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As both socioeconomic deprivation and the prevalence of childhood mental health difficulties continue to increase, exploring the relationship between them is important to guide policy. We aimed to replicate the finding of a mental health gap that widened with age between those living in the most and least deprived areas among primary school pupils. We used data from 2075 children aged 4–9 years in the South West of England recruited to the STARS (Supporting Teachers and childRen in Schools) trial, which collected teacher- and parent-reported Strength and Difficulties Questionnaire (SDQ) at baseline, 18-month and 30-month follow-up. We fitted multilevel regression models to explore the relationship between Index of Multiple Deprivation (IMD) quintile and SDQ total difficulties score and an algorithm-generated "probable disorder" variable that combined SDQ data from teachers and parents. Teacher- and parent-reported SDQ total difficulties scores indicated worse mental health in children living in more deprived neighbourhoods, which was attenuated by controlling for special educational needs and disabilities but remained significant by parent report, and there was no interaction year group status (age) at baseline. We did not detect an association between probable disorder and IMD although an interaction with time was evident (p = 0.003). Analysis by study wave revealed associations at baseline (odds ratio 1.94, 95% confidence interval 0.97–3.89) and 18 months (1.96, 1.07–3.59) but not 30 months (0.94, 0.54–1.57). These findings augment the existing, highly compelling evidence demonstrating worse mental health in children exposed to socioeconomic deprivation. [ABSTRACT FROM AUTHOR]

Background: Identifying and supporting young children who are at risk of developing anxiety disorders would benefit children, families, and wider society. Elevated anxiety symptoms, inhibited temperament, and high parental anxiety are established risk factors for later anxiety disorders, but it remains unclear who is most likely to benefit from prevention and early intervention programmes. Delivering an online intervention through schools to parents of young children who have one or more of these risks could maximise reach. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of delivering an online parent-led intervention, compared with usual school provision only, for children (aged 4-7) identified as at risk for anxiety disorders on the basis of at least one risk factor. We also aim to identify the characteristics of children who do and do not benefit from intervention and mechanisms of change from the intervention.Methods: The design will be a parallel group, superiority cluster randomised controlled trial, with schools (clusters) randomised to intervention or usual school practice arms in a 1:1 ratio stratified according to level of deprivation within the school. The study will recruit and randomise at least 60 primary/infant schools in England, and on the basis of recruiting 60 schools, we will recruit 1080 trial participants (540 per arm). Parents of all children (aged 4-7) in sampled Reception, Year 1, and Year 2 classes will be invited to complete screening questionnaires. Children who screen positive on the basis of anxiety symptoms, and/or behavioural inhibition, and/or parent anxiety symptoms will be eligible for the trial. Parents/carers of children in schools allocated to the intervention arm will be offered a brief online intervention; schools in both arms will continue to provide any usual support for children and parents throughout the trial. Assessments will be completed at screening, baseline (before randomisation), 6 weeks, 12 weeks, and 12 months post-randomisation. The primary outcome will be the absence/presence of an anxiety disorder diagnosis at 12 months.Discussion: The trial will determine if delivering an online intervention for parents of young children at risk of anxiety disorders identified through screening in schools is effective and cost-effective.Trial Registration: ISRCTN 82398107 . Prospectively registered on Jan. 14, 2021. [ABSTRACT FROM AUTHOR]

