Cessation of Smoking Trial in the Emergency Department (COSTED): a multicentre randomised controlled trial

BACKGROUND

Supporting people to quit smoking is one of the most powerful interventions to improve health. The Emergency Department (ED) represents a potentially valuable opportunity to deliver a smoking cessation intervention if it is sufficiently resourced. The objective of this trial was to determine whether an opportunistic ED-based smoking cessation intervention can help people to quit smoking.

METHODS

In this multicentre, parallel-group, randomised controlled superiority trial conducted between January and August 2022, adults who smoked daily and attended one of six UK EDs were randomised to intervention (brief advice, e-cigarette starter kit and referral to stop smoking services) or control (written information on stop smoking services). The primary outcome was biochemically validated abstinence at 6 months.

RESULTS

An intention-to-treat analysis included 972 of 1443 people screened for inclusion (484 in the intervention group, 488 in the control group). Of 975 participants randomised, 3 were subsequently excluded, 17 withdrew and 287 were lost to follow-up. The 6-month biochemically-verified abstinence rate was 7.2% in the intervention group and 4.1% in the control group (relative risk 1.76; 95% CI 1.03 to 3.01; p=0.038). Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (relative risk 1.80; 95% CI 1.36 to 2.38; p<0.001). No serious adverse events related to taking part in the trial were reported.

CONCLUSIONS

An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events.

TRIAL REGISTRATION NUMBER

NCT04854616.

Selecting an e-cigarette for use in smoking cessation interventions and healthcare services: findings from patient and public consultation for the COSTED trial

OBJECTIVES

The Cessation of Smoking Trial in the Emergency Department (COSTED) trial aims to ascertain whether brief advice, the provision of an e-cigarette starter kit and referral to stop smoking services (SSS), increases smoking cessation in people attending the emergency department. Patient and public involvement (PPI) and scoping work were undertaken to select an appropriate e-cigarette for the trial.

DESIGN AND SETTING

PPI consultation and feasibility scoping about potential devices with a professional and lay panel, all based in England. Consultation was via email, telephone or video interview. This work took place between April and July 2021, prior to recruitment commencing for the COSTED trial.

PARTICIPANTS

A professional panel (n=7) including representatives from academia, SSS and the independent vaping industry, and a PPI lay panel (n=3) who smoke or vape.

RESULTS

The professional panel recommended a shortlist of devices which were tested by the PPI lay panel. Key criteria for selecting an appropriate e-cigarette for smoking cessation intervention include satisfaction, usability, affordability and availability. Simplicity of use was highlighted by the PPI lay panel, who found refillable devices complex, and availability of consumables was highlighted as more important than price by both panels. The pod device selected for inclusion was rated highly for satisfaction and usability and had mid-price range and consumables which were widely available.

CONCLUSIONS

To select the most appropriate device for the COSTED trial, each criterion required assessment to ensure the best fit to the intervention context and needs of the target population. There is a need for guidance to help enable decision-making about choice of vape products, tailored to service users' needs. We propose a bespoke checklist template, based on our findings, to assist with this process. This has applicability to the recent government announcement of a 'Swap to Stop' programme, offering a vaping starter kit to smokers across England, allowing services flexibility to shape their own programmes and models of delivery.

TRIAL REGISTRATION NUMBER

Clinical trial number NCT04854616; pre-results.

"Taking from Peter to pay Paul": The experience of people in receipt of fuel and food vouchers from a UK foodbank

For people on very low incomes, household fuel and food environments are increasingly uncertain. Many live in precarious situations with little control over their lives. In addition to food parcels, many foodbanks also supply emergency fuel payments. There has been a surge in demand due to the cost of living crisis in the United Kingdom. This qualitative study, using semi-structured interviews, explored the lived experience of people who received a fuel voucher via a foodbank to gain insights into food preparation, eating practices and heating and appliance use in their homes. All participants (n = 6) described a change in life circumstances leaving them at crisis point with overwhelming uncertainty. Using Thematic Analysis, we identified four themes: (1) Bewilderment in using foodbank services; (2) The need to make trade-offs between food and fuel; (3) Feeling shame at using the services and (4) Missing out on pleasurable eating practices. Three case studies give fuller insights and context. All interviewees had acute and complex needs and described being 'at rock bottom', with fuel vouchers viewed as a 'lifeline' to address essential cooking, heating and electrical appliance needs. We, therefore, suggest the need for extra support and follow-up for first-time users who are in a state of denial and shock when seeking help. Further research is needed on how to best help organisations develop strategies to address and ameliorate a sense of powerlessness and shame felt by their clients which likely limits them from seeking help, despite being in acute, complex and dire need.

