INTRODUCTION: Paramedics in the UK are moving from emergency ambulance services into primary care, where they are employed to boost the clinical workforce. Whereas there is emerging research that seeks to understand the contribution of paramedics to the primary care workforce, there is none regarding the perceptions paramedics have regarding their role in primary care. METHODS: An analytic auto-ethnography was undertaken, utilising a peripheral membership approach for online communities used by paramedics on Facebook, Reddit and Twitter (now X). Over a 3-month period (December 2021 to February 2022), the primary researcher reflected on the conversations, comments and opinions posted within these communities within a reflexive (immersion) journal, considering them against the context of her own experience. RESULTS: Paramedics in primary care, who are generally isolated due to their geographical isolation from each other, utilise online social spaces to foster a community of practice. These forums are used to discuss their clinical role, education and experiences, as well as to consider their place within the primary care workforce. CONCLUSION: This is the first application of this methodology within online social spaces utilised by UK paramedics. This article also presents novel use of a peripheral membership approach within an analytic auto-netnography in public online spaces for researcher-practitioners.
\n \n\n \n \nBACKGROUND: Social prescribing is increasingly used to support well-being through non-clinical, community-based interventions. However, there is limited understanding of how cultural activities can be tailored for older people from global majority groups. The TOUS study (Tailoring cultural Offers with and for diverse older Users of Social prescribing) explores how cultural offers can be adapted to meet the needs of these communities. AIM: This study aims to understand how storytelling can be used within a realist evaluation to explore the role of cultural activities in enhancing well-being among older adults from global majority groups. METHOD: Storytelling was used as a key method of data collection in two case studies. This approach involves four open-ended questions that allow participants to share experiences in their own words. Each transcript is condensed into a two-page narrative, approved by the participant, and used in collaborative discussions with stakeholders. This method aligns with the patient-centred ethos of social prescribing and complements realist evaluation by highlighting mechanisms of change and barriers to participation. RESULTS: Preliminary findings suggest cultural institutions can foster inclusion, connection, and identity among participants. Storytelling revealed the importance of culturally relevant, welcoming spaces and captured the nuanced experiences of individuals often overlooked in traditional research. CONCLUSION: Storytelling enriches realist evaluation by offering a participant-led, less extractive method of data collection. It bridges individual experiences with broader programme outcomes and provides a valuable approach for researchers aiming to centre voices from underrepresented communities in primary care research.
\n \n\n \n \nBackground: In response to the unsustainable workload and workforce crises in primary care, paramedics (with their generalist clinical background acquired from ambulance service experience) are increasingly employed in primary care. However, the specific contribution paramedics can offer to the primary care workforce has not been distinctly outlined. We used realist approaches to understand the ways in which paramedics impact (or not) the primary care workforce. Methods: A realist evaluation was undertaken, consisting of three independent but inter-related research studies: In WP1, a mixed-methods cross-sectional survey of paramedics in primary care in the UK was conducted to comprehend the existing practices of paramedics within the NHS. WP2 involved an analytic auto-netnography, where online conversations among paramedics in primary care were observed to understand paramedics\u2019 perceptions of their role. WP3 utilised focused observations and interviews to delve into the impact of paramedics on the primary care workforce. This comparative study collected data from sixty participants across fifteen sites in the UK, and twelve participants across three sites in a specific region in Canada, where Community Paramedicine is well established. Results: The culmination of findings from each phase led to the development of a final programme theory, comprising of 50 context-mechanism-outcome configurations (CMOCs) encompassing three conceptual categories: Expectations associated with paramedics in primary care, the transition of paramedics into primary care roles, and the roles and responsibilities of paramedics in primary care. Conclusions: Our realist evaluation used a mixed-method approach to present empirical evidence of the role of paramedics in primary care. It offers insights into factors relating to their deployment, employment, and how they fit within the wider primary care team. Based on the evidence generated, we produced a series of practice implementation recommendations and highlighted areas for further research.