Emergency ambulance calls represent one of the routes of emergency hospital admissions from care homes. We aimed to describe the pattern of ambulance call rates from care homes and identify factors predicting those homes calling for an ambulance most frequently. We obtained data from South Western Ambulance Service NHS Foundation Trust on 3138 ambulance calls relating to people aged 65 and over from care homes in the Torbay region between 1 April 2012 and 31 July 2013. We supplemented this with data from the Care Quality Commission ( CQC) website on home characteristics and outcomes of CQC inspections. We used descriptive statistics to identify variation in ambulance call rates for residential and nursing homes and fitted negative binomial regression models to determine if call rates were predicted by home type (nursing versus residential), the five standards in the CQC reports, dementia care status or travel time to hospital. One hundred and forty-six homes (119 residential and 27 nursing) were included in the analysis. The number of calls made ranged from 1 to 99. The median number ( IQR; range) of calls per resident per year was 0.51 (0.21-0.89; 0.03-2.45). Nursing homes had a lower call rate than residential homes [adjusted rate ratio ( ARR) 0.29; 95% CI: 0.22-0.40; P < 0.001]; care homes failing the quality and suitability of management standard had a lower call rate compared to those who passed ( ARR 0.67; 95% CI: 0.50-0.90; P = 0.006); and homes specialising in dementia had a higher call rate compared to those not specialising ( ARR 1.56; 95% CI: 1.23-1.96; P < 0.001). These findings require replication in other regions to establish their generalisability and further investigation is required to determine the extent to which call rate variability reflects the different needs of resident populations or differences in care home policies and practice. [ABSTRACT FROM AUTHOR]

Purpose: To explore the association between children’s self-reported contact with people with disabilities and attitudes towards them, as well the potential mediating influence of anxiety about interacting with people with disabilities and empathy for them.Method: 1881 children, aged 7–16 years, from 20 schools in South West England completed a survey assessing their contact with people with disabilities and their attitudes towards them. Anxiety about interacting with people with disabilities and empathy towards them were examined as potential mediators. Gender, school year, perceived similarity between people with and without disabilities, proportion of children with additional needs at the school and socioeconomic status (SES) were assessed as moderators. A random effects (“multilevel”) regression model was used to test the contact–attitude association and moderation, and path analysis was used to test for mediation.Results: Participants with more self-reported contact reported more positive attitudes towards disability (p < 0.001). Less anticipated anxiety and greater empathy together mediated around a third of this association. Only school year moderated the contact–attitude association (affective attitudes), with stronger contact–attitude associations in primary school children than secondary school children.Conclusions: Self-reported contact was observed to be associated with more positive attitudes towards disability, which was partially mediated by empathy and anxiety. Providing opportunities for contact with people with disabilities that reduces anxiety and increases empathy may improve attitudes to disability and merits evaluation in interventions.Implications for RehabilitationChildren who reported greater levels of contact with people with disabilities had more positive attitudes towards disability.Anxiety about interacting with people with disabilities and empathy towards them partially mediated the contact–attitude associations.Providing opportunities for contact with people with disabilities, reducing anxiety and increasing empathy may improve children’s attitudes to disability. [ABSTRACT FROM PUBLISHER]

Background: For most cancers, only a minority of patients have symptoms meeting the National Institute for Health and Clinical Excellence guidance for urgent referral. For gastro-oesophageal cancers, the 'alarm' symptoms of dysphagia and weight loss are reported by only 32 and 8 % of patients, respectively, and their presence correlates with advanced-stage disease. Electronic clinical decision-support tools that integrate with clinical computer systems have been developed for general practice, although uncertainty remains concerning their effectiveness. The objectives of this trial are to optimise the intervention and establish the acceptability of both the intervention and randomisation, confirm the suitability and selection of outcome measures, finalise the design for the phase III definitive trial, and obtain preliminary estimates of the intervention effect.Methods/design: This is a two-arm, multi-centre, cluster-randomised, controlled phase II trial design, which will extend over a 16-month period, across 60 general practices within the North East and North Cumbria and the Eastern Local Clinical Research Network areas. Practices will be randomised to receive either the intervention (the electronic clinical decision-support tool) or to act as a control (usual care). From these practices, we will recruit 3000 adults who meet the trial eligibility criteria and present to their GP with symptoms suggestive of gastro-oesophageal cancer. The main measures are the process data, which include the practitioner outcomes, service outcomes, diagnostic intervals, health economic outcomes, and patient outcomes. One-on-one interviews in a sub-sample of 30 patient-GP dyads will be undertaken to understand the impact of the use or non-use of the electronic clinical decision-support tool in the consultation. A further 10-15 GPs will be interviewed to identify and gain an understanding of the facilitators and constraints influencing implementation of the electronic clinical decision-support tool in practice.Discussion: We aim to generate new knowledge on the process measures regarding the use of electronic clinical decision-support tools in primary care in general and to inform a subsequent definitive phase III trial. Preliminary data on the impact of the support tool on resource utilisation and health care costs will also be collected.Trial Registration: ISRCTN Registry, ISRCTN12595588 . [ABSTRACT FROM AUTHOR]