Lest we forget. Illuminating lived experience of the Covid-19 pandemic and lockdown

The COVID-19 pandemic and associated 'lockdowns' profoundly impacted people's lives in 2020-2021 and beyond. This study sought to understand unique person-centred insights into health and wellbeing during the restrictive measures in the United Kingdom and to enable us to remember and give testimony to these lived experiences. Using photo-methods, participants from a larger cohort study which tracked people's behaviours during the pandemic were invited to share photographs and short text to visually illustrate their ephemeral and unique COVID-19 experiences. In total 197 participants shared 398 photographs. Using a critical realist approach in our design and analysis, we sought to gain an alternative viewpoint on what 'lockdown' and the pandemic meant. Our major findings revealed starkly contrasting experiences illustrated in our two major themes. Firstly loss, including ambiguous losses and a sense of loss, loss of freedoms and death. Secondly, salutogenesis (what makes us well) whereby participants were able to draw on assets which helped to keep them well by maintaining social connection, 'making the best of it', reconnecting with nature and appreciating the outdoors, creativity for pleasure and faith. Our findings illuminate widely differing experiences and indicate the powerful effect of assets that were perceived by our participants to protect their wellbeing. Understanding differential vulnerability will be essential going forward to target resources appropriately to those who have the least control over their lives, those with the greatest vulnerabilities and least assets which in turn could support a self-perpetuating recovery.

Biochemical Verification of Tobacco-Use as an Inclusion Criterion in Smoking Cessation Trials- Lessons From the Cessation of Smoking Trial in the Emergency Department

INTRODUCTION

Biochemical verification of smoking status prior to recruitment into smoking cessation trials is widely used to confirm smoking status, most commonly using exhaled carbon monoxide (CO). There is variation in the level of CO used as a biochemical inclusion criterion, and thus the possibility for people reporting to be current smokers to be incorrectly excluded from trials.

METHODS

As part of the Cessation of Smoking Trial in the Emergency Department, people attending the Emergency Department (ED) who reported being current daily smokers underwent CO testing to confirm eligibility. Elective semi-structured interviews were undertaken with the researchers who recruited participants. As part of the interviews, researchers were asked their views and experiences with CO testing.

RESULTS

Of the 1320 participants who reported being current daily smokers and underwent CO testing, 300 (22.7%) blew a CO reading of 7 ppm or less and were excluded from taking part. Possible explanations offered by researchers for participants blowing low CO readings were (1) long wait times in the ED, therefore a long period having elapsed since people had last smoked and (2) patients having reduced smoking for the period before the ED attendance due to ill health.

CONCLUSIONS

Biochemical verification has the potential to improve internal validity of smoking cessation for inclusion in trials, but at the cost of reduced generalisability through exclusion of participants who would receive the intervention if it were implemented in practice. We would recommend researchers carefully consider whether it is appropriate and necessary to include biochemical verification as an inclusion criterion.

Behaviour Change Techniques to promote self-management and home exercise adherence for people attending physiotherapy with musculoskeletal conditions: A scoping review and mapping exercise

BACKGROUND

Many patients with musculoskeletal problems do not adhere to home exercises or self-management advice provided by physiotherapists. This is due to numerus factors, many of which can be targeted by Behaviour Change Techniques.

OBJECTIVES

1) Undertake a scoping review to identify the modifiable determinants (barriers and facilitators) of home exercise adherence and self-management for the physiotherapy management of people with musculoskeletal problems and map them to the Theoretical Domains Framework and Behaviour Change Techniques. 2) For determinants with supporting evidence from ≥2 studies, provide examples of Behaviour Change Techniques for clinical practice.

DESIGN

This review follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

METHOD

Four electronic databases were searched from inception to December 2022. Two independent reviewers carried out manuscript selection, data extraction, quality assessment, and mapping, the latter using the Theory and Techniques Tool.

RESULTS

Thirteen modifiable determinants were identified in 28 studies. The most frequently identified were self-efficacy, social support, and task appreciation. Determinants were mapped to 7 of 14 Theoretical Domains Framework categories, which in turn mapped onto 42 of 93 Behaviour Change Techniques, the most common being problem solving and instruction on how to perform behaviour.

