in schools; whether lessons should be taught in single sex classes; the format that guidance and lesson plans should take; the relevance and acceptability to students and teachers; and the need for the flexibility for materials to adapt to different school contexts. Genuine consultation and incorporation of school stakeholder views was challenging where stakeholder availability was limited and intervention development and implementation timelines were tight. Challenges also arose in relation to the weight to give divergent opinions among stakeholders and between stakeholders and researchers. Interpretation Carrying out structured stakeholder engagement activities can yield valuable insights that can improve the applicability of interventions to local contexts before they are formally trialled. To genuinely engage stakeholders in intervention development requires sufficient time to both consult and adapt. In such consultations, it is important to attend not just to the voices of those who are the loudest and most powerful. Funding National Institute for Health Research (NIHR).

It has become increasingly common for UK patients to travel to malarial regions: in 2004 over 2.5 million visits were made by UK individuals to countries in which malaria is endemic, representing a 300% increase since 1987.1 Malaria prophylaxis routinely provided in general practice comprises atovaquone–proguanil, mefloquine, doxycycline, or chloroquine plus proguanil. This article describes two cases of malaria that presented 8 months after foreign travel, despite adherence to antimalarial prophylaxis. Two 16-year-old boys presented to the same UK hospital during the same week. Both had a 2-week history of unexplained fever and myalgia. They had travelled together to a malarious area of Kenya for a fortnight 8 months previously on a school trip, and had shared a tent. Both pupils reported adherence to a complete course of atovaquone–proguanil (Malarone®, GSK) on this trip, and had not been to any other malarious regions subsequently. Neither patient reported symptoms at the time of the trip or on initial return to the UK; nor were any other pupils or staff member on the …

Previous studies suggest that physical activity may be protective for dementia and cognitive impairment. We report findings comparing leisure-time and work-related physical activity from the Caerphilly Prospective study (CaPS) with dementia and cognitive impairment not dementia (CIND) after around 16 years of follow-up. We synthesized our results with a meta-analysis specifically testing if length of follow-up was associated with the size of any association. Age-adjusted models found no real association with dementia, and if anything increased risk for CIND (odds ratio (OR) highest versus lowest tertile 2.61, 95% CI 1.58 to 4.31), though this was attenuated after adjustment for other confounders (OR highest versus lowest tertile 1.38, 95% CI 0.78 to 2.44). There was no evidence that this differed by type (vascular versus non-vascular) of cognitive disease. Meta-analysis of other published effect estimates showed a protective effect of physical activity on cognitive impairment (OR 0.66, 95% CI 0.52 to 0.85) but with significant heterogeneity which was partially explained by length of follow up (p = 0.03). A protective association was also seen for dementia (OR 0.78, 95% CI 0.65, 0.94), which did not appear to be related to follow-up length but there was evidence of small study bias (p = 0.002) suggesting an absence of small null studies. The apparent protective effects of physical activity on cognitive health may partially reflect reverse causation and current estimates may be overly optimistic in terms of cognitive benefits.

BackgroundImmunocompromised patients are vulnerable to severe or complicated influenza infection. Vaccination is widely recommended for this group. This systematic review and meta-analysis assesses influenza vaccination for immunocompromised patients in terms of preventing influenza-like illness and laboratory confirmed influenza, serological response and adverse events.Methodology/principal findingsElectronic databases and grey literature were searched and records were screened against eligibility criteria. Data extraction and risk of bias assessments were performed in duplicate. Results were synthesised narratively and meta-analyses were conducted where feasible. Heterogeneity was assessed using I(2) and publication bias was assessed using Begg's funnel plot and Egger's regression test. Many of the 209 eligible studies included an unclear or high risk of bias. Meta-analyses showed a significant effect of preventing influenza-like illness (odds ratio [OR]=0.23; 95% confidence interval [CI]=0.16-0.34; pConclusions/significanceInfection prevention and control strategies should recommend vaccinating immunocompromised patients. Potential for bias and confounding and the presence of heterogeneity mean the evidence reviewed is generally weak, although the directions of effects are consistent. Areas for further research are identified.

Background Whilst there have been several robust reviews of the quantitative literature surrounding physical activity in older adults, less has been published on the qualitative literature in this field. Qualitative data can be of great value to researchers designing interventions as it can lead to greater insight into how individuals understand the social world and how they conceptualise and understand health messages. This can be used to aid selection of the theoretical elements of an intervention and to design specific components. Previous qualitative syntheses in this field have been limited in scope or methodology, or have comprised a narrative review of the quantitative and qualitative literature. It is therefore clear that there is a need for a thorough, rigorous, and interpretive synthesis of the qualitative literature surrounding older adults and physical activity. Methods The electronic databases MEDLINE, EMBASE, CINAHL, PsychINFO and Web of Science were systematically searched for qualitative studies with adults aged 50 years and over on physical activity. Following title/abstract and full-text screening, eligible papers were included in the final synthesis. Findings from all papers were coded and descriptive themes constructed. We attempted a meta-ethnographic approach, aiming to go beyond the findings of the primary studies to generate third order interpretations about older adults’ accounts of physical activity. Results After de-duplication, 5038 titles were retrieved from the database search. All retrieved papers were screened by title and abstract, and a random sample of 10% were double-screened (kappa score for agreement 0.74; strong agreement). 380 papers were subject to full-text screening, and of these 66 papers met the inclusion criteria. The findings from the included papers were subject to in-depth, line-by-line coding. Studies varied greatly in methodological and analytical quality. Descriptive themes, including for example ideas on mortality, life as purposeful, and concept of self, were constructed from the studies, and studies were translated into one another to generate additional understandings on the topic. Discussion We will present details of the results of our meta-ethnography, and we shall discuss our conclusions on the value of this exercise in this topic area.