Background: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalised patients. VTE prevention has been identified as a major health need internationally to improve patient safety. A National Institute for Health and Clinical Excellence (NICE) guideline was issued in February 2010. Its key priorities were to assess patients for risk of VTE on admission to hospital, assess patients for bleeding risk and evaluate the risks and benefits of prescribing VTE prophylaxis. The aim of this study was to evaluate the implementation of NICE guidance and its impact on patient safety. Methods: A before-after observational design was used to investigate changes in VTE risk assessment documentation and inappropriate prescribing of prophylaxis between the year prior to (2009) and the year following (2010) the implementation of NICE guidance, using data from a 3-week period during each year. A total of 408 patients were sampled in each year across four hospitals in the NHS South region.Results: Implementation strategies such as audit, education and training were used. The percentage of patients for whom a VTE risk assessment was documented increased from 51.5% (210/408) in 2009 to 79.2% (323/408) in 2010; difference 27.7% (95% CI: 21.4% to 33.9%; p < 0.001). There was little evidence of change in the percentage who were prescribed prophylaxis amongst patients without a risk assessment (71.7% (142/198) in 2009 and 68.2% (58/85) in 2010; difference −3.5% (95% CI: -15.2% to 8.2%; p =0.56) nor the percentage who were prescribed low molecular weight heparin amongst patients with a contraindication (14% (4/28) in 2009 and 15% (6/41) in 2010; RD = 0.3% (95% CI: -16.5% to 17.2%; p =0.97). Conclusions: The documentation of risk assessment improved following the implementation of NICE guidance; it is questionable, however, whether this led to improved patient safety with respect to prescribing appropriate prophylaxis. [ABSTRACT FROM AUTHOR]

Background: Despite the health risks, physical inactivity is common. Identifying the correlates of physical activity to inform the design of interventions to reduce the disease burden associated with physical inactivity is a public health imperative. Rural adults have a unique set of characteristics influencing their activity behaviour, and are typically understudied, especially in England. The aim of this study was to identify the personal, social, and environmental correlates of physical activity in adults living in rural villages. Methods: The study used baseline data from 2415 adults (response rate: 37.7%) participating in the first time period of a stepped-wedge cluster randomised trial, conducted in 128 rural villages from south-west England. Data collected included demographic characteristics, social factors, perception of the local environment, village level factors (percentage male, mean age, population density, Index of Multiple Deprivation, and sport market segmentation), and physical activity behaviour. Random effects ("multilevel") logistic regression models were fitted to the binary outcome whether individuals met physical activity guidelines, and random effects linear regression models were fitted to the continuous outcome MET-minutes per week leisure time physical activity, using the personal, social, environmental, and village-level factors as predictors. Results: The following factors both increased the odds of meeting the recommended activity guidelines and were associated with more leisure-time physical activity: being male (p = 0.002), in good health (p < 0.001), greater commitment to being more active (p = 0.002), favourable activity social norms (p = 0.004), greater physical activity habit (p < 0.001), and recent use of recreational facilities (p = 0.01). In addition, there was evidence (p < 0.05) that younger age, lower body mass index, having a physical occupation, dog ownership, inconvenience of public transport, and using recreational facilities outside the local village were associated with greater reported leisure-time physical activity. None of the village-level factors were associated with physical activity. Conclusions: This study adds to the current literature on the correlates of physical activity behaviour by focusing on a population exposed to unique environmental conditions. It highlights potentially important correlates of physical activity that could be the focus of interventions targeting rural populations, and demonstrates the need to examine rural adults separately from their urban counterparts. [ABSTRACT FROM AUTHOR]