\n \n\n \n \nBackground: Prognostic tools for febrile illnesses are urgently required in resource-constrained community contexts. Circulating immune and endothelial activation markers stratify risk in common childhood infections. We aimed to assess their use in children with febrile illness presenting from rural communities across Asia. Methods: Spot Sepsis was a prospective cohort study across seven hospitals in Bangladesh, Cambodia, Indonesia, Laos, and Viet Nam that serve as a first point of contact with the formal health-care system for rural populations. Children were eligible if aged 1\u201359 months and presenting with a community-acquired acute febrile illness that had lasted no more than 14 days. Clinical parameters were recorded and biomarker concentrations measured at presentation. The primary outcome measure was severe febrile illness (death or receipt of organ support) within 2 days of enrolment. Weighted area under the receiver operating characteristic curves (AUC) were used to compare prognostic accuracy of endothelial activation markers (ANG-1, ANG-2, and soluble FLT-1), immune activation markers (CHI3L1, CRP, IP-10, IL-1ra, IL-6, IL-8, IL-10, PCT, soluble TNF-R1, soluble TREM1 [sTREM1], and soluble uPAR), WHO danger signs, the Liverpool quick Sequential Organ Failure Assessment (LqSOFA) score, and the systemic inflammatory response syndrome (SIRS) score. Prognostic accuracy of combining WHO danger signs and the best performing biomarker was analysed in a weighted logistic regression model. Weighted measures of classification were used to compare prognostic accuracies of WHO danger signs and the best performing biomarker and to determine the number of children needed to test (NNT) to identify one additional child who would progress to severe febrile illness. The study was prospectively registered on ClinicalTrials.gov, NCT04285021. Findings: 3423 participants were recruited between March 5, 2020, and Nov 4, 2022, 18 (0\u00b75%) of whom were lost to follow-up. 133 (3\u00b79%) of 3405 participants developed severe febrile illness (22 deaths, 111 received organ support; weighted prevalence 0\u00b734% [95% CI 0\u00b728\u20130\u00b741]). sTREM1 showed the highest prognostic accuracy to identify patients who would progress to severe febrile illness (AUC 0\u00b786 [95% CI 0\u00b782\u20130\u00b790]), outperforming WHO danger signs (0\u00b775 [0\u00b771\u20130\u00b780]; p<0\u00b70001), LqSOFA (0\u00b774 [0\u00b769\u20130\u00b778]; p<0\u00b70001), and SIRS (0\u00b763 [0\u00b758\u20130\u00b768]; p<0\u00b70001). Combining WHO danger signs with sTREM1 (0\u00b788 [95% CI 0\u00b785\u20130\u00b791]) did not improve accuracy in identifying progression to severe febrile illness over sTREM1 alone (p=0\u00b724). Sensitivity for identifying progression to severe febrile illness was greater for sTREM1 (0\u00b780 [95% CI 0\u00b773\u20130\u00b785]) than for WHO danger signs (0\u00b772 [0\u00b766\u20130\u00b779]; NNT=3000), whereas specificities were comparable (0\u00b781 [0\u00b778\u20130\u00b783] for sTREM1 vs 0\u00b779 [0\u00b776\u20130\u00b782] for WHO danger signs). Discrimination of immune and endothelial activation markers was best for children who progressed to meet the outcome more than 48 h after enrolment (sTREM1: AUC 0\u00b794 [95% CI 0\u00b789\u20130\u00b798]). Interpretation: sTREM1 showed the best prognostic accuracy to discriminate children who would progress to severe febrile illness. In resource-constrained community settings, an sTREM1-based triage strategy might enhance early recognition of risk of poor outcomes in children presenting with febrile illness. Funding: M\u00e9decins Sans Fronti\u00e8res, Spain, and Wellcome. Translations: For the Arabic and French translations of the abstract see Supplementary Materials section.