CONCLUSIONS

By identifying determinants to home exercise adherence and self-management and mapping these to Behaviour Change Techniques, this review has improved understanding of their selection, targeting, and potential application to musculoskeletal physiotherapy practice. This provides support for physiotherapists targeting the determinants of importance for the patient in front of them.

We care but we're not carers: perceptions and experiences of social prescribing in a UK national community organisation

AIMS

(1) To explore how social prescribing referrals impact experiences of existing members of a voluntary and community-based organisation and (2) to describe the processes and relationships associated with joining community and voluntary organisations.

METHODS

Online survey and qualitative interviews with members of Men's Sheds, a global volunteer-led initiative to address loneliness and social isolation in men. 93 self-selecting Shed members (average age 67 years, 93% male) from across England and Scotland took part in the survey about demographics, joining the Shed, and free-text questions about experiences in the Shed. From the survey participants, 21 Shed members were purposively sampled and interviewed to explore the impact of social prescribing and referrals on the Sheds.

RESULTS

Participating in the Men's Shed was often associated with a significant change in personal circumstances, and Sheds provided a unique social support space, particularly valuable for men. Key factors around experiences of social prescribing and referral mechanisms were identified. We developed three themes: the experience of joining a Shed, success factors and risks of social prescribing, and 'we care but we're not carers'.

CONCLUSIONS

The results show that Men's Sheds are a caring organisation, but their members are not trained as professional carers, and men come to the Shed for their own personal reasons. They are concerned about the potential additional responsibilities associated with formal referrals. They encourage the development of relationships and local-level understanding of the essence of Sheds to enable social prescribing. As models of social prescribing grow nationally and internationally, collaboratively working with voluntary and community organisations to develop a mutually beneficial approach is essential for the effectiveness and sustainability of social prescribing in community health.

A Pilot E-Cigarette Voucher Scheme in a Rural County of the United Kingdom

INTRODUCTION

E-Cigarette voucher schemes have been piloted across the UK to support populations to quit smoking. This short report evaluates a scheme that targets vulnerable and disadvantaged smokers who had failed to quit smoking by other means.

METHODS

Descriptive summary evaluation of service data on smoking outcomes and qualitative data from selected participants, as "key-informants" (n = 4) and key stakeholders (stop smoking staff, vape shop staff, and general practitioners [GPs]).

RESULTS

In total, 668 participants were referred to the scheme, and 340 participants redeemed a voucher. By intention to treat analysis (ITT) 143/668 (21%) were recorded as quit smoking at 4 weeks. At 12 weeks, 7.5% of participants had quit, by ITT. Overall, the pilot project was well received by clients as it offered an affordable route into vaping for smoking cessation. GPs supported the scheme and appreciated being able to offer an alternative to entrenched smokers.

CONCLUSIONS

The scheme shows promise in supporting entrenched smokers to quit smoking. The offer of similar voucher schemes across the UK suggests the potential to reduce overall smoking prevalence and associated morbidity and mortality.

IMPLICATIONS

Working with GPs in a deprived area, it was possible to set-up a vape shop voucher scheme for smoking cessation. Patients with comorbidities who had tried and failed to quit smoking previously were referred to receive a vape shop voucher to be redeemed for an initial starter kit, alongside support from the stop smoking service. This innovative scheme enabled 42% of entrenched smokers who redeemed a voucher to successfully quit smoking within 4 weeks.

Cessation of smoking trial in the emergency department (CoSTED): protocol for a multicentre randomised controlled trial

INTRODUCTION

Attendees of emergency departments (EDs) have a higher than expected prevalence of smoking. ED attendance may be a good opportunity to prompt positive behaviour change, even for smokers not currently motivated to quit. This study aims to determine whether an opportunist smoking cessation intervention delivered in the ED can help daily smokers attending the ED quit smoking and is cost-effective.

METHODS AND ANALYSIS

A two-arm pragmatic, multicentred, parallel-group, individually randomised, controlled superiority trial with an internal pilot, economic evaluation and mixed methods process evaluation. The trial will compare ED-based brief smoking cessation advice, including provision of an e-cigarette and referral to local stop smoking services (intervention) with the provision of contact details for local stop smoking services (control). Target sample size is 972, recruiting across 6 National Health Service EDs in England and Scotland. Outcomes will be collected at 1, 3 and 6 months. The primary outcome at 6 months is carbon monoxide verified continuous smoking abstinence.