The authors estimated components of variance and intraclass correlation coefficients (ICCs) to aid in the design of complex surveys and community intervention studies by analyzing data from the Health Survey for England 1994. This cross-sectional survey of English adults included data on a range of lifestyle risk factors and health outcomes. For the survey, households were sampled in 720 postal code sectors nested within 177 district health authorities and 14 regional health authorities. Study subjects were adults aged 16 years or more. ICCs and components of variance were estimated from a nested random-effects analysis of variance. Results are presented at the district health authority, postal code sector, and household levels. Between-cluster variation was evident at each level of clustering. In these data, ICCs were inversely related to cluster size, but design effects could be substantial when the cluster size was large. Most ICCs were below 0.01 at the district health authority level, and they were mostly below 0.05 at the postal code sector level. At the household level, many ICCs were in the range of 0.0–0.3. These data may provide useful information for the design of epidemiologic studies in which the units sampled or allocated range in size from households to large administrative areas. Am J Epidemiol 1999;149:876–83. [ABSTRACT FROM PUBLISHER]

Background: It has been proposed that greater availability of primary medical care practitioners (GPs) contributes to better population health. We evaluated whether measures of the supply and structure of primary medical services are associated with health and health care indicators after adjusting for confounding. Methods: Data for the supply and structure of primary medical services and the characteristics of registered patients were analysed for 99 health authorities in England in 1999. Health and health care indicators as dependent variables included standardised mortality ratios (SMR), standardised hospital admission rates, and conceptions under the age of 18 years. Linear regression analyses were adjusted for Townsend score, proportion of ethnic minorities and proportion of social class IV/ V. Results: Higher proportions of registered rural patients and patients ≥ 75 years were associated with lower Townsend deprivation scores, with larger partnership sizes and with better health outcomes. A unit increase in partnership size was associated with a 4.2 (95% confidence interval 1.7 to 6.7) unit decrease in SMR for all-cause mortality at 15-64 years (P = 0.001). A 10% increase in single-handed practices was associated with a 1.5 (0.2 to 2.9) unit increase in SMR (P = 0.027). After additional adjustment for percent of rural and elderly patients, partnership size and proportion of single-handed practices, GP supply was not associated with SMR (-2.8, -6.9 to 1.3, P = 0.183). Conclusions: After adjusting for confounding with health needs of populations, mortality is weakly associated with the degree of organisation of practices as represented by the partnership size but not with the supply of GPs. [ABSTRACT FROM AUTHOR]

Describes the treatment protocol and baseline characteristics of subjects with a history of repeated parasuicide recruited in centers in England and Scotland to a randomized therapeutic trial of manual assisted cognitive-behavior therapy (MACT) and treatment as usual (TAU). Comparison between the efficacy of MACT and that of TAU in reducing the proportion having a repetition of self-harm in year after a parasuicide episode; Patient criteria in eligibility for the study; Description of MACT and TAU.

Abstract: Objectives: The study aims to test the hypothesis that physical activity (PA) and cardiorespiratory fitness (CRF) are associated with cardiometabolic risk factors; and to test the hypothesis that CRF modifies (changes the direction and/or strength of) the associations between PA and cardiometabolic risk factors. Methods: PA and CRF were objectively measured in the 2008 Health Survey for England and the present study included 536 adults who completed at least 4min of the eight-minute sub-maximal step test and wore an accelerometer for at least 10h on at least four days. Linear regression models were fitted to examine the relationship between PA and cardiometabolic risk factors and between CRF and cardiometabolic risk factors. A test of interaction was performed to examine whether CRF modifies the associations between PA and cardiometabolic risk factors. Results: PA and CRF were associated with HDL cholesterol, the ratio of total to HDL cholesterol, glycated haemoglobin and BMI after adjustment for potential confounders. There was little evidence that CRF changed the direction or strength of associations between PA and cardiometabolic risk factors. Conclusions: PA and CRF are associated with cardiometabolic risk factors. A larger sample is required to determine if CRF modifies associations between PA and cardiometabolic risk factors. [Copyright &y& Elsevier]

