Rhiannon Tudor Edwards’s research while affiliated with Bangor University and other places

In the UK, more than 100,000 strokes occur each year, and this is expected to rise to over 2.1 million by 2035. Life after stroke services aim to support peoples physical and emotional state, are complimentary to rehabilitation and take a non-medical holistic approach to living well after a stroke. This rapid review aimed to identify evidence on the cost-effectiveness of life after stroke services, and the impact of these interventions on health or social care resource use. The review included evidence from 12 studies (7 economic evaluations and 5 randomised controlled trials), published between January 2000 and August 2024. The economic evaluations assessed a number of interventions to support stroke survivors, their families and caregivers. Two of the randomised controlled trials were partial economic evaluations, reporting on cost and resource use data related to training caregivers, and an arts and health-based intervention. The other three trials reported on resource use but not cost data, and assessed family support interventions, and a telehealth intervention to assist stroke survivors and their carers. There was a lack of evidence on the cost-effectiveness of life after stroke as a comprehensive service. However, this review identified evidence on the cost-effectiveness and resource utilisation of specific interventions within these services. Findings include that a community-based Individual Management Program for post-stroke survivors was cost-effective from a societal perspective at 24-month follow-up. A carer training intervention, delivered whilst the stroke patient was in hospital, was associated with a reduction in health and social care resource use when evaluated at a single hospital. However, this intervention was not cost-effective when rolled out and assessed across multiple hospitals. Other findings included that a combination of speech and language therapy with voluntary support services had a lower cost per session compared to NHS speech and language therapy alone. Family support organiser interventions for stroke survivors and carers were associated with reduced healthcare utilisation. To fully understand the effectiveness and cost-effectiveness of life after stroke interventions, research is needed to assess potential long-term impacts. A reduction in resource use may be associated with cost savings and reduced burden on the NHS. However, an increase in health care and social care use may also be appropriate due to better signposting or identification of peoples needs. Evidence is also needed on the cost-effectiveness of supporting stroke survivors in returning to the workforce. Many of the sample sizes in the included studies lacked ethnic diversity. Stroke trials need strategies to achieve equity of access. This review focused on evidence of cost-effectiveness and resource utilisation. Decisions relating to policy and practice should also consider evidence on clinical effectiveness and patient preferences.

Background Childhood bullying is a public health priority. We evaluated the effectiveness and costs of KiVa, a whole-school anti-bullying program that targets the peer context. Methods A two-arm pragmatic multicenter cluster randomized controlled trial with embedded economic evaluation. Schools were randomized to KiVa-intervention or usual practice (UP), stratified on school size and Free School Meals eligibility. KiVa was delivered by trained teachers across one school year. Follow-up was at 12 months post randomization. Primary outcome: student-reported bullying-victimization; secondary outcomes: self-reported bullying-perpetration, participant roles in bullying, empathy and teacher-reported Strengths and Difficulties Questionnaire. Outcomes were analyzed using multilevel linear and logistic regression models. Findings Between 8/11/2019–12/02/2021, 118 primary schools were recruited in four trial sites, 11 111 students in primary analysis (KiVa-intervention: n = 5944; 49.6% female; UP: n = 5167, 49.0% female). At baseline, 21.6% of students reported being bullied in the UP group and 20.3% in the KiVa-intervention group, reducing to 20.7% in the UP group and 17.7% in the KiVa-intervention group at follow-up (odds ratio 0.87; 95% confidence interval 0.78 to 0.97, p value = 0.009). Students in the KiVa group had significantly higher empathy and reduced peer problems. We found no differences in bullying perpetration, school wellbeing, emotional or behavioral problems. A priori subgroup analyses revealed no differences in effectiveness by socioeconomic gradient, or by gender. KiVa costs £20.78 more per pupil than usual practice in the first year, and £1.65 more per pupil in subsequent years. Interpretation The KiVa anti-bullying program is effective at reducing bullying victimization with small-moderate effects of public health importance. Funding The study was funded by the UK National Institute for Health and Care Research (NIHR) Public Health Research program (17-92-11). Intervention costs were funded by the Rayne Foundation, GwE North Wales Regional School Improvement Service, Children's Services, Devon County Council and HSBC Global Services (UK) Ltd.