ETHICS AND DISSEMINATION

The trial was approved by the South Central-Oxford B Research Committee (21/SC/0288). Dissemination will include the publication of outcomes, and the process and economic evaluations in peer-reviewed journals. The findings will also be appropriately disseminated to relevant practice, policy and patient representative groups.

TRIAL REGISTRATION NUMBER

NCT04854616; protocol V.4.2.

"I have travelled along on my own"-Experiences of seeking help for serious non-COVID health problems during the COVID-19 pandemic: A qualitative study

OBJECTIVES

During COVID-19 the UK general population has been given strong messages to stay at home. Concurrently unprecedented changes occurred in healthcare access with moves to remote/triage systems. Data have shown that the number of people accessing healthcare services decreased and there are significant concerns that the pandemic has negatively affected help-seeking for serious conditions, with potentially increased morbidity and mortality. An understanding of help-seeking is urgently needed to inform public campaigns. We aimed to develop an in-depth, theory-based understanding of how, when and why people sought help for potentially serious symptoms (e.g., related to major cardiovascular events or cancer diagnoses) during the pandemic, and what influenced their decisions.

DESIGN

Qualitative semi-structured interviews.

METHODS

We interviewed 25 adults recruited through a targeted social media campaign. Interviews were conducted via telephone or online platform. Our topic guide was informed by the Model of Pathways to Treatment and the Capability-Opportunity-Motivation-Behaviour model.

RESULTS

The analysis identified four main themes: Delay in recognition, Holding on to concerns, Weighing it up and Long-term impacts. Multiple societal and environmental factors influenced participants' help-seeking and motivation, capability and opportunity to seek help, with long-term impacts on well-being and future help-seeking.

CONCLUSIONS

There is a need for clear guidance about pathways to raise concerns about symptoms and gain advice while usual healthcare contacts are paused or stopped. Recommendations for future interventions to support help-seeking during pandemics include clearer messaging, co-produced with end-users, on when, where and how to seek help.

Disruption and adaptation in response to the coronavirus pandemic - Assets as contextual moderators of enactment of health behaviours

PURPOSE

During the COVID-19 UK first national lockdown (March-July 2020) enactment of healthy behaviours was fundamentally changed due to social restrictions. This study sought to understand perspectives on health behaviour change, as part of a wider study tracking reported health behaviour change over time.

METHODS

A purposive sample was selected. N = 40 qualitative interviews were conducted remotely (phone/video) from participants across England and Wales, and transcribed verbatim. Descriptive case studies were shared at regular analysis meetings. Inductive reflexive thematic coding was undertaken and coding was discussed using a team approach to agreeing analytical codes. A multiple lens theoretical perspective was adopted to illuminate the perceived influences and restrictions on participants' reports of health behaviour change.

RESULTS

There was a clear progressive narrative for all participants, through initial responses and reactions to the pandemic, framed as 'disruption', then, as lockdown was acclimatized to, evidence of 'adaptation'. Adaptation was seen in terms of modification, substitution, adoption, discontinuation/cessation, stultification, maintenance and recalibration of health behaviours. An illustrative case study exemplifies the narrative encompassing these features and demonstrating the complex non-linear interactions between context and enacted health behaviours.

CONCLUSIONS

Individuals responded to pandemic-related social restrictions in complex ways. Those in contexts with existing social assets, community links and established patterns of healthy behaviours were able to respond positively, adapting by modifying behaviour and using technology to engage in healthy behaviours in new and innovative ways. For those in more vulnerable contexts, enacting (negative) health behaviour change was an expression of frustration at the limitations imposed by social restrictions.

Impact of COVID-19 pandemic social restriction measures on people with rheumatic and musculoskeletal diseases in the UK: a mixed-methods study

OBJECTIVES

To determine the impact of COVID-19 pandemic social restriction measures on people with rheumatic and musculoskeletal diseases (RMDs) and to explore how people adapted to these measures over time.

DESIGN

Mixed-methods investigation comprising a national online longitudinal survey and embedded qualitative study.

SETTING

UK online survey and interviews with community-dwelling individuals in the East of England.