\n \n\n \n \nBACKGROUND: It is unclear whether weight loss before in vitro fertilization (IVF) improves reproductive outcomes in women with obesity. PURPOSE: To assess whether weight loss interventions before IVF improve reproductive outcomes. DATA SOURCES: Five electronic databases through 27 May 2025. STUDY SELECTION: Randomized controlled trials (RCTs) in women with obesity who were offered a weight loss intervention before planned IVF. DATA EXTRACTION: Dual independent screening, data extraction, and assessment of risk of bias (RoB) and certainty of evidence. Primary outcomes were pregnancy and live birth rates. Where appropriate, studies were pooled using random-effects meta-analyses. DATA SYNTHESIS: Twelve RCTs (1921 randomly assigned participants) were included, 7 of which had high RoB. There was moderate certainty that pre-IVF weight loss interventions were associated with an increase in total pregnancy rates (risk ratio [RR], 1.21 [95% CI, 1.02 to 1.44]; 11 studies) and pregnancies resulting from unassisted conception (RR, 1.47 [CI, 1.26 to 1.73]; 10 studies), whereas the effect on pregnancies resulting solely from IVF was uncertain. Weight loss interventions were not associated with pregnancy loss rates (RR, 1.05 [CI, 0.98 to 1.13]; 8 studies; moderate certainty), but their effect on live birth rates was unclear (RR, 1.15 [CI, 0.95 to 1.40]; 9 studies; very low certainty). LIMITATIONS: Studies were small, had high RoB, and often did not report important outcomes, such as live births. Substantial clinical and methodological heterogeneity was unexplained by exploratory analyses. CONCLUSION: Weight loss interventions before IVF appear to increase the chances of pregnancy, especially unassisted conceptions. However, studies were small, and heterogeneity made it difficult to determine the benefit of any particular intervention. PRIMARY FUNDING SOURCE: National Institute for Health and Care Research Applied Research Collaboration Oxford and Thames Valley. (PROSPERO: CRD42023441457).
\n \n\n \n \nBackground: Social prescribing (SP) seeks to support patients\u2019 wider needs by connecting them to non-medical community resources. Link workers (LWs) facilitate SP\u2019s delivery across the National Health Service (NHS) in England. As a concept, SP may be perceived in different ways by various stakeholders. This study set out to explore how SP is understood among healthcare professionals (HCPs), voluntary and community sector (VCS) representatives, LWs, and patients (Ps) in England. Methods: A secondary qualitative analysis was conducted using interview data from a realist evaluation on the implementation of LWs in primary care. Interview data from 106 participants (HCPs, VCS representatives, LWs, Ps), across seven sites in England, were analysed using reflexive thematic analysis. Results: Analysis resulted in 127 codes. These were clustered into the following themes: (1) the need for system optimisation, (2) SP as a tool for personal empowerment, (3) SP\u2019s broad and inclusive nature, (4) community engagement through LWs, and (5) a holistic approach to well-being. These themes highlight SP\u2019s potential as an integrated and empowering ecosystem; requiring effective collaboration and clearer communication among stakeholders to enhance understanding of its purpose, streamline referral processes, and align expectations for greater impact. Understanding of SP could be related to five broad questions around how, who, what, where, and why; the themes produced from the analysis aligned with these questions, each exploring different dimensions of SP. Through this, we developed the 5Ws Framework, which is outlined in the paper. Conclusions: SP is not a standalone intervention; it is a complex system that requires optimisation and balance across its elements. Its effectiveness as an integrated empowerment ecosystem depends on addressing all facets of the 5Ws\u2014how, who, what, where, and why it operates\u2014engaging the right stakeholders, clearly defining its scope, and implementing it appropriately. Policymakers and commissioners could use the 5Ws Framework to guide decision-making, align health system priorities, and ensure the effective integration of SP within primary care.
\n \n\n \n \nBackgroundIn England, over 2 million patients are referred each year on urgent pathways to investigate suspected cancer. The content and quality of referrals have often been audited, but there is no consensus on what should be included in a referral to optimise diagnostic outcomes.AimTo identify and describe the characteristics of referral letters for suspected cancer from primary to secondary care that may optimise diagnostic outcomes.MethodThe scoping review employed the methodology developed by Arksey and O'Malley in 2005 and further expanded by Levac and Colquhoun 2010. We searched PubMed, Embase, and PsycINFO to identify relevant studies in English Language published between 2000 and 2023. All findings were reported according to PRISMA guidelines for scoping reviews.ResultsOf 3463 identified records, only thirteen met the inclusion criteria, employing qualitative and mixed methods, as well as retrospective audits of referrals. The studies noted that symptom information such as duration, appearance, and descriptive qualities was often missing. There was limited evidence suggesting that the inclusion of clinical examination findings, test information, and the motivation of the referring clinician were beneficial. Evidence relating to the benefits of guidelines and template referral forms was mixed. There was a paucity of research linking referral content to patient diagnostic outcomes.ConclusionDespite a small number of studies retrieved, there was broad consensus about the benefit of conveying detailed information in referrals for suspected cancer, particularly with respect to comprehensive symptom description and relevant tests and clinical examinations. Further research linking referral quality to diagnostic outcomes would be beneficial to drive improvement to diagnostic outcomes.