The risks of illness associated with bathing in UK coastal waters have not been quantified since the early 1990s. Efforts have been made since then to improve the quality of bathing waters. The aim of this study was to quantify the prevalence of symptoms of illness associated with sea bathing in bathers in England and Wales. A cross-sectional study was conducted between June 2014 and April 2015. An online survey collected information from sea bathers and non-bathers on their visits to beaches in England and Wales along with the occurrence of symptoms of illness. 2631 people (1693 bathers, 938 non-bathers) responded to the survey. Compared to non-bathers, bathers were more likely to report skin ailments (adjusted prevalence odds ratio (AOR) = 2.64, 95% confidence interval (CI) 1.23 to 5.65, p = 0.01), ear ailments (AOR = 3.77, 95% CI 1.84 to 7.73, p < 0.001), and any symptoms of illness (AOR = 3.73, 95% CI 2.63 to 5.29, p < 0.001). There was weak evidence of an increase in the odds of gastrointestinal illness (AOR = 1.59, 95% CI 0.96 to 2.65, p = 0.07), respiratory ailments (AOR = 2.44, 95% CI 0.92 to 6.48, p = 0.07) and eye ailments (AOR = 2.12, 95% CI 0.83 to 5.39, p = 0.11). While the study design does not allow inference of causality, we do observe an association between sea bathing in England and Wales and reported symptoms of ill health. This suggests that despite higher rates of compliance with water quality criteria among bathing waters nowadays, the odds of illness for bathers relative to non-bathers is similar in magnitude to estimates made in the 1990s. • Bathing water quality in the UK has improved over the last few decades. • A cross-sectional study of self-reported illness in bathers and non-bathers was done. • Bathers reported a higher frequency of illness compared to non-bathers. • The reported risks of illness were similar to those measured in the 1990s. [ABSTRACT FROM AUTHOR]

Background: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, for which there are effective pharmacological treatments that improve symptoms and reduce complications. Guidelines published by the National Institute for Health and Care Excellence recommend that primary care practitioners prescribe medication for adult ADHD under shared-care agreements with Adult Mental Health Services (AMHS). However, provision remains uneven, with some practitioners reporting a lack of support., Aim: This study aimed to describe elements of support, and their availability/use, in primary care prescribing for adult ADHD medication in England to improve access for this underserved population and inform service improvement., Design and Setting: Cross-sectional surveys were used to elicit data from commissioners, health professionals (HPs), and people with lived experience of ADHD (LE) across England about elements supporting pharmacological treatment of ADHD in primary care., Method: Three interlinked cross-sectional surveys were used to ask every integrated care board in England (commissioners), along with convenience samples of HPs and LEs, about prescribing rates, AMHS availability, wait times, and shared-care agreement protocols/policies for the pharmacological treatment of ADHD in primary care. Descriptive analyses, percentages, and confidence intervals were used to summarise responses by stakeholder group. Variations in reported provision and practice were explored and displayed visually using mapping software., Results: Data from 782 responders (42 commissioners, 331 HPs, 409 LEs) revealed differences in reported provision by stakeholder group, including for prescribing (95% of HPs versus 64% of LEs). In all, >40% of responders reported extended AMHS wait times of ≥2 years. There was some variability by NHS region - for example, London had the lowest reported extended wait time (25%), while East of England had the highest (55%)., Conclusion: Elements supporting appropriate shared-care prescribing of ADHD medication via primary care are not universally available in England. Coordinated approaches are needed to address these gaps., (© The Authors.)