Background Anxiety in pregnancy and postpartum is highly prevalent but under-recognized and few women receive adequate support or treatment. Identification and management of perinatal anxiety must be acceptable to women in the perinatal period to ensure that women receive appropriate care when needed. We aimed to understand the acceptability to women of how anxiety was identified and managed by healthcare professionals. Method We conducted in-depth qualitative interviews with 60 women across England and Scotland approximately 10 months after birth. Women were sampled from an existing systematically recruited cohort of 2,243 women who recorded mental health throughout pregnancy and after birth. All women met criteria for further assessment of their mental health by a healthcare professional. We analyzed the data using a theoretical framework of acceptability of healthcare interventions. Results Interview data fitted the seven constructs within the theoretical framework of acceptability. Women valued support before professional treatment but were poorly informed about available services. Services which treated women as individuals, which were accessible and in which there was continuity of healthcare professional were endorsed. Experience of poor maternity services increased anxiety and seeing multiple midwives dissuaded women from engaging in conversations about mental health. Having a trusted relationship with a healthcare professional facilitated conversation about and disclosure of mental health problems. Conclusion Women’s experiences would be improved if given the opportunity to form a trusting relationship with a healthcare provider. Interventions offering support before professional treatment may be valued and suitable for some women. Clear information about support services and treatment options available for perinatal mental health problems should be given. Physiological aspects of maternity care impacts women’s mental health and trust in services needs to be restored. Findings can be used to inform clinical guidelines and research on acceptable perinatal care pathways in pregnancy and after birth and future research.

Currently, there is a significant demand for tier 3 weight management services, with individuals waiting between three and five years to access these services in parts of Wales. This rapid review aimed to identify and synthesise the evidence for the effectiveness of strategies for supporting the health and well-being of individuals with obesity on such waiting lists, with a focus on practical and resource-efficient interventions that can be implemented within current healthcare constraints. Seven studies were included, and these were published between 2017 and 2024. Studies were conducted in a range of countries, and no relevant UK based study was identified. Studies investigated exercise, physical activity counselling, education and text message-based prehabilitation interventions in people awaiting surgery. This review did not identify any studies assessing the effectiveness of interventions that could be feasibly implemented or scaled up within the resource limitations of typical tier 3 weight management services in Wales. Most studies required significant resource and input from healthcare professionals, and were delivered in-person at healthcare settings or remotely via teleconferencing. All studies assessed patients with obesity on a waiting list for surgery, but none included a patient population that matched those on waiting lists for tier 3 weight management services in Wales. None of the studies evaluated the cost-effectiveness of interventions. Overall, we are not confident in the evidence. Most studies were of low quality, with significant methodological and reporting limitations affecting the reliability of their findings. Although we have little confidence in the evidence, there is some evidence from four studies, that suggest exercise interventions may support the quality of life and anthropometric measures of people with obesity waiting for surgery. This evidence could be cautiously considered to inform interventions in practice, but those designing interventions should be mindful of the population and setting in which they are applied. Other interventions, including text message-based prehabilitation interventions, preoperative educational interventions and physical activity counselling interventions were reliant on findings from single low-quality studies. Some of these interventions showed improvements for participants quality of life, mental well-being and anthropometric measures. In relation to obesity weight management services, allocation of resources should allow for conducting and evaluating robust studies and economic evaluations investigating interventions for those awaiting obesity weight management services. Given the current healthcare resource constraints, it may be beneficial to consider the feasibility and scalability of interventions during their design.

Citizens Advice on Prescription (CAP), a Liverpool (UK) based service, provides welfare advice and link worker social prescribing support to people experiencing and at risk of financial or social hardship. CAP, which receives referrals from healthcare and third sector services, aims to improve service users’ financial security, health, and wellbeing. A mixed-method Social Return on Investment (SROI) analysis was used to evaluate the service. Between May 2022 and November 2023, a subset of service users (n=538) completed the Short Warwick-Edinburgh Mental Wellbeing Survey (SWEMWBS) at baseline and 2-month follow-up. Supporting quantitative and qualitative economic data was also collected (Feb 2023 - Feb 2024) through semi-structured interviews (n=16). Social value changes were generated using the change in SWEMWBS scores and social valuations from the Mental Health Social Value Bank (MHSVB). SROI ratios were calculated from change of social value against service provision costs. The mean service provision cost was £148.66 per person. The overall study reported a positive SROI return of £1: £3.40-£4.69. Results indicate that non-clinical support services, like CAP, can be an effective intervention to address the wider determinants of health and wellbeing.