PARTICIPANTS

People in the UK with RMDs were invited to participate in an online survey. A subsection of respondents were invited to participate in the embedded qualitative study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The online survey, completed fortnightly over 10 weeks from April 2020 to August 2020, investigated changes in symptoms, social isolation and loneliness, resilience and optimism. Qualitative interviews were undertaken assessing participant's perspectives on changes in symptoms, exercising, managing instrumental tasks such a shopping, medication and treatment regimens and how they experienced changes in their social networks.

RESULTS

703 people with RMDs completed the online survey. These people frequently reported a deterioration in symptoms as a result of COVID-19 pandemic social restrictions (52% reported increase vs 6% reported a decrease). This was significantly worse for those aged 18-60 years compared with older participants (p=0.017). The qualitative findings from 26 individuals with RMDs suggest that the greatest change in daily life was experienced by those in employment. Although some retired people reported reduced opportunity for exercise outside their homes, they did not face the many competing demands experienced by employed people and people with children at home.

CONCLUSIONS

People with RMDs reported a deterioration in symptoms when COVID-19 pandemic social restriction measures were enforced. This was worse for working-aged people. Consideration of this at-risk group, specifically for the promotion of physical activity, changing home-working practices and awareness of healthcare provision is important, as social restrictions continue in the UK.

Health behaviour change during the UK COVID‐19 lockdown: Findings from the first wave of the C‐19 health behaviour and well‐being daily tracker study

Objectives

To provide baseline cohort descriptives and assess change in health behaviours since the UK COVID‐19 lockdown.

Design

A prospective cohort (N = 1,044) of people recruited online, purposively targeting vulnerable populations.

Methods

After a baseline survey (April 2020), participants completed 3 months of daily ecological momentary assessments (EMA). Dietary, physical activity, alcohol, smoking, vaping and substance use behaviours collected retrospectively for the pre‐COVID‐19 period were compared with daily EMA surveys over the first 30 days during early lockdown. Predictors of behaviour change were assessed using multivariable regression models.

Results

30% of the cohort had a COVID‐19 at risk health condition, 37% were classed as deprived and 6% self‐reported a mental health condition. Relative to pre‐pandemic levels, participants ate almost one portion of fruit and vegetables less per day (vegetables mean difference −0.33, 95% CI −0.40, −0.25; fruit −0.57, 95% CI −0.64, −0.50), but showed no change in high sugar portions per day (−0.03, 95% CI −0.12, 0.06). Participants spent half a day less per week doing ≥30 min of moderate to vigorous physical activity (−0.57, 95% CI −0.73, −0.40) but slightly increased days of strength training (0.21, 95% CI 0.09, 0.34), increased alcohol intake (AUDIT‐C score change 0.25, 95% CI 0.13, 0.37), though did not change smoking, vaping or substance use behaviour. Worsening health behaviour change was associated with being younger, female and higher body mass index.

Conclusions

The cohort reported worsening health behaviours during early lockdown. Longer term changes will be investigated using further waves of data collection.

Fatal child maltreatment in England, 2005-2009

OBJECTIVE

This paper presents comprehensive and up-to-date data covering 4 years of Serious Case Reviews into fatal child maltreatment in England.

METHODS

Information on all notified cases of fatal maltreatment between April 2005 and March 2009 was examined to obtain case characteristics related to a systemic classification of 5 broad groups of maltreatment deaths (severe physical assaults; covert homicide/infanticide; overt homicide; extreme neglect/deprivational abuse; deaths related to but not directly caused by maltreatment).

RESULTS

A total of 276 cases were recorded giving an incidence of 0.63 cases per 100,000 children (0-17) per year. 246 cases could be classified based on the data available. Of these the commonest specific group was those children who died as a result of severe physical assaults. Apparently deliberate overt and covert homicide was less common, while deaths as a direct consequence of neglect were rare. In contrast, some evidence of neglect was found in at least 40% of all cases, though not the direct cause of death.

CONCLUSIONS

Class characteristics differ between the different categories of death and may suggest the need for different strategies for prevention.

Healthcare use by children fatally or seriously harmed by child maltreatment: analysis of a national case series 2005-2007

AIM

To determine antecedent patterns of healthcare use by children fatally or seriously harmed by maltreatment.

METHODS

The authors analysed recorded healthcare use for children who were the subject of a serious case review (SCR) in England in 2005-2007. The SCRs were initiated when a child under 18 years old died or was seriously harmed, maltreatment (abuse or neglect) was a factor, and there were lessons for interagency working. The authors analysed a purposive sample (N=40), similar in key demographics to all 189 SCRs in England in 2005-2007.