Objective: To determine the feasibility of a definitive trial in primary care of electronic clinical decision support (eCDS) for possible oesophago-gastric (O-G) cancer., Design and Setting: Feasibility study in 42 general practices in two regions of England, cluster randomised controlled trial design without blinding, nested qualitative and health economic evaluation., Participants: Patients aged 55 years or older, presenting to their general practitioner (GP) with symptoms associated with O-G cancer. 530 patients (mean age 68 years, 58% female) participated., Intervention: Practices randomised 1:1 to usual care (control) or to receive a previously piloted eCDS tool for suspected cancer (intervention), for use at the discretion of the GPs, supported by a theory-based implementation package and ongoing support. We conducted semistructured interviews with GPs in intervention practices. Recruitment lasted 22 months., Outcomes: Patient participation rate, use of eCDS, referrals and route to diagnosis, O-G cancer diagnoses; acceptability to GPs; cost-effectiveness. Participants followed up 6 months after index encounter., Results: From control and intervention practices, we screened 3841 and 1303 patients, respectively; 1189 and 434 were eligible, 392 and 138 consented to participate. Ten patients (1.9%) had O-G cancer. eCDS was used eight times in total by five unique users. GPs experienced interoperability problems between the eCDS tool and their clinical system and also found it did not fit with their workflow. Unexpected restrictions on software installation caused major problems with implementation., Conclusions: The conduct of this study was hampered by technical limitations not evident during an earlier pilot of the eCDS tool, and by regulatory controls on software installation introduced by primary care trusts early in the study. This eCDS tool needed to integrate better with clinical workflow; even then, its use for suspected cancer may be infrequent. Any definitive trial of eCDS for cancer diagnosis should only proceed after addressing these constraints., Trial Registration Number: ISRCTN125595588., Competing Interests: Competing interests: JAU-S was funded by a CRUK Prevention Fellowship (C55650/A21464). OCU was supported by the National Institute for Health Research Applied Research Collaboration South West Peninsula., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: We evaluated the effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management (TCM) programme as a universal intervention, given schools' important influence on child mental health., Methods: A two-arm, pragmatic, parallel group, superiority, cluster randomised controlled trial recruited three cohorts of schools (clusters) between 2012 and 2014, randomising them to TCM (intervention) or Teaching As Usual (TAU-control). TCM was delivered to teachers in six whole-day sessions, spread over 6 months. Schools and teachers were not masked to allocation. The primary outcome was teacher-reported Strengths and Difficulties Questionnaire (SDQ) Total Difficulties score. Random effects linear regression and marginal logistic regression models using Generalised Estimating Equations were used to analyse the outcomes., Trial Registration: ISRCTN84130388., Results: Eighty schools (2075 children) were enrolled; 40 (1037 children) to TCM and 40 (1038 children) to TAU. Outcome data were collected at 9, 18, and 30-months for 96, 89, and 85% of children, respectively. The intervention reduced the SDQ-Total Difficulties score at 9 months (mean (s.d.):5.5 (5.4) in TCM v. 6.2 (6.2) in TAU; adjusted mean difference = -1.0; 95% CI-1.9 to -0.1; p = 0.03) but this did not persist at 18 or 30 months. Cost-effectiveness analysis suggested that TCM may be cost-effective compared with TAU at 30-months, but this result was associated with uncertainty so no firm conclusions can be drawn. A priori subgroup analyses suggested TCM is more effective for children with poor mental health., Conclusions: TCM provided a small, short-term improvement to children's mental health particularly for children who are already struggling.

Background: Around 17% of people attending UK cardiac rehabilitation programmes have depression. Optimising psychological wellbeing is a rehabilitation goal, but provision of psychological care is limited. We developed and piloted an Enhanced Psychological Care (EPC) intervention embedded within cardiac rehabilitation, aiming to test key areas of uncertainty to inform the design of a definitive randomised controlled trial (RCT) and economic evaluation., Methods: An external pilot randomised controlled trial (RCT) randomised eight cardiac rehabilitation teams (clusters) to either usual care of cardiac rehabilitation provision (UC), or EPC in addition to UC. EPC comprised mental health care coordination and patient-led behavioural activation with nurse support. Adults eligible for cardiac rehabilitation following an acute coronary syndrome and identified with new-onset depressive symptoms during an initial nurse assessment were eligible. Measures were performed at baseline and 5- and 8-month follow-ups and compared between EPC and UC. Team and participant recruitment and retention rates, and participant outcomes (clinical events, depression, anxiety, health-related quality of life, patient experiences, and resource use) were assessed., Results: Eight out of twenty teams were recruited and randomised. Of 614 patients screened, 55 were eligible and 29 took part (5%, 95% CI 3 to 7% of those screened), with 15 patient participants cluster randomised to EPC and 14 to UC. Nurse records revealed that 8/15 participants received the maximum number of EPC sessions offered; and 4/15 received no sessions. Seven out of fifteen EPC participants were referred to another NHS psychological service compared to none in UC. We followed up 27/29 participants at 5 months and 17/21 at 8 months. The mean difference (EPC minus UC) in depressive symptoms (Beck Depression Inventory) at follow-up (adjusting for baseline score) was 1.7 (95% CI - 3.8 to 7.3; N = 26) at 5 months and 4.4 (95% CI - 1.4 to 10.2; N = 17) at 8 months., Discussion: While valued by patients and nurses, organisational and workload constraints are significant barriers to EPC implementation. There remains a need to develop and test new models of psychological care within cardiac rehabilitation. Our study offers important data to inform the design of future trials of similar interventions., Trial Registration: ISRCTN34701576 . Registered on 29 May 2014. Funding details: UK NIHR HTA Programme (project 12/189/09).