The Making Every Contact Count MECC programme encourages staff to have opportunistic brief behaviour change conversations with service users. It uses the day-to-day interactions that healthcare professionals, or those within other organisations, including the not-for-profit sector have with people, to support them in making positive changes to their physical and mental health, and wellbeing. The aim of this review is to assess which elements or types of MECC training, or comparable interventions, are most effective and preferred by those who would implement MECC in practice. The review included evidence available up until June 2024. 11 studies were included. These all focused on healthcare organisations and included health care or public health professionals, with two also including trainees who worked in a local authority. There was consistent evidence that training increased both trainee confidence and use of MECC-related techniques immediately following training. There was some evidence that despite a slight reduction, these improvements were at least maintained up to one year later. There was no evidence on the longer-term effect, other than an indication that refresher training would be appreciated. There was also no evidence assessing whether improvements in trainee confidence and competence had any impact on service user behaviour change and outcomes. There was an indication that face-to-face training was preferred to online training. Barriers to MECC training attendance included a feeling that there was not enough time, and a lack of managerial support. Barriers to MECC utilisation included a feeling that there was not enough time, a lack of organisational and managerial support, a fear of upsetting patients, and a lack of awareness of downstream support services to refer service users to following healthy behaviour conversations. The evidence indicated that barriers to MECC training and utilisation could be overcome via provision of information about downstream support services, and improved organisational and managerial support for both attendance at MECC training and its use in practice. Further research is needed. This should include research into the impact from MECC on patient behaviour and eventual outcomes, and how these change following training. Funding statement The authors and their Institutions were funded for this work by the Health and Care Research Wales Evidence Centre, itself funded by Health and Care Research Wales on behalf of Welsh Government EXECUTIVE SUMMARY What is a Rapid Review? Our Rapid Reviews (RR) use a variation of the systematic review approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. Who is this Rapid Review for? The review question was suggested by Cwm Taf Morgannwg University Health Board Public Health Team. The review is intended to inform those responsible for commissioning and leading Making Every Contact Count (MECC) training. Background / Aim of Rapid Review The MECC programme encourages staff to have opportunistic brief behaviour change conversations with service users. It uses the day-to-day interactions that healthcare professionals, or those within other organisations, including the not-for-profit sector have with people, to support them in making positive changes to their physical and mental health, and wellbeing. The aim of this review is to assess which elements or types of MECC training, or comparable interventions, are most effective and preferred by those who would implement MECC in practice. Findings may be used to inform creation of future training, or to update current offerings, and improve consistency across health boards. Results of the Rapid Review Recency of the evidence base The review included evidence available up until June 2024. Publication dates of included evidence ranged from 2013 to 2023. Extent of the evidence base 11 studies were identified for inclusion in this review; all focused on healthcare organisations. 10 studies took place in the UK (eight of which were in England, and none in Wales), and one was undertaken in Australia. All studies included health care or public health professionals, with two also including trainees who worked in a local authority. Study designs included pre-test/ post-test, post-test only, qualitative study designs (e.g. interviews, surveys), and mixed methods studies. No study included a separate control group. Five of the included studies used surveys or questionnaires only, three used interviews only (either with individuals or focus groups), two used a combination of surveys and interviews, and one undertook surveys, interviews and performed observations of participants. Key findings and certainty of the evidence There was consistent evidence that training increased both trainee confidence and use of MECC-related techniques immediately following training. There was some evidence that despite a slight reduction, these improvements were at least maintained up to one year later . There was no evidence on the longer-term effect, other than an indication that refresher training would be appreciated . There was also no evidence assessing whether improvements in trainee confidence and competence had any impact on service user behaviour change and outcomes. There was an indication that face-to-face training was preferred to online training . However, some trainees did seem to prefer online training due to its increased flexibility. Barriers to MECC training attendance included a feeling that there was not enough time, and a lack of managerial support . Barriers to MECC utilisation included a feeling that there was not enough time, a lack of organisational and managerial support, a fear of upsetting patients, and a lack of awareness of downstream support services to refer service users to following healthy behaviour conversations. The evidence indicated that barriers to MECC training and utilisation could be overcome via provision of information about downstream support services, and improved organisational and managerial support for both attendance at MECC training and its use in practice. Policy and Practice Implications MECC training can be beneficial in improving trainee confidence and competence in using MECC. However, there are consistently reported barriers both to undertaking training and using MECC in practice, as summarised above. Although this review identified some potential ways of overcoming barriers both for attending training and utilising MECC in practice, the best and most effective ways of overcoming them remain unclear, and many require a widespread culture change. The lack of evidence around whether changes to MECC training have an impact on service user behaviour and eventual outcomes, may impact how effective attempted changes to MECC training and workplace culture could be. This review indicates that there appears to be a preference for standardised training with some capacity for tailoring to local needs. This should be taken into account when considering any updates to the Welsh MECC training modules. Research Implications and Evidence Gaps There needs to be further research into the impact from MECC on patient behaviour and eventual outcomes, and how these change following training in both the short and long term. Research specifically into the MECC training being implemented across Wales, how people interact with and use this, and what they find useful and relevant would also be worthwhile. Identification of methods to overcome the specific barriers and enhance the enablers-particularly around encouraging organisational and managerial support for MECC training and utilisation. Economic considerations The Public Health England MECC evaluation guidance 2020 recommends producing a business case for MECC programmes that includes the costs of delivery and considers the value for money of its implementation. Most policy documents discussing the cost-effectiveness of MECC programmes cite the National Institute for Health and Care Excellence (NICE) public health guidance 2014 (PH49). This guidance however, does not directly refer to MECC programmes, but rather brief behaviour change and signposting interventions.