\n \n\n \n \nQualitative Longitudinal Research (QLR) is a dynamic and evolving methodology using time as a lens to inform study design, data collection and analysis. A key feature of QLR is the collection of data on more than one occasion, often described as waves or time points. Thus, researchers embarking on designing a new study need to consider several key features including the study duration (timeframe) and the frequency and intensity of data collection (tempo). Yet, how to embed these features in practice is not well described. Leveraging the intensive-extensive temporal plane of time, we explore research approaches employing both shorter and longer timeframes, as well as intensive and extensive tempos. Drawing on six studies that we have conducted, we discuss four pivotal aspects including: (i) crafting intensive-extensive tempo and timeframes; (ii) defining baseline and closure points; (iii) planning for flexibility; and (iv) working ethically within a temporal lens. By examining and critically analysing these case studies through the lens of the intensive-extensive plane of time, this article aspires to offer insights for researchers interested in using the QLR design in healthcare. We thus aim to prepare researchers for embedding these features during the research process.
\n \n\n \n \nBackground: Self-sampling and self-testing have been increasingly used for sexually transmitted infections (STIs) and quickly became widespread during the COVID-19 pandemic. User acceptability, preferences, and experiences are important factors affecting self-sampling/self-testing uptake. Understanding these factors is key to managing infections and planning responses to health emergencies. This review aimed to identify user views and experiences related to the acceptability, usability, motivations and preferences for self-sampling/self-testing for infections. Methods: We conducted a rapid systematic review. We searched Medline, EMBASE, PsycINFO, CINAHL, and Web of Science, limiting records to those published in English between 2014 and 2023. We also searched manually for additional peer-reviewed and grey literature. We included reports of public users\u2019 views on self-sampling/self-testing for any symptomatic and asymptomatic infections (except human papillomavirus) with qualitative, mixed-methods or survey data relevant to the review aim. Data were extracted into tables and qualitative findings were coded in NVivo. We synthesised data narratively. Results: We identified 194 eligible reports, including 64 from Europe (which we prioritised for detailed synthesis) and 130 from outside of Europe. In Europe, the studied infections were respiratory (n = 42, including 37 for COVID-19), STIs/HIV/genital infections (n = 20), and hepatitis C (n = 2). Findings indicate that users found self-sampling/self-testing acceptable across infection/sampling types, populations, settings, and countries. Users wanted self-sampling/self-testing to help determine infection status and protect others. The main benefits were privacy and convenience, helping reduce the potential stigma of STIs/HIV/genital infections, and (for COVID-19) informing behaviour (e.g., socialising, self-isolating) and contributing to research. Easier to perform and less invasive sampling approaches were more acceptable. However, some participants reported challenges to self-sampling/self-testing, such as not understanding instructions, pain/discomfort in collecting samples, and lack of confidence in interpreting results. Conclusions: This review synthesised evidence on the acceptability of SS/ST and factors affecting it across different infections, sampling approaches, settings, and populations. Evidence shows that most people with experience of self-sampling/self-testing found it acceptable and were willing to accept some discomfort in favour of several perceived benefits. This amenability to self-sampling/self-testing could be leveraged for diagnosing infections and preventing transmission. It can be used to support the viability of new models of clinical care and pandemic preparedness. Trial registration: The review was pre-registered on PROSPERO (ref. CRD42024507656).