RESULTS

Children had extensive recorded contact with universal (N=34/40; 85%) and secondary (N=26/40; 65%) healthcare services and children's social care (N=21/40; 53%). Thirty-one children (78%) had recorded health visitor and/or school nurse contact. Fourteen children (35%) had missed appointments. Almost three-quarters (N=29) had complex family problems recorded (parental domestic violence, alcohol/drug and/or mental health problems). Data quality regarding healthcare use was poor, and the extent and type of 'missing data' varied by age.

CONCLUSIONS

Complex paediatric and family problems and a high level of contact with services preceded serious adverse events. Universal health services are likely to be well placed for giving ongoing and family-orientated support to vulnerable families. The absence of standardised data collection and any control group limits how far the Biennial Analyses of SCRs can meet their stated objective of identifying national trends and patterns. Linking SCRs to healthcare databases would provide a control group, improve understanding of the population context and diminish demands for data from professionals delivering care.

Does breakfast-club attendance affect schoolchildren's nutrient intake? A study of dietary intake at three schools

Lack of breakfast has been implicated as a factor contributing to children's poor diets and school performance. Breakfast-club schemes, where children are provided with breakfast in school at the start of the school day, have been initiated by the Department of Health in schools throughout England, UK. The aim of the present study was to compare the energy and nutrient intakes of schoolchildren who attended breakfast clubs (attendee subjects) with those who did not (control subjects). Three different schools were studied, involving a total of 111 children aged between 9 and 15 years. There were fifty-nine attendee and fifty-two control subjects. The two groups were matched for eligibility for school meals. All subjects completed a 3 d weighed food diary for estimation of nutrient intake. Height and weight were measured and BMI calculated. Nutrient intake data were analysed using a general linear model with age as a covariate. The demographic and anthropometric characteristics of the attendee and control subjects were similar. Children who attended breakfast clubs had significantly greater intakes of fat (% energy), saturated fat (% energy) and Na than control subjects. Thus, in these schools breakfast-club participation was not associated with superior nutrient intake or improvements in dietary pattern.

A national evaluation of school breakfast clubs: evidence from a cluster randomized controlled trial and an observational analysis

STUDY OBJECTIVE

To measure the health, educational and social impacts of breakfast club provision in schools serving deprived areas across England.

DESIGN

A cluster randomized controlled trial and an observational analysis.

SETTING

England, the UK.

INTERVENTION

funding to establish a school-based breakfast club vs. control (no funding).

MAIN RESULTS

Intention to treat analysis showed improved concentration (Trail Making Test Part A) amongst the intervention group at 3 months. Fewer pupils within the intervention group reported having skipped classes within the last month and fewer pupils within the intervention group reported having skipped 1 or more days of school within the last month at 1 year. Observational analysis at 1 year showed a higher proportion of primary-aged breakfast club attendees reported eating fruit for breakfast in comparison to non-attendees. A higher proportion of breakfast club attendees had borderline or abnormal conduct and total difficulties scores (primary-aged pupils) and prosocial score (secondary-aged pupils).

CONCLUSIONS

Analyses revealed a mixed picture of benefit and apparent disbenefit. This study illustrated the challenges of evaluating a complex intervention in which the evaluators had less control than is usual in randomized trials over recruitment, eligibility checking and implementation. If the impact of new policy initiatives is to be assessed using the most robust forms of evaluation, social policy needs to be organized so that evaluations can be constructed as experiments. This is likely to prove most difficult where the perceived value of implementing an intervention rapidly is high.

A national evaluation of school breakfast clubs: where does economics fit in?

STUDY OBJECTIVE

To describe the economics of UK school breakfast clubs, to estimate costs resulting from clubs and to investigate relationships between costs and outcomes.

DESIGN

A postal survey of schools with a 1-year follow-up, a cluster randomized controlled trial, case studies, semi-structured interviews with parents and a secondary econometric analysis.

SETTING

England, the UK.

MAIN RESULTS

Key economic differences were identified between clubs based in primary schools and those based in secondary schools in terms of both funding levels and cost structures. However, funding levels were not a significant determinant of the observed outcomes in either type of school.

CONCLUSIONS

For formal economic evaluation to succeed during implementation of a new initiative, a clearer understanding of relevant outcomes and the distinction between short- and long-term outcomes and potential individual, institutional and societal benefits are required from an early stage.