Over one-quarter of children in Wales aged four-to-five are overweight or obese. Children who are overweight or obese may experience health issues during childhood or adolescence, or both. They are also more likely to be overweight or obese through to adulthood. A wide range of biological (e.g. genetics), psychological, environmental (e.g. barriers to physical activity and access to healthier foods) and societal (e.g. lifestyle and peer influence) factors can potentially be associated with childhood obesity or overweight. Evidence reviews of factors associated with childhood obesity or overweight already exist, but these examine the influence of the above factors across a range of ages. No up-to-date review focuses specifically on factors associated with obesity or overweight when both the factor and its impact on weight status were studied in children under five years of age. We aimed to review existing reviews to identify the factors associated with obesity and overweight, specifically when impact on weight status was reported in children under five years of age. The review included evidence available up until December 2023, and 30 systematic reviews were identified. A wide range of biological, psychological, environmental and societal factors were consistently found to be associated with an increased risk of childhood obesity and/or overweight. Factors consistently found to be associated with a decreased risk of childhood obesity and/or overweight were breastfeeding and larger household size. Most of the high-certainty evidence related to childhood overweight. No high-certainty evidence was identified on the association between factors and childhood obesity specifically, and further research studies are needed. The high-certainty evidence supports helping overweight women (who are thinking about having a baby or trying to conceive) to lose weight, reducing rapid weight gain during the first 12 months of life, providing opportunities for children of working mothers to access healthier foods and be more physically active. The moderate-certainty evidence supports promoting breastfeeding, reducing rapid weight gain during the first 13 months of life, monitoring the childs growth rate during the first two years of life (particularly for babies with catch-up growth), promoting baby-led weaning, reducing consumption of sugary drinks, and educating and supporting the wider caregivers to provide healthier foods and opportunities for play and physical activity. The findings from this review may differ from other reviews conducted to inform practice. This review only reports on obesity or overweight outcomes where they are measured before the age of five years, whereas previous reviews have measured these outcomes over a wider age range. This review also focusses on evidence that specifically classifies children as overweight or obese using body mass index (or other well-accepted measures for children under two years).