\n \n\n \n \nABSTRACTBackgroundPatient\u2010reported outcome measures (PROMs) are used to evaluate the effectiveness of interventions, particularly for subjective health states such as well\u2010being. A parent carer is an adult primary caregiver for a child with a disability. Parent carers are at risk of poorer mental and physical health; targeted health promotion interventions are being developed, requiring evaluation. This study aimed to identify the important health and well\u2010being outcomes for parent carers for evaluating parent carer\u2010focused interventions.MethodsWe recruited parents of children with special educational needs and disabilities living in England. Participants took part in individual, semi\u2010structured interviews via video in two parts. First, participants were asked open\u2010ended questions about health and well\u2010being; second, there was an elicitation exercise, in which the interviewees were asked to consider the aspects of health assessed by the Warwick\u2010Edinburgh Mental Wellbeing Scale (WEMWBS). Verbatim transcripts were analysed in two stages. Initially, data were analysed inductively, taking a thematic analysis approach. Subsequently, the data were analysed deductively with reference to a comprehensive framework of well\u2010being composed of 6 domains and 196 dimensions of well\u2010being.ResultsThirty parent carers participated. We found support for diverse dimensions across all six well\u2010being domains. Eighteen dimensions were perceived to be of greater importance for parent carers: \u2018stress reaction\u2019, \u2018anxiety/depression\u2019, \u2018acceptance\u2019, \u2018autonomy\u2019, \u2018self\u2010esteem\u2019, \u2018cognition\u2019, \u2018achievement\u2019, \u2018interests/hobbies\u2019, \u2018learning\u2019, \u2018need for relatedness\u2019, \u2018rest\u2019, \u2018sleep\u2019, \u2018physical exercise\u2019, \u2018life purpose and satisfaction\u2019, \u2018community wellbeing\u2019, \u2018status\u2019, \u2018financial situation\u2019 and \u2018future security\u2019. WEMWBS items focus on positive aspects of mental health. Not measuring reduction in \u2018negative\u2019 well\u2010being dimensions risks missing important changes.ConclusionsAll six domains of health and well\u2010being were relevant to parent carers. However, some dimensions were more significant for the well\u2010being of parent carers, and these dimensions should be captured when evaluating their health and well\u2010being outcomes.Patient or Public ContributionParent carers were involved in all aspects of the research, including research aims, recruitment and sampling, data collection and analysis, and dissemination.
\n \n\n \n \nThe \u201cBaby Ubuntu\u201d programme is a well-established, low-cost, community-based intervention to support caregivers of children with complex neurodisability, like cerebral palsy, in low- and middle-income country (LMIC) contexts. This process-focused paper describes our utilisation of the ADAPT guidance to adapt \u201cBaby Ubuntu\u201d for use in ethnically and linguistically diverse, and economically deprived urban boroughs in the United Kingdom (UK). The process was guided by an adaptation team, including parents with lived experience, who explored the rationale for the intervention from local perspectives and its fit for this UK community. Through qualitative interviews and co-creation strategies, the perspectives of caregivers and healthcare professionals substantially contributed to the \u201cEncompass\u201d programme theory, drafting the content, and planning the delivery. Ten modules were co-produced with various topics, based on the \u201cBaby Ubuntu\u201d modules, to be co-facilitated by a parent with lived experience and a healthcare professional. The programme is participatory, allowing caregivers to share information, problem solve, and form supportive peer networks. The \u201cEncompass\u201d programme is an example of a \u201cdecolonised healthcare innovation\u201d, as it aims to transfer knowledge and solutions developed in low- and middle-income countries to a high-income context like the UK. Piloting of the new programme is underway.