Background: The majority of adults are not meeting the guidelines for physical activity despite activity being linked with numerous improvements to long-term health. In light of this, researchers have called for more community-level interventions. The main objective of the present study was to evaluate whether a community-level physical activity intervention increased the activity levels of rural communities., Methods: 128 rural villages (clusters) were randomised to receive the intervention in one of four time periods between April 2011 and December 2012. The Devon Active Villages intervention provided villages with 12 weeks of physical activity opportunities for all age groups, including at least three different types of activities per village. Each village received an individually tailored intervention, incorporating a local needs-led approach. Support was provided for a further 12 months following the intervention. The evaluation study used a stepped wedge cluster randomised controlled trial design. All 128 villages were measured at each of five data collection periods using a postal survey. The primary outcome of interest was the proportion of adults reporting sufficient physical activity to meet internationally recognised guidelines. Minutes spent in moderate-and-vigorous activity per week was analysed as a secondary outcome. To compare between intervention and control modes, random effects linear regression and marginal logistic regression models were implemented for continuous and binary outcomes respectively., Results: 10,412 adults (4693 intervention, 5719 control) completed the postal survey (response rate 32.2%). The intervention did not increase the odds of adults meeting the physical activity guideline (adjusted OR 1.02, 95% CI: 0.88 to 1.17; P = 0.80), although there was weak evidence of an increase in minutes of moderate-and-vigorous-intensity activity per week (adjusted mean difference = 171, 95% CI: -16 to 358; P = 0.07). The ineffectiveness of the intervention may have been due to its low penetration-only 16% of intervention mode participants reported awareness of the intervention and just 4% reported participating in intervention events., Conclusions: A community-level physical activity intervention providing tailored physical activity opportunities to rural villages did not improve physical activity levels in adults. Greater penetration of such interventions must be achieved if they are to increase physical activity prevalence at the community level., Trial Registration: Current Controlled Trials ISRCTN37321160.

Background: The number of thyroid function tests (TFTs) performed in the UK and other countries has increased considerably in recent years. Inconsistent clinical practice associated with inappropriate requests for tests is thought to be an important cause for this increase., Aim: To study the extent of variability in requests for TFTs from general practices., Methods: We analysed routine data on all TFTs on patients aged 16 years and over carried out by two hospitals in south-west England (Royal Cornwall Hospital and Royal Devon & Exeter Hospital) during 2010 at the request of 107 general practices., Results: A total of 195 309 TFT requests were made for 148 412 patients (63% female). The total requests included 192 108 tests for thyroid-stimulating hormone (TSH), 43 069 for free thyroxine (FT4) and 1972 for free tri-iodothyronine (FT3). The number of TSH tests per 1000 list size varied widely across the practices, ranging from 84 to 482. Most of the variation was due to heterogeneity across practices and only 24% of this was accounted for by prevalence of hypothyroidism and socio-economic deprivation., Conclusions: There is wide variation in TFT requests from general practice and scope to reduce both unnecessary TFTs and the variability in the clinical practice. Further studies are required to understand the causes for the variability in testing thyroid function.