Objectives Nature Based Social Prescribing (NBSP) is a means of connecting people with non-clinical, nature-based community-led interventions delivered by 3rd sector organisations using local community assets. This research used a mixed-method Social Return on Investment (SROI) of a six-month pilot ‘Making Well’ NBSP programme to support individuals with chronic mental health conditions in Wales. Methods The ‘Making Well’ programme costs were estimated by means of SROI along projected 20% overheads, were incorporated to reflect sustainable costs as the charity develops and more accurately estimate the future social value expected to be generated. The ‘Making Well’ project delivered two separate programmes between October 2021 and April 2022. Data was collected from participants (n = 12) at baseline and eight-week follow-up along with interviews to collect in-depth data on individuals lived experience of participating in the programme. The ‘Making Well’ programme costs were estimated and financial proxies from the HACT Social Value (SV) bank were applied to identified benefits. Results The estimated cost of ‘Making Well’ programme inputs were £1,312 per participant and the net value of well-being benefits were £4,313 to £6,130 per participant, giving a range of SVR’s between £3.30 to £4.70 for every £1 invested in this NBSP intervention. The SROI forecast provides a three-year projection of the annual social value created and the estimated forecast cost of programme inputs was £797 per participant. The net value of well-being benefits was £4,313 to £6,130 per participant, giving a range of social value ratios between £5.40 to £7.70 for every £1 invested. Conclusions The SROI results demonstrate that the ‘Making Well’ programme is an effective NBSP intervention for supporting people with enduring mild to moderate mental health conditions. This SROI contributes to emerging evidence on the use of community assets and NBSP in generating a return on investment and positive social value. SROI forecasting for socially prescribed interventions delivered by local community assets, such as The Fathom Trust, can help organisations demonstrate transparent and effective investment of public funds and support optimal future social value creation and long-term public health outcomes.

Urinary and faecal incontinence, which are often linked to the stresses and strains of childbirth, particularly perineal trauma, are debilitating conditions that can significantly impact womens quality of life. Approximately 85% of vaginal births in the United Kingdom (UK) are affected by childbirth related perineal trauma, either spontaneously or due to episiotomy. Incontinence also places a significant financial burden on the healthcare system. Previous estimates have shown that stress urinary incontinence alone costs the National Health Service (NHS) 177 million UK pounds per year. The aim of this rapid review was to identify evidence on the clinical effectiveness and cost-effectiveness of interventions for preventing continence issues resulting from birth trauma. Twenty-three studies, published between 2023 and 2024, were included in this review: 20 systematic reviews of clinical effectiveness and three economic evaluations. A number of key findings, research implications and evidence gaps were identified. The findings support the use of exercise-based interventions including pelvic floor muscle training for prenatal and postnatal women to prevent urinary incontinence. However, there is limited evidence supporting their long-term effectiveness. Incontinence is a potential long-term burden as pregnancy and childbirth can weaken the pelvic floor, making women more susceptible to incontinence in later life. Menopause often exacerbates these issues due to hormonal changes and by further weakening the pelvic floor muscles. Non exercise-based interventions, such as prenatal perineal massage and vaginal devices were less represented in the available evidence base, especially for faecal incontinence outcomes. There was a paucity of economic evaluations assessing the cost-effectiveness of interventions for incontinence, however, the substantial economic burden of incontinence on the NHS necessitates investment in clinically effective, preventative options. Our findings present the case for investing in exercise-based interventions. Further research is needed to evaluate the maintenance and long-term effects of exercise-based therapy. More research is also needed that focus on alternative type interventions and the prevention of faecal incontinence. Future reviews need to consider qualitative findings of womens experiences and the acceptability and feasibility of rolling out interventions for the prevention of incontinence.

Health economics of prevention is fundamental to improving our health and well-being. In this book we advocate the concept of ‘well-becoming’. This is how we create life-course health and well-being opportunity architecture in society. Fifty percent of mental health problems emerge before the age of fourteen years and 75 per cent by age twenty-four. Likewise, the lifestyle choices we make in our fifties determine how we age. In this book, we ask the reader to think about the life-course and where we should be investing in cost-effective interventions to support the prevention of chronic disease, disability, and premature death. Life expectancy in the United Kingdom has fallen due to over a decade of austerity prior to the COVID-19 pandemic. Brexit and the war in Ukraine have contributed to the current cost of living crisis, adversely affecting the worst off in society. In this book we draw on the work of Professor Sir Michael Marmot on the widening inequalities in healthy life expectancy. This is set to persist in an increasingly unequal society. The economic and health economics evidence we present, drawing on systematic review evidence where possible, provokes discussion of the tension between prevention and cure in our health and social care systems. We introduce our new infographic called the ‘Well-being and well-becoming wheel’. We set out an agenda for health economics research and policy support in the field of public health and prevention economics relating to well-being and well-becoming. We close the book with consideration of global priorities for health economics research with an increased emphasis on sustainability and climate change as a fundamental basis for future human well-being and well-becoming. We hope this book will be of interest to health economists working in public health and prevention, social care economics, public health and local authority decision-makers, and students in health economics, public health, public policy, and medicine.