\n \n\n \n \nIntroduction: The fight against sepsis is an ongoing healthcare challenge, where digital tools are increasingly used with some promising results. The experience of survivors and their family members can help optimize digital alerts for sepsis/deterioration. This study pairs the experiences of survivors of their sepsis journey and family members with their knowledge and views on the role of digital alerts. Methods: A qualitative study with online, semi-structured interviews and focus groups with sepsis survivors and family members in England. Data were analyzed inductively using thematic analysis. Results: We included 11 survivors, and 5 family members recruited via sepsis charities and other social media, for a total of 15 sepsis cases. Identified categories correspond to the three stages of the sepsis journey: 1. Pre-hospital, onset symptoms and help-seeking; 2. Hospital admission and stay; 3. Post-sepsis syndrome. The role of digital alerts at each stage of the sepsis journey is discussed. Participants\u2019 experiences were varied, previous sepsis awareness scant, and knowledge of digital alerts minimal. However, participants were confident in the potential of alerts contributing along the sepsis journey. They perceived digital alerts as important in healthcare professionals\u2019 decision-making to expedite identification and treatment of sepsis and suggested their expansion across healthcare services. Participants expressed that awareness should be increased among the general public about digital alerts for sepsis/deterioration. Discussion: In light of sepsis\u2019 insidious and variable manifestation, the involvement of patients and family members in the development of digital alerts is crucial to optimize their design and deployment towards improving outcomes. Digital alerts should enhance the connection across healthcare services as well as the care quality. They should also enhance the communication between patients and healthcare professionals. Clinical trial registration: The ClinicalTrials.gov registration identifier for this study is NCT05741801; the protocol ID is 16347.
\n \n\n \n \nBackground: Equity is fundamental to health promotion programmes. However, unintentional or unseen barriers may exist for some underserved groups. We aimed to identify how to ensure equitable access and engagement for diverse parent carers of disabled children to benefit from health promotion programmes. Methods: We purposively sampled parent carers with potentially intersecting characteristics including those who self-identified as from ethnic groups, whose children were educated other than at school, with sensory impairments, or neurodiversity, and fathers. Participants were recruited through local and national organisations and parent carer networks. Data collection involved semi-structured individual interviews, which were transcribed verbatim and analysed thematically and iteratively alongside data collection. Core researchers performed early analysis independently, followed by research team and advisory group cross-validation. Results: Thirty-six parent carers with intersecting characteristics across the sampled backgrounds participated. We identified various perceived barriers around finding out about, attending and engaging with health programmes. We organised the findings into five themes focused on concepts capturing challenges and potential solutions to contextual barriers to access and participation in health programmes. (i) Reach\u2014judiciously using targeted and universal strategies to ensure equitable distribution; (ii) Credibility\u2014demonstrating trustworthiness of those advertising and/or delivering the programme; (iii) Opportunity\u2014ensuring that the programme is seen as fulfilling a relevant need; (iv) Reservations\u2014addressing barriers of readiness to participate; and (v) Optimisation\u2014tailoring to improve the inclusivity of the programme delivery. Conclusion: We identified modifiable factors that impede members of some social groups from engaging with, and benefiting from, health promotion programmes, and potential solutions. We advocate a multifaceted approach is required from outreach to delivery, tailored to be mindful of extant diverse needs of parent carers in underserved communities. We catalogue key considerations to inform implementation strategies to optimise equity in health programmes for parent carers. The implications are likely transferable to other interventions and contexts.
\n \n\n \n \nBackground: People from lower socioeconomic groups are more likely to smoke and less likely to succeed in achieving abstinence, making tobacco smoking a leading driver of health inequalities. Contextual factors affecting subpopulations may moderate the efficacy of individual-level smoking cessation interventions. It is not known whether any intervention performs differently across socioeconomically-diverse populations and contexts. Objectives: To assess whether the effects of individual-level smoking cessation interventions on combustible tobacco cigarette use differ by socioeconomic groups, and their potential impact on health equalities. Search methods: We searched the Cochrane Database of Systematic Reviews from inception to 1 May 2023 for Cochrane reviews investigating individual-level smoking cessation interventions. We selected studies included in these reviews that met our criteria. We contacted study authors to identify further eligible studies. Selection criteria: We included parallel, cluster or factorial randomised controlled trials (RCTs) investigating any individual-level smoking cessation intervention which encouraged complete cessation of combustible tobacco cigarette use compared to no intervention, placebo, or another intervention in adults. Studies must have assessed or reported smoking quit rates, split by any measure of socioeconomic status (SES) at longest follow-up (\u2265 six months), and been published in 2000 or later. Data collection and analysis: We followed standard Cochrane methods for screening, data extraction, and risk of bias assessment. We assessed the availability of smoking abstinence data by SES in lieu of selective reporting. The primary outcome was smoking cessation quit rates, split by lower and higher SES, at the longest follow-up (\u2265 six months). Where possible, we calculated ratios of odds ratios (ROR) with 95% confidence intervals (CIs) for each study, comparing lower to higher SES. We pooled RORs by intervention type in random-effects meta-analyses, using the generic inverse-variance method. We subgrouped by type of SES indicator and economic classification of the study country. We summarised all evidence in effect direction plots and categorised the intervention impact on health equality as: positive (evidence that the relative effect of the intervention on quit rates was greater in lower rather than higher SES groups), possibly positive, neutral, possibly neutral, possibly negative, negative, no reported statistically significant difference, or unclear. We evaluated certainty using GRADE. Main results: We included 77 studies (73 from high-income countries), representing 127,791 participants. We deemed 12 studies at low overall risk of bias, 13 at unclear risk, and the remaining 52 at high risk. Included studies investigated a range of pharmacological interventions, behavioural support, or combinations of these. Pharmacological interventions. We found very low-certainty evidence for all the main pharmacological interventions compared to control. Evidence on cytisine (ROR 1.13, 95% CI 0.73 to 1.74; 1 study, 2472 participants) and nicotine electronic cigarettes (ROR 4.57, 95% CI 0.88 to 23.72; 1 study, 989 participants) compared to control indicated a greater relative effect of these interventions on quit rates in lower compared to higher SES groups, suggesting a possibly positive impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring higher SES groups. There was a lower relative effect of bupropion versus placebo on quit rates in lower compared to higher SES groups, indicating a possibly negative impact on health equality (ROR 0.05, 95% CI 0.00 to 1.00; from 1 of 2 studies, 354 participants; 1 study reported no difference); however, the CI included the possibility of no clinically important difference. We could not determine the intervention impact of combination or single-form nicotine replacement therapy on relative quit rates by SES. No studies on varenicline versus control were included. Behavioural interventions. We found low-certainty evidence of lower quit rates in lower compared to higher SES groups for print-based self-help (ROR 0.85, 95% CI 0.52 to 1.38; 3 studies, 4440 participants) and text-messaging (ROR 0.76, 95% CI 0.47 to 1.23; from 3 of 4 studies, 5339 participants; 1 study reported no difference) versus control, indicating a possibly negative impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring lower SES groups. There was very low-certainty evidence of quit rates favouring higher SES groups for financial incentives compared to balanced intervention components. However, the CI included the possibility of no clinically important difference and of favouring lower SES groups (ROR 0.91, 95% CI 0.45 to 1.85; from 5 of 6 studies, 3018 participants; 1 study reported no difference). This indicates a possibly negative impact on health equality. There was very low-certainty evidence of no difference in quit rates by SES for face-to-face counselling compared to less intensive counselling, balanced components, or usual care. However, the CI included the possibility of favouring lower and higher SES groups (ROR 1.26, 95% CI 0.18 to 8.93; from 1 of 6 studies, 294 participants; 5 studies reported no difference), indicating a possibly neutral impact. We found very low-certainty evidence of a greater relative effect of telephone counselling (ROR 4.31, 95% CI 1.28 to 14.51; from 1 of 7 studies, 903 participants; 5 studies reported no difference, 1 unclear) and internet interventions (ROR 1.49, 95% CI 0.99 to 2.25; from 1 of 5 studies, 4613 participants; 4 studies reported no difference) versus control on quit rates in lower versus higher SES groups, suggesting a possibly positive impact on health equality. The CI for the internet intervention estimate included the possibility of no difference. Although the CI for the telephone counselling estimate only favoured lower SES groups, most studies narratively reported no clear evidence of interaction effects. Authors' conclusions: Currently, there is no clear evidence to support the use of differential individual-level smoking cessation interventions for people from lower or higher SES groups, or that any one intervention would have an effect on health inequalities. This conclusion may change as further data become available. Many studies did not report sufficient data to be included in a meta-analysis, despite having tested the association of interest. Further RCTs should collect, analyse, and report quit rates by measures of SES, to inform intervention development and ensure recommended interventions do not exacerbate but help reduce health inequalities caused by smoking.
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